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D Racial Disparities in Healthcare: Highlights from Focus Group Findings Meredith Grady Tim Edgar Westat 1650 Research Boulevard Rockville, Maryland June 2001 STORIES OF RACIAL DISCRIMINATION IN HEALTHCARE PRACTICE Racial discrimination occurs on many levels, in a variety of contexts, intertwined with income, education level, and other sociodemographic factors. It can be subtle or disturbingly overt. During the eight focus groups, participants were asked to talk about their own personal experi- ences with racism in healthcare. When asked whether discrimination ex- ists in receiving quality healthcare, one African-American participant summed up the collective response in this way: âThe medical world just reflects the real world.â Throughout the following section, participantsâ stories and opinions are presented in their own words, providing evi- dence of healthcare inequity that participants attributed directly or indi- rectly to racial or ethnic discrimination, their lack of English-language proficiency, or both. Effect of Stereotyping Participants often felt that the quality of health care services they re- ceived stemmed from misperceptions and stereotypes, not the reality of who they are. They said they often feel that health care providers treat them differently and assume they are less educated, poor, or deserving of less respect because of their race or culture. A Hispanic physician, speak- ing of the perceptions of his colleagues, corroborated participantsâ opin- ions that health care providers make assumptions about their patients based on race or ethnicity. âAs soon as they look at the patient and see 392
393 D: RACIAL DISPARITIES IN HEALTHCARE heâs African American or Latino, they assume automatically that he doesnât have insurance at all.â The following quotes provide examples of encounters that partici- pants had with healthcare providers who made stereotypical assumptions about their education or culture. My name is . . . [a common Hispanic surname] and when they see that name, I think there is . . . some kind of a prejudice of the name. . . . Weâre talking about on the phone, thereâs a lack of respect. Thereâs a lack of acknowledging the person and making one feel welcome. All of the courtesies that go with the profession that they are paid to do are kind of put aside. They think they can get away with a lot because âHereâs another dumb Mexican.â (Hispanic participant) Iâve had both positive and negative experiences. I know the negative one was based on race. It was [with] a previous primary care physician when I discov- ered I had diabetes. He said, âI need to write this prescription for these pills, but youâll never take them and youâll come back and tell me youâre still eating pigâs feet and everything. . . . Then why do I still need to write this prescription.â And Iâm like, âI donât eat pigâs feet.â (African-American participant) My son broke my glasses so I needed to go get a prescription so I could go buy a pair of glasses. I get there and the optometrist was talking to me as if I was like 10 years old. As we were talking, they were saying, âWhat do you do,â and as soon as they found out what I did [professionally], the whole attitude of this person changed towards me. I donât know if they come in there thinking, âOh this poor Indian does not have a clue.â I definitely felt like I was being treated differently. (Native-American participant) One participant spoke about a relative who did not want to take her husbandâs name after marriage for fear of being negatively stereotyped. My granddaughter, sheâs a doctor herself. She graduated in Mexico and then she came here. She [studied here] so she could become a doctor here. She married a Mexican guy named [a common Hispanic surname]. You know what she did? She took off [a common Hispanic surname] and kept [another surname], her fatherâs name. (Hispanic participant) Language Barriers Many participants in the Chinese- and Spanish-speaking focus groups voiced concern about being treated unfairly because of their lack of English-language proficiency. As a result, they perceived that healthcare providers treat them differently and were concerned that they receive lower quality care. If you speak English well, then an American doctor, they will treat you better. If you speak Chinese and your English is not that good, they would also kind of look down on you. They would [be] kind of prejudiced. (Chinese participant)
