Foreign-born doctors reignite Italy’s citizenship debate

Of note:

When the Italian government labeled Sicily a high-risk region last month over fears that the island’s limited resources would hamper its response to the second wave of the pandemic, Rumon Siddique got ready to help.

The region, one of Italy’s poorest, is struggling with a lack of doctors and nurses — and Siddique, a 29-year-old junior doctor born in Bangladesh and trained in Italy, has the necessary skills to step in. But because he doesn’t hold Italian citizenship, he’s unable to apply for open positions.

He was puzzled to learn that Sicilian authorities had instead asked the government of Cuba to deploy 60 health care workers.

“The paradox is that we already have doctors here, without having to ask Cuba,” said Siddique, who works at the Paolo Giaccone University Hospital in the Sicilian capital Palermo. “There are many foreign doctors already living in Italy, willing to fill that void. But because they don’t have Italian citizenship, they are often forgotten.”

At the height of the first wave of the pandemic, medical personnel from abroad, including teams from Cuba, Romania and Norway, were deployed in the hardest-hit northern regions of Italy. During the second wave, several regions have asked NGO workers, junior doctors — who have yet to complete their training — and retirees to prepare themselves to help out if needed.

In March, the government issued the so-called “Cure Italy” decree, which allowed hospitals and regional authorities to hire non-EU staff with legal permission to live and work in the country.

But many institutions have continued their decades-long practice of requiring either Italian or EU citizenship in their job openings, excluding foreigners trained and educated in Italy, even as the country’s intensive care units began filling up again this fall.

That has triggered a discussion on labor rights, with several immigrants’ organizations calling on the government to ensure the law is followed.

But beyond that, with first- and second-generation immigrants finding citizenship a core obstacle to employment, foreign doctors have reignited a longstanding debate on who gets to have an Italian passport — and the rights it bestows.

Paths to citizenship

In Italy, citizenship is acquired mainly through blood ties, as is the case throughout the European Union.

Most EU citizens attain that status through jus sanguinis, a principle that allows parents to pass on their citizenship to their children. Some EU countries allow for a limited version of jus soli, which in its unrestricted form — used in the United States, for example — bestows citizenship on anyone born in the country. Naturalization is usually possible via other routes, albeit subject to conditions.

But acquiring Italian citizenship without ancestral ties or marriage is a particularly lengthy process. The country is one of only five EU countries requiring non-EU citizens to document 10 years of residency to qualify for naturalization. (The EU average is seven years, according to 2018 data.)

Under the current citizenship law, which dates back to 1992, children born to immigrants can apply for citizenship — but only if they apply between ages 18 and 19, and if they can prove uninterrupted legal residency in Italy for their whole lives up to that point.

For children not born in Italy, like Siddique — who arrived in 1999 — naturalization often depends on the status of their parents. As he was already 18 by the time his parents could prove 10 years of uninterrupted legal residency in the country, he wasn’t eligible to apply as their dependent.

He could apply individually as an adult, a route open to all immigrants after 10 years, but it’s a long and difficult path: The waiting time can be as long as four years. Applicants also need to prove regular employment or income — a vicious circle for medical staff that face difficulties obtaining steady employment due to their nationality. (A trainee scholarship, like Siddique has, is not enough.)

There have been efforts to change that. First- and second-generation immigrants have started pushing for citizenship rights, and in 2016 Matteo Renzi’s centrist government made an attempt to reform the 1992 law.

His coalition’s proposal — dubbed ius culturae (Latin for “cultural right”) to contrast with jus sanguinis, “blood right” — aimed to grant automatic citizenship to all children who are either born in Italy or arrived before the age of 12 and who completed at least five years of Italian schooling.

But the vote on the proposal was postponed in summer 2017 amid fierce opposition from both within the coalition and the far right, as the national mood on immigration shifted, with tens of thousands of migrants and refugees arriving in Italy that year.

Then, in early 2018, a populist coalition comprised of the anti-establishment 5Star Movement and the far-right League took power and enacted what critics have labeled as xenophobic laws. The new government also made it harder to apply for Italian citizenship by introducing longer approval times and higher application costs.

These days, the 5Stars — who have been since 2019 in a coalition with the center-left Democratic Party — are striking a different tone. The two parties have been involved in discussions to formally reopen the debate on citizenship reform by mid-2021.

“We recognize it is a lost opportunity when qualified doctors, or valid workers of any field, don’t have the same labor rights as Italians,” says Simona Suriano, a spokesperson for the party.

“We don’t have any prejudice regarding the ius culturae, times are now ripe to extend citizenship rights to those who mainly grew up and studied in Italy,” she added. “But I don’t think either that we would agree to go beyond that and accept, for instance, a ius soli model like that of the U.S.”

‘A loss for Italy’

Italy’s aging population means that the country’s medical staff shortage — more than 10,000, according to 2018 data — is only going to become more acute.

Foreign-born medics could boost their numbers, however. About 77,500 foreign-born health care professionals are qualified to work in Italy, according to data collected by the Association of Foreign Doctors in Italy (AMSI).

