As 2020 Census data will further reveal upon public release, the United States is an increasingly diverse country. Language, race, sexual orientation, disability, sexual identity, and national origin are common topics when discussing diversity and embracing cultural proficiency. Such proficiency and its related tolerance and understanding are increasing necessities to facilitate productive relationships in our complex society in business, education, health care and all day-to-day interactions that comprise America’s societal fabric.
A deficit in and lack of such cultural proficiency and awareness are increasingly problematic in 21st century America. Indeed, cultural deficits and personal discomfort can have serious consequences – health, safety, life and death.
New Health Affairs Study – Disturbing Conclusions
A new Health Affairs study is a paradigm reveal of cultural proficiency deficit. Entitled ‘Physicians’ Perceptions Of People With Disability And Their Health Care,’ the study, published in February 2021, dramatically demonstrates how far health care needs to go to achieve basic comfort and understanding when treating and caring for people with disabilities.
In summary, as Health Affairs describes:
“Increasing evidence documents that [people with disabilities] experience health care disparities. Although many factors likely contribute to these disparities, one little-studied but potential cause involves physicians’ perceptions of people with disability.
Sixty-one million Americans have some type of disability, and these numbers are growing. All physicians and health care providers can expect to see increasing volumes of patients with disability. Our findings about physicians’ willingness to welcome patients with disability, confidence in caring for these patients, and problematic perceptions of quality of life were therefore deeply concerning and have important implications for health care delivery in the US
Only 40.7 percent of physicians were very confident about their ability to provide the same quality of care to patients with disability, just 56.5 percent strongly agreed that they welcomed patients with disability into their practices, and 18.1 percent strongly agreed that the health care system often treats these patients unfairly.
More than thirty years after the Americans with Disabilities Act of 1990 was enacted, these findings about physicians’ perceptions of this population raise questions about ensuring equitable care to people with disability. Potentially biased views among physicians could contribute to persistent health care disparities affecting people with disability… One concern that has received relatively little empirical attention is the attitudes of physicians and specifically whether physicians have implicit or explicit biased views of people with disability. Over centuries, societies have stigmatized people with disability, although the nature of these negative perceptions varies by disability type (for example, people with intellectual disability or serious mental illness are typically more marginalized than people with other types of disabilities). Limited research suggests that physicians can share these societal prejudices toward people with disability.”
“The magnitude of physicians’ stigmatizing views was very disturbing.”
The significant depth of physician discomfort concerning patients with disabilities in the new study was unexpected, according to its lead author. Dr. Lissa J. Iezzoni, lead study author and a health policy researcher at Massachusetts General Hospital opined: “That physicians have negative attitudes about patients with disability wasn’t surprising. But the magnitude of physicians’ stigmatizing views was very disturbing.”
The pandemic has also starkly revealed disability-based implicit bias and disability discrimination in health care. In 2020, the U.S. Department of Health and Human Services’ Office for Civil Rights (OCR) launched multiple investigations and enforcement efforts concerning disability discrimination in providing COVID-19 care. In multiple states, such as Kansas, Washington, and Alabama, OCR confirmed that care decisions were based upon discriminatory assumptions and attitudes about people with disabilities.
For example, in Alabama, OCR’s investigation was initiated by a complaint alleging that the State’s ‘Criteria for Mechanical Ventilator Triage Following Proclamation of Mass-Casualty Respiratory Emergency’ allegedly allowed for denying ventilator services to individuals based on the presence of intellectual disabilities. Such denials would be disability discrimination under federal law.
In resolving the Alabama complaint, OCR noted that Alabama disavowed “problematic triage plans” and committed to “coming into compliance with federal civil rights law.” As OCR further noted, “Persons with disabilities have equal worth and dignity and should not be deprioritized for health care based on a supposedly lower ‘quality of life’ compared to persons without disabilities.”
Unaware of disability discrimination legal protections
In 2019, Health Affairs also revealed that physicians are generally not familiar with disability discrimination protections and prohibitions. This lack of familiarity often impacts how physicians interact with and care for their patients, according to ‘Knowledge Of Practicing Physicians About Their Legal Obligations When Caring For Patients With Disability.’
As Health Affairs concluded in 2019:
“To examine one possible contributing factor [for disability related healthcare disparities], we interviewed practicing physicians to explore their knowledge of their obligations to accommodate patients with disability under federal civil rights law. Interviewees reported having had little formal training about, and demonstrated superficial or incorrect understanding of, their obligations in three potentially problematic areas: deciding which accommodations their practices should implement, refusing patients with disability, and holding patients accountable for costs of accommodations. The fact that practicing physicians might not fully understand their legal responsibilities when caring for people with disability may contribute to persisting inequity in their care, and it suggests that further education in the Americans with Disabilities Act and other disability civil rights laws may be warranted.”
What do we do now?
With disability related bias and lack of related cultural understanding now dramatically illustrated, what next?
Health Affairs has multiple recommendations:
“All levels of medical education should include more training about disability, including disability cultural competence and etiquette. Training that provides greater empathy about patients’ daily lives, such as house calls or standardized patients who have disability, might offer important insights. Similar to programs in which trainees take online Implicit Association Tests relating to race and ethnicity, educators could add an Implicit Association Test disability module. Finally, situations in which people with disability confront special vulnerability, such as decision making around crisis standards of care, require heightened attention to ensure equitable care.”
I concur. Through my own medical and law school scholarship, I see in the classes I teach the first hand value of such education and cultural proficiency for future health care providers and leaders. Health Affairs has provided invaluable wake-up calls. The next steps await swift adoption and implementation.
© Bruce L. Adelson 2021. All Rights Reserved The material herein is educational and informational only. No legal advice is intended or conveyed.
Bruce L. Adelson, Esq., is nationally recognized for his compliance expertise. Mr. Adelson is a former U.S Department of Justice Civil Rights Division Senior Trial Attorney. Mr. Adelson is a faculty member at the Georgetown University School of Medicine and University of Pittsburgh School of Law where he teaches organizational culture, implicit bias, cultural and civil rights awareness.
Mr. Adelson’s blogs are a Bromberg exclusive