394 UNEQUAL TREATMENT When they see he canât explain himself, they look at him as if [they are] belittling him. They treat him with a lot of inferiorityâ¦ the doctor, nurses, receptionists. You can tell when the person is not liked by the doctors or the staff. I have seen a lot of discrimination in that manner. (Hispanic participant) I have a desire to improve my English so I can go to an American doctor and get better treatment. (Chinese participant) Healthcare providers were also concerned about not being able to communicate adequately with their patients because of a language bar- rier. One African-American nurse spoke of âseeing the fear in their eyesâ and knowing how upset and frustrated patients were in trying to commu- nicate what was wrong with them. A Hispanic nurse acknowledged the language problem, stating that for ânew immigrants that do not speak the language properly . . . it is the biggest obstacle they encounter.â Non-English-speaking participants, especially those in the Hispanic group, recounted many examples of personal situations in hospitals and other settings where they were forced to deal with serious health condi- tions without the benefit of interpreters or patient healthcare staff willing to assist them. They said they encountered healthcare staff who ignored them and avoided trying to help them. Others pointed out instances where they or their family members have received poor quality healthcare services and have been treated disrespectfully because they speak little or no English. A long time ago my husband was in pain. I had to call an ambulance and they took him to the hospital. We waited three hours. I would ask the nurse to please treat him because he could not stand the pain. She would say, âWeâre going to call him, weâre going to call him.â I saw black people being called in, but they never called him back. I asked for some medication in the meantime. They never came out with the medicine. . . . Well, we left. [My husband] told me it must have been because we are Hispanic and donât speak English. They would call and call in black people. . . . I think if we wouldâve been black or American we would have been treated faster. (Hispanic participant) [My wife] was treated badly. They wouldnât take care of her. They were chang- ing her IV and the nurse was very rough in the way she would take the needle out and put it back in. I felt bad. I had to go and tell them with the little English I speak what was happening. So, they changed the nurse. Thatâs the way it is. All the situations we are experiencing are because we canât communicate in English. (Hispanic participant) My son was in a bed and another boy was with his mother. Of course, they didnât speak English. The lady didnât know . . . she wanted to know where they were taking the boy. She asked for the girl who was interpreting for her. One of the nurses said, âI donât know why they send these people here without any- body to interpret for them. Weâll come back later,â and they left . . . but they
395 D: RACIAL DISPARITIES IN HEALTHCARE didnât do anything about finding out where the interpreter was. (Hispanic participant) I had eye surgery two or three years ago. The specialist was black. There were Hispanics out front. I told them I had an appointment with the doctor. They asked me if I spoke English . . . one said to the other in Spanish, âGo inside with her.â âNo, you go.â I asked them who was going to go with me because the doctor was waiting for me. Once we were inside, he would speak [only to the interpreter] directly. I felt rejected. (Hispanic participant) Five years ago my son got double pneumonia. The doctors wanted to operate [on] him. . . . They called my husband and he said he had to talk with the special- ist who was treating my son to see what he had to say about the surgery. We called . . . and the specialist said my son would not be able to resist that type of surgery. My husband called the hospital and told me not to sign any papers. I didnât speak English. I didnât know anything. They put the paper in front of me to sign. They insisted I sign the paper. My husband told me not to sign anything and [that] he was on his way [to pick us up]. In the end my son didnât have the surgery and he didnât die like they said he would. Three days after they said he needed the surgery he got better. The surgery was not necessary. (Hispanic participant) I called a pharmacy to see if my daughterâs medicine was ready and they put me on hold. They put the phone down and said, âSheâs a Spanish speaker,â and they put me on hold. She left me waiting a long time until I hung up. (Hispanic participant) The Role of Economics Oftentimes, participants noted, a personâs perceived or actual socio- economic status can be an obstacle to obtaining quality healthcare ser- vices. Participants were concerned that they may receive a lower stan- dard of care because healthcare providers make assumptions about the type of treatment or medication that they can afford because they are ra- cial or ethnic minorities. I know there have been a couple of times the doctor wanted to prescribe a certain medication but because of how much it was, he prescribed some- thing else. Not what was best, but what I could afford. (African-American participant) Often times, the system gets the concept of black people off the 6 oâclock news, and they treat us all the same way. Hereâs a guy coming in here with no insur- ance. Heâs low breed. (African-American participant) A lot of black people donât have money so I guess you would say that itâs hard [to get quality healthcare.] A lot of black people donât have any insurance. (African- American participant)