They include 22,000 doctors and 38,000 nurses, with the majority working in the private sector as only 10 percent of them managed to access the struggling public health care sector, said Foad Aodi, AMSI’s president.

“There have been around 13,500 [openings] for health care professionals across Italy since the pandemic, but we keep being excluded. We don’t want to take the jobs from Italians, we only ask to integrate in the country we’ve chosen to call home,” Aodi said.

After ASGI, the lawyers’ organization, sent a letter to the Italian interior ministry complaining that many regions were still not complying with the “Cure Italy” decree, some hospitals and regions changed their stance and opened jobs to non-EU applicants.

Yet Alberto Guariso, an immigration lawyer with ASGI, said the organization has found at least seven of Italy’s 20 regions are still not implementing the decree. Even in regions that changed their stance after ASGI’s intervention, the options often remain limited for foreign medics.

For example, Tuscany opened jobs for non-EU nationals recently. “But in terms of rights, it is insignificant,” says Hamilton Dollaku, an Albanian nurse and trade unionist based in Florence, who currently works in the private sector. “It offers a one-year contract with no possibility of renewal. It works through direct calls only” — meaning employment is dependent on the hospitals’ needs — “and many foreigners will rightly refuse.”

Byzantine hiring practices and a lack of suitable positions also present challenges to Italian medicine graduates. But the discrimination is a major factor in pushing foreign-born staff and students to seek their fortunes elsewhere in droves, said Siddique.

“It only damages the image of Italy’s health care system and disrupts our lives, forcing many of us to leave for elsewhere in Europe,” he said.

Plus, he pointed out, it’s a waste of money if the very institutions that spend thousands of euros on training him and others without EU citizenship don’t benefit from their investment.

“We are talking about €150,000 for every [medical student] for the whole duration of studies,” says Siddique. “Excluding us is a loss not just for us, but also for Italy.”

Source: Foreign-born doctors reignite Italy’s citizenship debate

For Doctors of Color, Microaggressions Are All Too Familiar

Of note:

When Dr. Onyeka Otugo was doing her training in emergency medicine, in Cleveland and Chicago, she was often mistaken for a janitor or food services worker even after introducing herself as a doctor. She realized early on that her white male counterparts were not experiencing similar mix-ups.

“People ask me several times if the doctor is coming in, which can be frustrating,” said Dr. Otugo, who is now an emergency medicine attending physician and health policy fellow at Brigham and Women’s Hospital in Boston. “They ask you if you’re coming in to take the trash out — stuff they wouldn’t ask a physician who was a white male.”

After years of training in predominantly white emergency departments, Dr. Otugo has experienced many such microaggressions. The term, coined in the 1970s by Dr. Chester Pierce, a psychiatrist, refers to “subtle, stunning, often automatic, and nonverbal exchanges which are ‘put downs’” of Black people and members of other minority groups; “micro” refers to their routine frequency, not the scale of their impact. Dr. Otugo said the encounters sometimes made her wonder whether she was a qualified and competent medical practitioner, because others did not see her that way.

Other Black women doctors, across specialties, said that such experiences were all too common. Dr. Kimberly Manning, an internal medicine doctor at Grady Memorial Hospital in Atlanta, recalled countless microaggressions in clinical settings. “People might not realize you’re offended, but it’s like death by a thousand paper cuts,” Dr. Manning said. “It can cause you to shrink.”

The field of medicine has long skewed white and male. Only 5 percent of the American physician work force is African-American, and roughly 2 percent are Black women. Emergency medicine is even more predominantly white, with just 3 percent of physicians identifying as Black. The pipeline is also part of the problem; at American medical schools, just 7 percent of the student populationis now Black.

But for Black female physicians, making it into the field is only the first of many challenges. More than a dozen Black women interviewed said that they frequently heard comments from colleagues and patients questioning their credibility and undermining their authority while on the job. These experiences damaged their sense of confidence and sometimes hampered teamwork, they said, creating tensions that cost precious time during emergency procedures.

Some physicians said they found the microaggressions particularly frustrating knowing that, as Black doctors, they brought an invaluable perspective to the care they offer. A 2018 study showed that Black patients had improved outcomes when seen by Black doctors, and were more likely to agree to preventive care measures like diabetes screenings and cholesterol tests.

In May, four female physicians of color published a paper in Annals of Emergency Medicine on microaggressions. The authors, Dr. Melanie Molina, Dr. Adaira Landry, Dr. Anita Chary and Dr. Sherri-Ann Burnett-Bowie, said they hoped that, by shining a spotlight on the problem, they might reduce the sense of isolation that Black female physicians experience and compel their white colleagues to take specific steps toward eliminating conscious and unconscious bias.

Discussions about lack of diversity in medicine resurfaced in early August, when the Journal of the American Heart Association retracted a paper that argued against affirmative action initiatives in the field and said that Black and Hispanic trainees were less qualified than their white and Asian counterparts.

