Download The NIH Diversity Mandate: Culture, Disparities, and Research Daniel Dohan, PhD

Daniel Dohan, PhD
The NIH Diversity Mandate:
Galen Joseph, PhD
Culture, Disparities, and Research UC San Francisco
Motivation: ‘higher’
stages
t
off disparities
di
iti work
k
Reducing
• Intervene
• Evaluate
• Translate and disseminate
• Change policy
Understand and reduce
disparities by analyzing culture
Culture and Minorityy Inclusion
in Cancer Clinical Trials
1. Community/patient trust in
medical research
2. Clinician/organizational
commitment to inclusion
Understanding
• Identifying determinants of health disparities at
the following levels
• Patient/Individual
• Provider
P id
• Clinical encounter
• Health care system
Detecting
• Define health disparities
• Define vulnerable populations
• Measure disparities in vulnerable populations
• Consider selection effects, confounding factors
Good M-JD, et al. “The Culture of Medicine” in Unequal
treatment, NAP, 2003; Kilbourne et al,. AJPH. 2006
Cli i culture
Clinic
lt
and
d commitment
it
t tto iinclusion
l i
• NIH Revitalization Act of 1993
Risk, Representation, Access/Opportunity
Epstein, 2007; Fisher, 2009
• How health care organizations reduce disparities
Jones,Trivedi and Ayanian, 2009
• Case studies: Leadership,
Leadership information,
information resources
Joseph and Dohan, 2009 & 2010
S. Epstein. Inclusion, U. Chicago; J. Fischer. Medical Research for Hire, Rutgers U.; Joseph and Dohan, Cancer, 2009, Cont Clin Trial, 2010;
Jones et al. SocSciMed 2009
C
Comparative
ti ethnography
th
h case study
t d approach
h
• 10 clinics in 3 healthcare settings in NoCal
• academic medical center (AMC)
• safety-net
f t
t hospital
h
it l (SNH)
• community private practice (CPP)
• Provider interactions with each other and patients
• Participant-observation
P ti i
t b
ti and
d in-depth
i d th iinterviews
t i
• Deductive and emergent coding and analysis
• PhD ethnographers: 3 sociologists, 1 anthropologist
Different potential to recruit diverse subjects
Safety-Net
S
f t N t Hospital
H
it l
(SNH)
Academic
A
d i M
Medical
di l
Center (AMC)
Race/Ethnicity of Patients at 3 Clinics
(source: internal reports; all names are pseudonyms)
Community
C
it Private
Pi t
Practice (CPP)
Minorityy inclusion in p
practice
Leadership
Private
Practice
Information
No business
Not a priority
case
Resources
Highly
professional
staff
Academic Low on list of Response to
Lack of
Center
priorities
mandate
enforcement
Safety
Net
Yes (MDs)
No (staff)
Resource
constraints
For care not
research
Minorityy inclusion in p
practice
Leadership
Information
No business
Private
Not a priority
case
Practice
Resources
Bi-cultural
staff
Academic Low on list Response to
Lack of
Center of priorities
mandate
enforcement
Safety
Net
Yes (MDs)
No (staff)
Resource For care not
constraints
research
Minorityy inclusion in p
practice
Leadership
Information
Resources
No business
Private
Not a priority
case
Practice
Bi-cultural
staff
Academic
Low on
Response to
Center
priority list
mandate
Few
Safety
Net
Yes (MDs)
No (staff)
Resource For care not
constraints
research
Minorityy inclusion in p
practice
Leadership
Information
Resources
No business
Private
Not a priority
case
Practice
Bi-cultural
staff
Academic
Low on
Response to
Center
priority list
mandate
Few
Safety
Net
Yes (MDs)
No (staff)
Antiquated
systems
For care not
research
“Good”
Good providers not doing the “right”
right thing
• No site had an effective minority recruiting program
• Federal law ineffective at triggering inclusion or outreach
Getting folks on board to reduce disparities
1. Oncologists are intrigued by genetic difference
- Leverage scientific curiosity to enhance mandate?
2. Communities recognize trials as potential opportunity
- Want access to care and are wary of scientific curiosity
3. Researcher strategies for enhancing the conversation
- Popular culture: www.cultureofmedicine.org
- Clinic cculture:
lt re Empower
Empo er patients