396 UNEQUAL TREATMENT Lack of Respect Many participants unequivocally believed that the lack of respect healthcare providers have for them leads to lower quality healthcare ser- vices than persons of other ethnicities, especially whites, receive. They spoke of instances where the office staff would not âlook them in the eyeâ when they spoke to them or greeted other patients with a more pleasant attitude. Others felt a lack of respect when they were rushed during ap- pointments and sensed that providers or their staff did not want to take the time to help them, answer their questions, or explain medical proce- dures to them. They wouldnât accept the appointment over the phone; they just put me on hold. I went in there and she looked at me and I told her Iâd been calling trying to make an appointment. She said, âWell, you see this stack of paper, you think youâre the only one?â She either thought I was Mexican or she recognized I was Indian, but she would not make that appointment. She just got smart with me and all. I told my husband about it. Heâs big and white. She got to him just like that. No problem. She got the appointment and got him through. She wouldnât do it for me. (Native-American participant) I felt that because of my race that I wasnât serviced as well as a Caucasian person was. The attitude that you would get. Information wasnât given to me as it would have [been given to] a Caucasian. The attitude made me feel like I was less important. I could come to the desk and they would be real nonchalant and someone of Caucasian color would come behind me and theyâd be like, âHi, how was your day?â (African-American participant) I donât have a problem with taking more time to be able to understand each other, but they get really annoyed when you donât understand them. Basically, they get really annoyed if you talk too much because they know they donât under- stand your language. When I go to the doctor I ask a lot of questions, so they can get really aggravated with me. I donât know if they would do the same thing to a white person. (African-American participant) Others felt they must wait for long periods of time before receiving medications and other medical assistance, while whites are cared for first. I would call [for the nurse] when I was feeling pretty bad. They wouldnât come until I finally had to yell, âHelp me, Iâm in pain! I need something to calm the pain!â They had to call someone and she gave it to me. There were American [patients] there. They would even close the curtains for them. (Hispanic par- ticipant) If your bell was on and the Caucasian lady, she doesnât even have to have her bell on. She was being attended to because they knew they better . . . do a certain quality [of service]. Whereas the same quality should have been given to the
397 D: RACIAL DISPARITIES IN HEALTHCARE black people, but their bell would be on and they still would have to wait. (African-American participant) Improper Diagnosis or Treatment More troubling are instances that participants mentioned where the quality of medical treatment was compromised by discriminatory atti- tudes or practices that participants believed led to either misdiagnosis or improper treatment. When I was growing up, my parents didnât have health insurance. We would go to the Indian Health Service. Youâd go there to the clinic and I think sometimes you wonder about the quality of the medical personnel that was examining you. My younger sister had appendicitis. It burst, and they told her she had a stom- ach flu. I donât know how they were hiring the medical personnel at that time. Itâs changed now, but back then I donât think we had some of the best medical officers or nurses. (Native-American participant) Being in a group practice seeing predominantly African-American patients, I have patients who have seen mainly white physicians in the past. When they come in to visit with us and speak with us, something as simple as [asking them to] sit up on a table and they got a question. âWhat are you going to do?â âIâm going to examine you.â âOh, my other doctor never did that.â (African- American physician) Of course, in psychiatry we see this [discrimination]. One area we see is in terms of diagnosis. Patients are inappropriately diagnosed and medications prescribed for the patients. We see errors in that. Minority patients will often be diagnosed inappropriately as being schizophrenic. (African-American physician) When I ask [my Hispanic patients] if the other doctor ever examines you, they say, âNo, they give me a prescription.â Itâs amazing. A lot of times these patients have these problems that are missed by the other doctors. (Hispanic physician) In some instances, participants noted, racial and ethnic minority pa- tients have difficulties gaining access to the specialists they need. One physician noted that specialists mistreat racial and ethnic minority pa- tients to avoid having to provide treatment for them. Iâm in private practice and we refer a lot. We kind of know what specialists to avoid because we hear the patients coming back and telling about what type of treatment theyâre getting from these specialists. A lot of the specialists in these institutions act like they donât want to see the minority patient at all. When the minority patient ends up there maybe because theyâre on [a particular] planâ¦ they are mistreated. (African-American physician)