Dr. Phindile Chowa, 33, an assistant professor of emergency medicine at Emory University, was in her second year of an emergency-medicine residency when an attending in her department mistook her for an electrocardiogram technician, even though she had previously worked with him on rotations. She approached him to give a report on her patients, and he wordlessly put out his hand, expecting her to hand over an electrocardiogram scan.

“He never apologized,” Dr. Chowa said. “He did not think he did a single thing wrong that day. I was the only Black resident in my class. How could he not know who I am?”

The derogatory encounters continued from there. Colleagues have referred to her as “sweetie” or “honey.” She recalled one patient who asked repeatedly who she was over the course of a hospital visit, while quickly learning the name of her white male attending physician. When she was first admitted to her residency, at Harvard, a medical school classmate suggested that she had had an “edge” in the selection process because of her race.

Such comments can create an environment of fear for Black women. Dr. Otugo recalled overhearing her Black female colleagues in Chicago discuss how they were going to style their hair for their clerkships. Many of them worried that if they wore their hair naturally, instead of straightening it or even changing it to lighter colors, their grades and performance evaluations from white physicians might suffer.

Dr. Sheryl Heron, a Black professor of emergency medicine at Emory University School of Medicine, who has worked in the field for more than two decades, said microaggressions can exact a long-lasting toll. “After the twelve-thousandth time, it starts to impede your ability to be successful,” she said. “You start to go into scenarios about your self-worth. It’s a head trip.”

This comes on top of the stresses that are already pervasive in emergency departments. A 2018 survey of more than 1,500 early-career doctors in emergency medicine found that 76 percent were experiencing symptoms of burnout.

But Black women doctors said they have seen how Black patients rely on their presence to get the best care. Monique Smith, a physician in Oakland, Calif., was working in the emergency room one night when a young Black man came in with injuries from a car accident. She was confused when some of her colleagues called him a “troublemaker,” so she visited the patient’s bed and asked him about his experience being admitted. He told her that he had begun to lash out when he felt he was being stereotyped by staff members because of his skin color and the neighborhood he came from.

“I was able to go into the room and say, ‘Hey dude, Black person to Black person, what’s up?’” Dr. Smith said. “Then I advocated for him and made sure he got streamlined care.”

The conversation made Dr. Smith more attuned to the degrading comments that Black patients experience at hospitals, and she now tries to intervene and identify her colleagues’ biases. She believes, for example, that physicians are sometimes quicker to order drug testing for Black patients, even if their symptoms are most likely unrelated to substance abuse.

But many Black physicians find it challenging to be advocates for themselves and their patients, particularly within the rigid hierarchies of the medical system. “You’re faced with situations where you’re going to be perceived as the angry Black woman even though you’re just being your own advocate,” said Dr. Katrina Gipson, an emergency medicine physician. “You’re constantly walking the line of how to be a consummate professional.”

Dr. Landry, an author of the recent paper and an emergency medicine physician at Brigham and Women’s Hospital, said that hospital and residency directors who are looking to address the deep-rooted problem should begin with hearing and validating the personal experiences of Black doctors. Continuing to diversify emergency medicine departments is also critical, she added, so that Black physicians are not working in isolation to implement cultural changes and arrange mentorship from more senior Black colleagues.

“I’m the only African-American female physician faculty member in my department, and that creates this feeling of not having a support system to speak up when something happens to you,” Dr. Landry said. “Having this paper is a validating tool for people to say, ‘See, I’m not the only one this is happening to.’”

Dr. Molina, an emergency medicine resident at Brigham and Women’s Hospital and one of the paper’s authors, said that spotlighting diversity in medicine was particularly important amid a pandemic that disproportionately impacts Black patients. “The Covid pandemic has served to emphasize health disparities and how they impact Black populations,” she said. “As emergency physicians, we have to present a united front recognizing racism is a public health issue.”


In a push for diversity, medical schools overhaul how they select Canada’s future doctors

This is what it takes to move the needle to address socioeconomic diversity:

Have you ever used a food bank? Were you raised by a single parent? What was your family income in the second decade of your life? And how should the answers to those questions influence who gets into medical school?

Medical schools used to say their job was to find the best and the brightest. But the selection method, based on grade-point averages, the Medical College Admission Test (MCAT) and a face-to-face interview, has resulted in classes that fall short of some universities’ goals for racial and socio-economic diversity.

Now some schools are asking if the process is truly fair, and if not, how it ought to change. Across Canada, medical schools are taking steps to shape incoming classes by offering advantages to applicants from certain demographic groups.

In a given year, only 10 per cent to 20 per cent of applicants are admitted. Many schools could probably choose a similarly capable cohort from among the applicants they reject. But finding the right demographic mix is increasingly an important concern.

Medical schools in Canada exercise overwhelming influence over admission to the profession. About 75 per cent of physicians in this country are Canadian graduates, so the process by which admissions decisions are made is crucial not only to the applicants but to society as a whole. They shape the future of health care.

