When the 2010 census data comes out, as many as 10 states could have a “minority majority,” meaning the population of minorities would outnumber Caucasians. (Currently there are four minority majority states — Texas, California, New Mexico, and Hawaii). By 2042, the U.S. Census Bureau predicts that minorities will make up more than 50 percent of the entire U.S. population.
While the country is rapidly becoming more diverse, there are disparities between the healthcare offered to minority groups and to Caucasians. Robert Meinzer, senior director, national CME, at the New Jersey Academy of Family Physicians, believes that continuing medical education can play a role in bringing minority healthcare up to the level of that of Caucasians. He also thinks that education that works in concert with the national healthcare agenda can set up the CME enterprise to become a stakeholder in the changing healthcare system.
NJAFP's CME Goes Nationwide
Because doctors are going to see more diversity in their patient populations, more doctors in more states will need to be aware of cultural and ethnic issues, says Meinzer. That's where CME comes in.
Meinzer began his search to address the minority healthcare gaps by going straight to government data, which he often plumbs when developing CME activities. The way he sees it, the best way to show politicians and regulators in Washington the value of CME is by addressing the gaps that federal healthcare officials have identified.
In recent years both the Institute of Medicine and the Agency for Healthcare Research and Quality, which is an arm of the U.S. Department of Health and Human Services Department, have published reports about healthcare disparities among different populations. In 2008, AHRQ's “National Healthcare Disparities Report” found that, in general, for a majority of African-Americans and Hispanics, care had neither improved nor gotten worse since the last report five years earlier.
Meinzer took a closer look and zeroed in on two specific areas where he found disparities in healthcare provided to minorities — treatment of depression (among African-Americans and Hispanics) and hypertension (among African-Americans).
Now the NJAFP is sponsoring two multi-state CME activities — one on depression among minorities and the other on hypertension among African-Americans — that seek to educate physicians on how to improve care for minority patients. Here's how it happened.
All CME Is Local
Once Meinzer had the CME topics, he had to target the activities to where they were most needed. While NJAFP is developing the content for these activities, they will be offered to multiple states through other state chapters of the American Academy of Family Physicians. NJAFP has been developing national CME programs for several years. Last year, for example, it developed a 15-state program addressing chronic obstructive pulmonary disease. Since many of the AAFP's state chapters don't have the resources or expertise to launch their own activities, they often welcome the opportunity to run sessions from other chapters at their annual meetings.
When Meinzer and his staff offer activities, they are targeted to meet specific healthcare needs in those states. “All CME is local,” says Meinzer, quoting Dave Davis, senior director, academic affairs, at the Association of American Medical Colleges, which is headquartered in Washington.
To determine the best locales for the sessions, he consulted the AHRQ Web site, which shows the incidence of a given disease for each of the 50 states. For the depression activity, they targeted states with the highest incidence of depression, the fewest psychiatrists, and a significant minority population. The depression intervention is expected to run in seven states — Colorado, Georgia, New Mexico, North Carolina, South Carolina, Wisconsin, and a seventh to be determined — over the next nine months.
For hypertension, they looked for states with the highest percentage of African-Americans and the highest rates of hypertension. Based on those criteria, some of the targeted states are Alabama, Arkansas, Delaware, Florida, Georgia, Louisiana, Maryland, Michigan, Mississippi, New Jersey, North Carolina, South Carolina, Tennessee, and Virginia. The decision to run an activity ultimately sits with the state chapter, so there is no guarantee that the activity will run in the targeted states. However, Meinzer expects that the hypertension activity, which will be introduced at the AAFP's 2009 Scientific Assembly in Boston this October, will run in as many as 10 states next year, although details have not yet been finalized.
“We've got to take it to places that need it the most, as opposed to the places that will give you the biggest audiences,” says Meinzer. That, he adds, is critically important to improving public health.
Simulating for Cultural Competency
It's also essential for the activities to address cultural competency, as opposed to medical skill or general knowledge. Doctors are familiar with the diseases, but are they taking into account cultural and ethnic differences in treating patients of different racial backgrounds? That is the question the activities are addressing.