398 UNEQUAL TREATMENT In contrast to situations described by participants in which healthcare providers sought to limit their access to healthcare services, two female participants described being pressured to have surgical procedures that, in retrospect, were deemed unnecessary by other doctors. The first thing they wanted to do was a hysterectomy. I was 36 years old and they never really examined me. I was just telling them the symptoms and it scared me and I left. . . . I guess they were trying to stop the population birth, whatever, because [the hospital] back then was for people who didnât have insur- ance. (African-American participant) My Ob-Gyn is Caucasian. I have fibroid tumors and the doctor Iâve been going to, heâs been my Ob-Gyn for 14 years and for the last 2 years he told me I have to have this hysterectomy. I had a girlfriend at the office recommend me to a female African-American physician. . . . A week later she called me at home and said to me, âThereâs nothing wrong with you. The fibroid is there but if itâs not bothering you, if itâs not broke, donât fix it. You donât need to have a hysterec- tomy.â (African-American participant) To overcome discriminatory attitudes from healthcare providers, one participant suggested that it is necessary for minorities to be âstrongâ and not âhumble in your voice and toneâ to have a better chance at getting the care they wanted. I believe that African Americans do get a lower quality of care. I think if youâre educated, if somebodyâs not treating you right then you kind of push past some of the stuff, but for somebody that doesnât have a good feeling about themselves, whether itâs because of race or literacy, that makes it very hard for them to get the care that they need. (African-American nurse) CHALLENGE OF IDENTIFYING RACIAL AND ETHNIC DISCRIMINATION Some participants found it difficult to identify obvious examples of discrimination they encountered in their healthcare experiences, although they were certain that discrimination exists in healthcare settings. As one African American participant aptly described, âItâs hard to identify dis- crimination because they donât show it. Theyâll be sweet and smooth, all the way through it.â Participants mentioned experiencing discrimination in many situations, but because of the subtleties often inherent in dis- crimination, it was challenging to identify overt examples. They often said, âYou just know,â or âYou can feel itâ when describing incidences of discrimination. Overall, participants felt that racial discrimination could not easily be separated from other forms of discrimination. The quotes that appear in the following section illustrate participantsâ concerns about not receiving
399 D: RACIAL DISPARITIES IN HEALTHCARE appropriate healthcare services, but they also show that the link between oneâs race or ethnicity and poor treatment can be very complex. While the underlying issues (e.g., economics, improper diagnosis) mentioned here parallel those discussed in an earlier section, the claims made in the fol- lowing quotes only suggest that a lower quality of healthcare stems from racial or ethnic discrimination. The evidence for this causal relationship tends to be circumstantial. Patientsâ Appearance Some participants hinted that attention to appearance, (e.g., being well-dressed) might counteract discriminatory tendencies. One Hispanic participant said he felt it was important to âbe presentable,â otherwise the healthcare staff would likely make him wait for hours before helping him. Another said: Iâve noticed that, outward appearance has a lot to do with the rapport that you have with your provider. They talk to you a little different, they treat you a bit differently. You can walk in, youâre all battered and crummy looking, and their whole personality changes. You walk in looking half-way decent, and theyâre very pleasant, and they react and act completely different. (African-American participant) Patientsâ Economic/Insurance Status Some participants provided examples of how they or their family members received poor healthcare services because of their lack of insur- ance or perceived inability to pay for these services. They believed that they were being treated differently by the healthcare system, although they did not make a direct link to race or ethnicity. I went back [to IHS] after I found out everything that needed to be done. I went back to the clinic and chewed out the doctor. Then she said, âWait a minute. Wait a minute. Do you realize how much itâs going to cost you? Itâs like buying a new car.â I said âI donât care at this point. Itâs my life. I donât care how much money I have to pay out of my pocket.â Then she says, âWait a minute. Letâs send you to a specialist.â I said, âWhy didnât you tell me this to begin with? Now that Iâm making my move, now youâre telling me, OK, now you can do this and that for me?â I said, âNo thank you. This is it.â (Native-American participant) My niece went to this hospital and they wouldnât wait on her because she didnât have insurance. They told her she would have to go to the county hos- pital. So I had to take her to the county hospital. She was bleeding all the way. It was just terrible, because she didnât have insurance. (African-American participant)