At the University of Manitoba, the admissions committee studied years of data and found a pretty clear pattern: Wealthy white students from big cities were more likely to be interviewed and more likely to get in, partly because of built-in advantages. As undergrads they don’t have to work part-time to pay for school, they’re able to pay for MCAT prep courses and, in interviews, they can cite an impressive range of travel and volunteer experiences.

The result is that a public university’s system seems to ensure opportunity for the already fortunate.

Bruce Martin, the U of M’s dean of admissions, set out to tinker with the crucial first stage of the admissions process so that more applicants from different backgrounds got through. He knew he could do so by systematically boosting scores based on certain attributes or experiences. But which attributes to target?

Sample questions appearing on University of Manitoba medical school applications: family history
  1. Were you raised by a single parent due to divorce, death of a parent, or a teen parent?
  2. Were you ever a child or youth in care?
  3. Are you a parent taking care of one or more children on your own?
  4. Did your parents or guardians graduate from college or university?
  5. Were you or your family admitted to Canada with refugee status?

Source: Dr. Bruce Martin, University of Manitoba Admissions

He convened a panel of people from outside the university with experience in race relations and alleviating poverty and asked them to consider how the medical school could diversify its student body.

They decided to add a section to the application that would elicit the information they sought. They came up with more than 30 questions, many of them deeply personal and revealing, including factors such as visible minority status, sexual orientation, involvement with the child-welfare system and living with family members who suffer from addiction.

The committee then ranked each question based on the perceived level of disadvantage suffered by the applicant. Should having a family member with a disability be a greater consideration than whether your parents graduated from university, or having a child-welfare file?

U of M sample questions: economic information
  1. Did you or your family ever have to use a food bank?
  2. During the second decade of your life, was the annual gross income in the household in which you lived between $40,000-$75,000?
  3. During the second decade of your life, did you have to work to contribute to family income?
  4. Will your parent(s) be paying for the tuition fees if you get accepted to our medical school?
  5. Do you currently receive student aid?

Source: Dr. Bruce Martin, University of Manitoba Admissions

The numerical values assigned to each answer are combined to create an arithmetic modifier meant to reflect the degree to which the applicant’s background would put them at a disadvantage in the application, Dr. Martin said. (It turns out that a history of substance abuse moved the needle more than being a visible minority, while needing student aid rated well below using a food bank.)

The goal was relatively modest: a 5-per-cent increase in the number of medical students with diversity attributes.

“We didn’t want to have a quota system. But we want to increase the number of diverse individuals on an incremental basis,” Dr. Martin said.

U of M sample questions: other sociocultural determinants
  1. Do you consider yourself to be a member of a Visible Minority?
  2. Do you identify as First Nations, Metis, Inuit or other North American Indigenous ancestry?
  3. Is your primary language other than English or French?
  4. Do you have a participation or activity limitation that has an impact on your day-to-day life?
  5. Were you raised or are you living in a household in which there was/is a person living with substance abuse?

Source: Dr. Bruce Martin, University of Manitoba Admissions

Other schools have set a similar goal but have taken a different approach. The University of Saskatchewan, for example, now reserves six of its 100 seats for applicants whose families earn less than $80,000 a year. At the University of Toronto, a special stream has been created for black applicants. At Dalhousie University, in Halifax, the medical school says it recognizes that affirmative action is required to increase admissions of African-Nova Scotians and Indigenous people. And at the University of Calgary, applicants from underrepresented groups are asked to “highlight their background and experiences.”

Many schools have the same goals as the University of Manitoba, Dr. Martin said, but are not as transparent about how they aim to achieve a diverse incoming class.

At Newfoundland’s Memorial University, for example, acting dean of admissions Paul Dancey said the school takes a “holistic approach,” which is common at Canadian universities. He said it involves looking in great detail at all aspects of the candidate, not just their academic record, and paying particular attention to barriers that may have affected their grades or extracurricular activities. (Dr. Martin said Manitoba chose not to take the holistic approach because it relies on the judgment of individual evaluators and can be susceptible to bias.)

The drive to consider racial and socio-economic equality in admissions is also leading major changes in the U.S. college system. The College Board now includes what’s being called an adversity score in SAT test results based on demographic factors such as crime and poverty levels in a student’s neighbourhood and school district. The board said it could no longer ignore the extent to which differences in wealth and race were reflected in test scores, which are very influential in the admissions process. The method for calculating the score has not been released, but it’s based on public information, not answers submitted by students.

For students, the application process remains slightly mysterious, to prevent someone from gaming the system.

Fatemeh Bakhtiari, a second-year medical student at the U of M, was born in Afghanistan and came to Canada as a child. Growing up in Winnipeg, her family was not wealthy. Her mother worked as a grocery clerk and her father was a truck driver. Ms. Bakhtiari excelled in school and at university set her sights on medicine. But she didn’t have many of the advantages that other applicants could rely on, such as a family member who is a doctor. She also had to work part-time in restaurants and retail while studying.