About a dozen states, including New Jersey, have laws that require physicians to get a certain number of hours of CME on cultural competency in order to be relicensed. But NJAFP wanted to get more specific than that, so it will tailor cultural competency to a particular disease and show physicians how it applies to their practice.
“We are taking a patient-centered approach to CME where the physicians need to be culturally competent and look at their patients' unique experiences,” says Meinzer. To do that, they are employing patient simulations for the hypertension activity, which is funded by Boehringer Ingelheim, a pharmaceutical company based in Germany with U.S. headquarters in Ridgefield, Conn. Actors will be hired to play various types of black patients afflicted with the disease. One of the actors portrays an obese woman who is barely above the poverty level. The “cookbook” approach is to counsel her about the importance of diet and exercise, but that might not work for her, says Meinzer. She might work two jobs and not have time the time and energy to exercise or prepare healthy meals; or she might not have access to a gym or feel safe jogging in her neighborhood. And because she is overweight, she might have more problems than just hypertension.
Another actor will play a man who doesn't understand the health issues or won't comply with the treatments, for whatever reasons. Maybe the physician doesn't adequately explain the problems and risks. Some people hear hypertension and think they just need to relax because they are tense, says Meinzer — that won't work. Or, perhaps the patient uses folk remedies or alternative methods.
The simulations are designed to allow the doctor to get to know the individual circumstances of the patient and treat the whole patient — not just one problem. The scenes are videotaped in advance with built-in stops where live presenters ask the audience for input on what to do next via audience-response technology.
In addition, NJAFP developed an online toolbox for physicians to give to their patients. “Part of the problem is the physician has a limited amount of time with patients,” says Meinzer. This toolkit will give patients 24-hour access to information and education about their disease in an effort to increase health literacy. “The person most responsible for their own care is the patient. If the patient doesn't really understand their disease and what their responsibility is, then the likelihood of success is diminished,” says Meinzer. After the CME activities are complete, the video presentations will be posted online.
Finding the Funds
NJAFP didn't get as much funding as it wanted for the depression intervention, so it had to be scaled back from 10 states to about seven. Plus, instead of patient simulations, this activity will be delivered via a case study-based lecture, which is less expensive.
Getting funding for CME programs focused on health disparities of minority populations has not always been easy, but that is starting to change. While there has been a lot of talk about the need for education in this area, only recently has that discussion moved to action, says Matt Lewis, director of strategic development at Outcomes Inc., Birmingham, Ala., which is conducting the outcomes measurement for NJAFP's programs. “A lot of the rhetoric from the last couple of years is starting to actually be supported with thoughtfully planned activities, and it really matters because we know that cultural competency can reduce racial and ethnic health disparities,” says Lewis.
Using clinical vignettes, Out-comes Inc., will assess participating physicians' changes in performance and practice at least 30 days after taking the CME activity, as compared to a control group of demographically similar physicians who were not exposed to the education. “We want to make sure learners can provide the most effective care to all patients,” says Lewis, as well as demonstrate more positive attitudes related to cultural sensitivity and competence. The results will then be shared with the participating physicians.
“We partner with providers that are developing innovative activities that have the potential to not just transfer knowledge but really improve clinical performance, and NJAFP is an exemplar of that approach,” he says. “They recognize that improving attitudes can translate into better patient care.”
A Seat at the Table
“It is imperative for healthcare systems to understand that reducing health disparities and addressing health literacy are important strategies for improving healthcare-system quality,” wrote the authors of a 2009 report published by the IOM. Meinzer firmly believes that targeted CME can make a difference in closing the disparity gaps while filling a critical healthcare need as determined by the federal government. It's important to show the public that CME is part of the solution, not the problem, says Meinzer.
The challenge for the CME community is documenting and promoting its impact on healthcare. Unfortunately, he says, that's been a weak link and needs to change if CME is to be seen as a vital stakeholder in the nation's healthcare system.
Projects like this, he says, can help set up CME for a seat at the table.