400 UNEQUAL TREATMENT Itâs almost like âOh well, this person doesnât have insurance. Letâs just give them the IHS treatment.â (Native-American participant) I have a son and heâs considered disabled. He had MediCal before. I got it before I got insurance through my job, and I had to wait 100 days before I got the insurance through my job. So I noticed thereâs a longer waiting periodâ¦ other people are coming in after me and have later appointments, but they have private insurance, so theyâre seen before me and my son. And it wasnât just the waiting period; the treatment was different. Now that I have private insurance, as soon as I get there, [they see me]. (Hispanic participant) An Ob/Gyn who had a large Medicaid population, not just black and Hispanic, but a large Medicaid population . . . they told the doctor they wanted him to have more deliveries at other hospitals. [He refused.] The hospital then, at that point, decided they would stop taking all Medicaid period because this doctor would not leave. For an entire year this hospital wouldnât pay Medicaid just so this doctor wouldnât deliver there anymore. (African-American physician) Healthcare Setting Native Americans, because of their unique access to healthcare through the Indian Health Service (IHS), spoke often about the poor quality of care at the IHS clinics. More than participants in the other groups, they defined their ability to get quality healthcare services by the setting in which they received care and not by their race. They did not blame poor healthcare on individual providers as much as they did on the IHS system. If you go into IHS for a problem, they donât investigate your problem to the extent that a private place does. [Private offices] go through everything like an ultrasound, blood work, the whole nine yards, and they pinpoint the problem. IHS, they give you a temporary solution or shot and it comes back up a month later. (Native-American participant) I think the way that race plays into it is because we all go to the Indian Health Service because weâre Indian. Thatâs where we start out with our healthcare. (Native-American participant) Iâve had experiences where I had no choice but to go to the Indian Health Service. You go in there, they rush through you. They misdiagnosed several things with me, and youâre just rushed through. Iâve dealt with accidents, and to get your accidents paid for and stuff, IHS takes forever to get those reports through. It took like 2 years, and thatâs a very long time. I donât know where they get that, but I donât think thatâs right. (Native-American participant) Attitude of Healthcare Providers Some participants were surprised and disappointed by the uncaring attitude exhibited by some of their healthcare providers or administrative
401 D: RACIAL DISPARITIES IN HEALTHCARE staff. In some cases, they felt staff were unwilling to help them, and infor- mation about their health was delayed or not provided to them. In other situations, doctors seemed more interested in insurance payment issues and less concerned with providing appropriate care for their patients. The doctor comes in and says, âWhy is he on oxygen?â I was recovering from surgery. Heâs looking at the chart and he says, âThe insurance doesnât cover it. Take it off.â Just like that. Iâm right there, and Iâm thinking âWow, thatâs pretty harsh if it comes from a doctor.â That was unfair I thought. (Hispanic participant) First of all, they didnât send me back the results for 5-6 months. I canât get an answer on the phone when I call. I have to call like 10 times and they put me on hold and say theyâll transfer me. They never transfer me. They hang up on me. (Hispanic participant) A few participants did not think their physicians took the time neces- sary to listen to them or examine them properly. They felt that their over- all health needs were being ignored. [The doctor] just walks in and has other patients to see, [she asks] âWhatâs wrong with you now?â and thatâs it. Sometimes I will go into other things that I have felt and itâs like, âOh, just take vitamins.â What if thereâs something else wrong? Theyâre not trying to find out whatâs wrong. Maybe I have cancer or something. (Hispanic participant) They just come in, look at the chart, say, âOK, are you taking your medications? See you in 3 months.â . . . if they find the chart. Sometimes they canât even find mine. (Hispanic participant) Other Stories About Misdiagnosis or Improper Treatment Some participants spoke of going to the hospital or doctor and receiv- ing misinformation or improper service from healthcare providers. In some cases, participants said their healthcare providers misdiagnosed their condition or were too passive in their treatment approach. A few participants questioned whether some providers they went to were quali- fied to make an accurate diagnosis of their health problem. Again, the concerns expressed in these specific instances were linked to race and ethnicity by implication only. At the hospital, they sent me over to a doctor, who was not an [eye] specialist. He diagnosed me with cataracts and said I needed surgery the next day. Thanks to a miracle from God, I did not end up blind. [Afterwards] eight days went by that I was blind in that eye. . . . Jose took me to another doctor. The [second] doctor told us I needed surgery the next day. Itâs a miracle from God that I can see. The other doctor left me with silicone. They put the entire amount that comes in the