“I had no idea where to start,” she said. “If it wasn’t for Google, I don’t where I would’ve been.”

She remembers answering questions on her application about her family income and whether she identifies as a visible minority or LGBTQ, but she didn’t understand why those questions were being asked. She said she has no idea whether her answers had any role in her success. She said her GPA was strong, she wrote her MCAT three times to improve her score and felt very confident about her interview performance.

“I don’t know the scoring system or how it works,” Ms. Bakhtiari said. “I don’t know if it was my MCAT, my GPA or my interview that got me through. They don’t tell you.”

At the white coat ceremony where new medical students are welcomed and take the Hippocratic Oath, the U of M’s dean of the faculty of medicine, Brian Postl, said the school was proud of the diversity of Ms. Bakhtiari’s class. More than half are women, 10 per cent are Indigenous, 20 per cent are from rural areas and 50 per cent are from families with incomes of less than $75,000. Ms. Bakhtiari said she believes the diversity of her class is valuable for two reasons: Diverse groups have been shown to be more innovative, and physicians should reflect the population they serve.

Manitoba’s diversity initiatives started more than 30 years ago with attempts to get more Indigenous people into medicine. About a decade ago, the medical school also began to see rural candidates as particularly desirable. Canada was facing a staffing crisis in rural and remote hospitals and medical offices, and researchers began trying to identify what made a medical student more likely to stay and practise in a rural area. A key factor was having grown up in a small town or farming community. That’s when Manitoba began using an arithmetic modifier to place students with a rural background at an advantage.

The university was following a path laid by the Northern Ontario School of Medicine (NOSM), which opened in 2005 with a mandate to turn out doctors for the region – and made no bones about giving priority to students with a rural or remote upbringing.

Roger Strasser, until recently the dean and chief executive officer of the NOSM, said his program gets about 2,000 applications a year. It whittles those down to 320, who are invited for interviews based on a three-pronged score comprising a grade-point average, a personal statement and what’s called a context score, derived from answers about a person’s background and upbringing. The algorithm for deriving the context score is confidential, Dr. Strasser said, but he was transparent about its key implication.

“Applicants who’ve grown up in Northern Ontario or other remote, rural, Indigenous or francophone settings, they get the highest score. The people who are not Indigenous or francophone or come from big cities like Toronto get the lowest score,” Dr. Strasser said.

Ninety-two per cent of NOSM students have grown up in Northern Ontario, and the other 8 per cent are from rural and remote parts of the rest of Canada. About 2 per cent of applicants are Indigenous, but in the past few years the selection system has been tweaked to increase the number of successful Indigenous applicants, including giving them training to succeed in the interview process. The class went from about 7-per-cent Indigenous over the school’s first decade to about 12 per cent for the past three years, Dr. Strasser said.

He said one of his biggest challenges as dean is the criticism from families in Toronto, who believe their children are excluded from his school.

“My response is, if you look at the numbers, this is just the reverse of the way it is for people from Northern Ontario applying to med school in Toronto or the other big cities. So in a sense, you could say it’s true, there is, let’s call it a bias, but what we’re doing is just countering the bias that’s built into the admissions process of other medical schools,” Dr. Strasser said.

It has become conventional wisdom, supported by research, to say medicine is done better when doctors come from diverse backgrounds, Dr. Martin said. A cohort of physicians with a broad range of life experiences are better able to understand the needs of the population.

The applicants selected under Manitoba’s diversity initiative all meet the school’s admissions criteria, but they might not otherwise have reached the top of the admissions heap. The flip side, however, is that some people who’ve worked hard and achieved a great deal won’t get in, Dr. Martin said. That’s difficult for some to reconcile.

Even his own colleagues, worried about their children’s prospects, have cornered him on this matter. The conversations were uncomfortable, he said.

“We in medicine have generally been white, socio-economically advantaged and male. And that’s not who we serve,” he said.

“It’s my mission to pick people who are suited to the profession and can meet the needs of the population.”

Source: In a push for diversity, medical schools overhaul how they select Canada’s future doctors

Doctors and Racial Bias: Still a Long Way to Go

Of note:

The racist photo in the medical school yearbook page of Gov. Ralph Northam of Virginia has probably caused many physicians to re-examine their past.

We hope we are better today, but the research is not as encouraging as you might think: There is still a long way to go in how the medical field treats minority patients, especially African-Americans.

A systematic review published in Academic Emergency Medicinegathered all the research on physicians that measured implicit bias with the Implicit Association Test and included some assessment of clinical decision making. Most of the nine studies used vignettes to test what physicians would do in certain situations.

The majority of studies found an implicit preference for white patients, especially among white physicians. Two found a relationship between this bias and clinical decision making. One found that this bias was associated with a greater chance that whites would be treated for myocardial infarction than African-Americans.

This study was published in 2017.

The Implicit Association Test has its flaws. Although its authors maintain that it measures external influences, it’s not clear how well it predicts individual behavior. Another, bigger systematic review of implicit bias in health care professionals was published in BMC Ethics, also in 2017. The researchers gathered 42 studies, only 15 of which used the Implicit Association Test, and concluded that physicians are just like everyone else. Their biases are consistent with those of the general population.

The researchers also cautioned that these biases are likely to affect diagnosis and care.

A study published three years earlier in the Journal of the American Board of Family Medicine surveyed 543 internal medicine and family physicians who had been presented with vignettes of patients with severe osteoarthritis. The survey asked the doctors about the medical cooperativeness of the patients, and whether they would recommend a total knee replacement.

Even though the descriptions of the cases were identical except for the race of the patients (African-Americans and whites), participants reported that they believed the white patients were being more medically cooperative than the African-American ones. These beliefs did not translate into different treatment recommendations in this study, but they were clearly there.

In 2003, the Institute of Medicine released a landmark report on disparities in health care. The evidence for their existence was enormous. The research available at that time showed that even after controlling for socioeconomic factors, disparities remained.

There’s significant literature documenting that African-American patients are treated differently than white patients when it comes to cardiovascular procedures. There were differences in whether they received optimal care with respect to a cancer diagnosis and treatment. African-Americans were less likely to receive appropriate care when they were infected with H.I.V. They were also more likely to die from these illnesses even after adjusting for age, sex, insurance, education and the severity of the disease.

Disparities existed for patients with diabetes, kidney disease, mental health problems, and for those who were pregnant or were children.

The report cited some systems-level factors that contributed to this problem. Good care may be unavailable in some poor neighborhoods, and easily obtained in others. Differences in insurance access and coverage can also vary by race.

But the report’s authors spent much more time on issues at the level of care, in which some physicians treated patients differently based on their race.

Physicians sometimes had a harder time making accurate diagnoses because they seemed to be worse at reading the signals from minority patients, perhaps because of cultural or language barriers. Then there were beliefs that physicians already held about the behavior of minorities. You could call these stereotypes, like believing that minority patients wouldn’t comply with recommended changes.

Of course, there’s the issue of mistrust on the patient side. African-American patients have good reason to mistrust the health care system; the infamous Tuskegee Study is just one example.

In its report, the Institute of Medicine recommended strengthening health plans so that minorities were not disproportionately denied access. It urged that more underrepresented minorities be trained as health care professionals, and that more resources be directed toward enforcing civil rights laws.

In practice, it endorsed more evidence-based care across the board. It noted the importance of interpreters, community health workers, patient education programs and cross-cultural education for those who care for patients.

All of this has met with limited success.

In 2017, the Agency for Healthcare Research and Quality issued its 15th yearly report on health care quality and disparities, as called for by the medical institute in 2002. It found that while some disparities had gotten better, many remained. The most recent data available showed that 40 percent of the quality measures were still worse for blacks than whites. Other groups fared worse as well. Measures were worse for 20 percent of Asian-Americans, 30 percent of Native Americans, and one third of Pacific Islanders and Hispanics.

Of the 21 access measures tracked from 2000 to 2016, nine were improving. Nine were unchanged. Three were worsening.

It would be easy to look at a racist photo from the 1980s and conclude that it was a different time and that things have changed. Many things have not. We know that racism, explicit and implicit, was pervasive in medical care back then. Many studies show that it’s still pervasive today. The recommendations from the medical institute in 2003 still hold. Any fair assessment of the evidence suggests much work remains to be done.

Dozens of Doctors Who Screen Immigrants Have Record of ‘Egregious Infractions,’ Report Says

Not unique to the US I suspect, given the power imbalance and potential for abuse. In percentage terms small (0.2 percent) but still unacceptable:

The doctors tapped by the federal government to medically screen immigrants seeking green cards include dozens with a history of “egregious infractions,” according to a report from a federal watchdog agency.

The report looked at more than 5,500 doctors across the country used by United States Citizenship and Immigration Services as of June 2017 to examine those seeking green cards. More than 130 had some background of wrongdoing, including one who sexually exploited female patients and another who tried to have a dissatisfied patient killed, the report said.

The report, made public Tuesday by the Department of Homeland Security’s Office of Inspector General, said the failure to effectively screen the doctors put immigrants “at risk of abuse.”

“USCIS is not properly vetting the physicians it designates to conduct required medical examinations of these foreign nationals, and it has designated physicians with a history of patient abuse or a criminal record,” the report states. “This is occurring because USCIS does not have policies to ensure only suitable physicians are designated.”

Alma Rosa Nieto, an immigration lawyer and vice chairwoman of the American Immigration Lawyers Association’s media advocacy committee, called the report’s findings “very troubling and frightening,” particularly given that the people undergoing the examinations are vulnerable.

“These are people that are in great need,” she said. “They are desperate to get their green card.”

Doctors must apply to be part of the government’s pool of screeners. Once approved, they conduct the mandatory medical exams for immigrants who are looking to become permanent residents and get green cards. Immigrants can be turned down if they are found to have a disease that could be a public health threat, have a mental disorder that could threaten others or are drug addicts.