402 UNEQUAL TREATMENT packet when they should have only put half. Why did the man who wasnât an eye specialist tell me I had cataracts, when what I had was a detached retina? (His- panic participant) My daughter was young and I took her to the hospital. She had stomach painsâ¦ I went to this private doctor and hospital and they sent us home with some medicines. . . . The next day I sent her to school. The school called me up and said, âYou [have] got to come pick up this child because she canât even walk.â So I said, âOK, Iâm going to County General because they will make sure this childâs taken care of.â Iâm not going back playing with these people [at the private office]. I took her to County General. They had her in there for 5 hours checking everything. I found out that she had walking pneumonia. (African- American participant) In my country, if they find you have a fibroma they remove it. They donât wait for it to grow. Maybe if they had taken them out this wouldnât have happened to me. (Hispanic participant) INSTITUTIONAL DISCRIMINATION IN HEALTHCARE In discussions with African-American and Hispanic physicians and nurses, they spoke not only about the discrimination their patients experi- ence at the provider-patient level, but also cited examples of how health- care institutions perpetuate discrimination in their policies and methods of practice. Providers felt institutions mandate policies that have a sig- nificant negative impact on the provision or access to services for racial and ethnic minority patients. Itâs very difficult to recruit Hispanics [for clinical trials] who cannot under- stand the consent form. I felt there was some resistance [to spending extra time counseling Spanish-speakers]. [I was told] it was just not really necessary, that I can just give them a synopsis of what is in that consent form. I said, âWait a minute. This is a very important piece of paper. Why should it be different? You donât give a synopsis to English-speakers.â So you can see sometimes the double standard there. (Hispanic nurse) They would not take certain doctors from certain ZIP codes, but we found out what was going on and that subsequently has changed a few years ago. Because they didnât want [minority] patients, they just excluded people from certain ZIP codes, from certain sections of the city. (African-American physician) Providers also cited examples of discrimination that they have had to contend with personally during their medical training or professional career. There are those that donât get promoted because of their race or whatever. The reason [may be because] theyâre not well liked by administration or it may be just that they donât want that person in that setting because of their raceâthat
403 D: RACIAL DISPARITIES IN HEALTHCARE is out there. Racism is alive and well, and those of us who think that itâs not are living in some kind of dream world. (African-American nurse) The local medical society . . . itâs got the good old boy attitude. Itâs the same old doctors that have been running it, and theyâre still running it. The new guys kind of have trouble getting in. (Hispanic physician) I heard an Anglo doctor complaining that his daughter is having trouble getting into medical school. Then another doctor jumps in, another Anglo, âOh, donât worry about it. I know the admissions coordinator. . . Iâll get her in. Iâll give him a call and sheâll be in.â When does a Hispanic or black student have those advan- tages, the connections? I certainly didnât have any connections, and I still donât have any connections. I couldnât get my son into medical school if I tried. (His- panic physician) INCLUSION OF AND RESPECT FOR CULTURE IN HEALTHCARE EXPERIENCES While some participants did not feel it was essential that providers and patients be of the same race or ethnic background, many participants felt that a cultural match between healthcare providers and patients is helpful in communicating more easily. One African-American physician summed up responses saying, âBasically, youâre comfortable with what youâre familiar with. Thatâs the bottom line.