The report did not identify the doctors who engaged in misconduct, nor did it reveal whether they are still on the government’s approved list.

United States Citizenship and Immigration Services said it “agreed that stricter eligibility requirements for civil surgeon designation and a strengthened vetting process will improve the quality and integrity of the program.” The agency said it was working to strengthen its screening process with new regulations by 2019.

A spokeswoman for the Office of Inspector General declined to comment further on the report Wednesday.

From a total pool of 5,569 doctors, 132 had been convicted of crimes, been penalized by state medical boards or had faced some other form of punishment, the report found. They included doctors convicted of health care fraud, doctors who had defaulted on health education loans or scholarships and doctors “engaged in dishonest, gross, and repeated negligent conduct in patient care and treatment.” It did not give a specific breakdown.

In a sample of 135 physicians, 14 percent were missing required papers, including proof of medical degrees.

“To guard against risking the health and safety of these foreign nationals, USCIS should more thoroughly scrutinize physicians before allowing them to become civil surgeons,” the report advises.

The report also found fault with the medical tests themselves, saying they possibly exposed the public to health hazards. An analysis of 151 files of immigrants approved for green cards found errors in 44 forms, such as missing proof of vaccinations or required medical tests.

“As a result, USCIS cannot be certain the civil surgeons actually administered all required tests and vaccinations and may have granted lawful permanent residence status to medically inadmissible foreign nationals who could pose a health risk to the U.S. population,” the report said.

Ms. Nieto said that she was not surprised at the findings, and that her clients routinely had errors in their files. She said she advised clients to get independent medical tests done, if possible, even if it costs extra money and time.

“I see my clients coming back with reports that are either incomplete or inaccurate,” she said.

How underprivilege made me a better doctor: Zhou

Interesting and pertinent account by Stephanie Y. Zhou of another aspect of diversity: social class in medical school and among doctors:

My family was supported by a homeless shelter before we moved into subsidized housing — the attic near the hospital. Food came from the food bank or soup kitchens. Clothing was second hand from the church donation bins. My parents did not have a university education, but they found jobs as factory workers and on most days, we seemed to have enough to get by.

To me, these were all part of a mundane, normal life, but in the context of privilege, these aspects suddenly became salient as a mark of “underprivilege.” Placed at a school attended by mostly middle-class students, this underprivileged experience became part of my identity, and to be different was incredibly isolating.

This identity of subordinance provided the impetus for me to pursue higher education. To be told that fields such as medicine or law were not in the realm of my socioeconomic class, that they carried an enormous financial investment with uncertain admission, made me resent my underprivileged identity even more. I wanted to be able to give my family the privileges we didn’t have and to break away from a cycle of poverty.

I studied hard and worked two part-time jobs during university to fund my medical school applications, but throughout the whole process, it was clear that one had to come from privilege to easily apply and assimilate into the medical culture.

In fact, not only are a disproportionate number of students from families of higher socioeconomic class, they come prepared with the social and cultural capital to navigate the medical school environment. Upon acceptance, I became a part of this new culture. Not wanting to be different, I hid my identity to feel included.

It wasn’t until I left the classroom that these sentiments began to change. I remember the single mother, with limited time to take off work, miss her own appointments to attend her daughter’s appointments instead. I saw patients who did not take their medications because they were too expensive. Patients with a language barrier who incorrectly interpreted their treatment plan because they didn’t understand. I saw myself and the experiences of my family in the lives of these patients, and I realized that I did fit into medicine — I fit in with my patients.

Although I initially tried to distance myself from my identity, I now acknowledge that it is a part of me I shouldn’t erase. To come from this background grants a different, more subtle form of privilege beyond that of wealth and social networks. I call it an “empathic privilege” that allows one to be more cognizant of the social determinants of health that patients often leave unspoken when seeking medical care.

In another sense, I also feel comfort in the presence of patients with lower socioeconomic status, whereas others might feel unease and frustration, because working with these patients helps close the gap between my identities.

I share my story because those with the underprivileged identity do exist in medicine, but they are a silent minority. Race and gender are easy to see, but low socioeconomic status may not be visible. Speaking about underprivilege may seem out of place, when now, as a result of luck and circumstance, you land among the most privileged.

Medical schools continue moving toward making the admissions process more equitable and diverse. However, measures to maintain and support diversity beyond the intake stage are often not in place. Students are then put in the position of negotiating a dual identity — one consistent with the medical culture, the other staying true to their social and cultural origins.

Medical schools should look one step back and one step forward in the admissions process. Before students from under-represented backgrounds can begin to use application subsidies or affirmative action initiatives, getting them to contemplate medicine in the first place requires an alignment between their identity and the identity associated with this vocation.

I encourage medical students and practicing physicians to be open about their stories, to humanize the identity of medicine so it doesn’t seem so lofty to those at a lower starting line — to show that a lived experience in poverty is valued by medical schools as much as, if not more than, having volunteered at a homeless shelter.