â Participants felt that it is easier to develop a rapport or discuss treatment options with healthcare providers of their own race who already understand their language and cultural idiosyncrasies. I donât think necessarily you have to be an African American to provide good care to African Americans, but if youâre not you really need to be aware of the culture and some of the issues in that culture, and really look at how you feel about dealing with people from that culture. (African-American nurse) For me, my doctor is a thin doctor, but she knows that I like Mexican food so she knows itâs hard for me to lose weight. She understands the way my parents brought me up, the culture, the background, so she knows. In other words, we understand each other because weâre both Hispanic. (Hispanic participant) If someone, the doctor for example, is of the same ethnicity, Hispanic, he under- stands the idiosyncrasies more. For example, for women, in our country there are certain taboos. It is more difficult to talk about private things. So, a doctor of our same race will understand those things more. (Hispanic participant) I feel I could relate better to the African American [doctor]. He knows black folks better. If youâre talking about high blood pressure, diabetes, sometimes these are things that traditionally do not happen to white folks. To the extent with the ills that we suffer, I believe he would be better suited for me. (African-American participant)
404 UNEQUAL TREATMENT I think there are just certain aspects of the culture that one may know a little bit more about by just being part of the culture. For example, with Hispanic pa- tients, itâs more of a touchy feelyâespecially my relationship with older women. Thereâs always a lot of hugging or kissing, whereas with the menânone of thatâ thereâs only hand shaking. When it comes to my African-American women, there is some touchy feely stuff, but, again, there is more distance. I think just being aware of the cultural attitudes makes it slightly different. (Hispanic physician) In instances where healthcare providers or administrative staff are of a different race or ethnicity than the patients they are treating, partici- pants expressed a desire for more patience and respect from their provid- ers. They felt that doctors and nurses who are treating a high proportion of patients from a particular racial or ethnic group should be familiar with relevant customs that may impact patientsâ healthcare decisions. One thingâthe eldersâtheyâre stubborn. You got to have a lot of patience with them because they think theyâre all right and they donât want to go to a doctor. It takes a lot just to get them to go. Have patience and be courteous towards them and respect them. (Native-American participant) A lot of Native Americans are shy. I think that would be good for a doctor to make sure the patient understands the treatment theyâre going to provide or the cause of their illness and make sure they understand whatâs going on. (Native- American participant) Our culture is very different. The Americans have a different way of treating people. We are more affectionate, sweet. We have a lot of time to give, they are very quick. (Hispanic participant) I think if [doctors] have a basic knowledge of the culture and are sensitive of that, culture is just the traditional part of healing. There was one doctor at IHS. My brother injured his leg, went in, had an x-ray. . . . I remember at the end of the visit, and this was the only time I heard one of the doctors there say, âIf you want to go visit your medicine man, feel free to do that.â(Native-American participant) Yeah, I had to have surgery and also my mom. In both cases this is the same doctor, a specialist, and when he explained about my mom, for example, he even took me in the room. He showed her and me, he even on a piece of paper showed how the liver and all this, what they had to do and this and that, and explained in language that we understood and took the time. It took him maybe a little more than 20 minutes, and that counts for something in my book you know. (Hispanic participant) If theyâre going to practice in a Native-American setting, they should under- stand how traditional medicine can lead to healing the patient. (Native- American participant)
405 D: RACIAL DISPARITIES IN HEALTHCARE Understand what the past healthcare history has been to Native Americans. Maybe just having an understanding of how Native-American healthcare has been across the U.S., not just here in the Southwest, but everywhere. I think that would make [healthcare providers] effective because then they would know whatâs happened in the past and not repeat the same mistakes. (Native-American participant) CONCLUSION The stories and recollections of participants across the eight focus groups provide supporting evidence for the concern that racial and ethnic minorities are less likely to receive appropriate medical services, and that they experience a lower quality of healthcare than do nonminorities. While racial and ethnic discrimination is not always easy to recognize or recall, participants offered many concrete examples of discriminatory situ- ations they encountered. This research adds to the growing body of lit- erature examining racial and ethnic disparities in healthcare and provides evidence of both interpersonal and institutional discrimination. Perhaps, through continued research and awareness, healthcare delivery will be- come more respectful and culturally appropriate for racial and ethnic mi- nority patients in the future.