Looking forward, schools should continue diversity initiatives postadmission, whereby physicians from under-represented backgrounds support a culture of mentorship for like students, to facilitate development of their identity and strengths.

I am grateful to have lived in the dual worlds of underprivilege and privilege. I know what it feels like to not have choice, to have external factors, such as money and other people, dictate the path of my life. For many patients, it may feel the same — when their bodies and their lives are now in the hands of others.

Underprivilege has also taught me the importance of valuing chances, to hold on to them, offering my wholehearted effort toward these opportunities, because they were the threads of luck that helped pull me to the side of privilege. These experiences have taught me more about empathy and hard work than any medical school class could, and for that, to have been underprivileged is perhaps the greatest privilege in medicine.

Source: How underprivilege made me a better doctor | Toronto Star

Dalhousie medical school struggling to attract black and Indigenous students

Review of systemic barriers and ways to address them. The chart above shows the visible minority breakdown for the Atlantic provinces – for Nova Scotia, the NHS shows 50 Black Canadians out of some 3,400 working in doctors’ officers (1.5 percent):

Dalhousie University’s medical school is struggling to attract African-Canadian and Indigenous students, and its admission process is partly to blame, a review committee has found.

The committee’s 12-page report was submitted last August to the medical school’s dean, Dr. David Anderson, but it was just recently made public.

“The committee speculates that potential candidates from diverse backgrounds might not apply because of an apprehension of bias against them within the admissions process,” said the report.

Both African-Canadian and Indigenous people are under-represented in the medical profession, said the chair of the review committee, Dr. Gus Grant. He’s also the registrar and CEO of the College of Physicians and Surgeons of Nova Scotia, the body that regulates and licenses doctors in the province.

“I think it’s important that the profession be made up of individuals who represent the communities that are being served,” said Grant.

No figures are available on the number of black and Indigenous doctors practising in Nova Scotia because the college does not ask doctors to self-identify by race.

Last year, Anderson ordered the independent external review of the admissions process in part because of the lack of diversity. The last such review was done a decade ago.

Too much weight given to admission exam

The report also found the admissions committee placed too much weight on the medical college admission test (MCAT) scores and the grade-point average of candidates.

Grant said that while cognitive ability is important for practising medicine, grade-point average and MCAT results aren’t great measures of it.

“Cognitive ability is important for physicians, but I can’t fairly say that it’s more important than empathy, reliability, consistency, earnestness and other characteristics,” said Grant.

Starting in 2018, the medical school will use an online video-based tool to assess potential students for empathy, integrity, resiliency and communication skills.

Grant said it’s been long accepted that standardized tests like MCATs put minorities and people from lower socio-economic backgrounds at a disadvantage and they score lower on these exams. One reason Grant gave is that poorer applicants might not be able to afford to take MCAT preparatory courses.

Recommendations from report

Some of the report’s recommendations were to:

  • Institute a minimum requirement for test scores.
  • Require the 22-member admission’s committee to include gender-diverse representatives of the African-Canadian and Indigenous communities, while also collaborating with these two communities to determine admission criteria.

The first requirement has not yet changed, but the second one has been implemented.

More diversity needed in health-care system

Sharon Davis-Murdoch is co-president of the Health Association of African Canadians, a group that promotes health in the black community. She said for young children of African descent to see themselves in health professions, they need to be aware a career in the field is possible.

“The representation of people of African descent at every level of the health system, including the highest levels of health administration, needs to be in place in order for the system to be improved, for the system to serve appropriately and for the system to be reflective of all of us,” said Davis-Murdoch.

Source: Dalhousie medical school struggling to attract black and Indigenous students – Nova Scotia – CBC News

From language troubles to the female body, foreign doctors training in Canada can face challenges: study

Good overview of some of the challenges and discussion of whether better to be handled individually or through an orientation course (or both).

My experience during my various cancer treatments, dealing with a variety of  new Canadian doctors, was that language was sometimes an issue, manner generally less so:

It was one striking example of a culture clash the Alberta study suggests is common for graduates of foreign medical schools who do two-year family-medicine residencies here.

Some balk at being taught by female doctors, struggle with the nuances of English, use inappropriate body language, are uncomfortable with the mentally ill — or unfamiliar even with the concept of patient confidentiality, the researchers found.

Many of the “international medical graduates” (IMGs) also are highly educated, have rich cultural perspectives and strong characters, reported colleagues who were surveyed for the study.

But the authors say residency programs — whose on-the-job training is required to become a licensed doctor — should recognize the transition difficulties and incorporate “medico-cultural” education into their curriculums.

“In some countries, males look after males and females look after females,” said Olga Szafran, associate research director in the University of Alberta’s family-medicine department and the study’s lead author.

“(But) we can’t be selective in the kind of patients that our physicians end up treating. If you’re not familiar with the anatomy of the opposite sex, it’s very difficult to end up in the delivery room and deliver a baby.”

Canada relies heavily on IMGs, with graduates from medical schools outside North America making up about a quarter of practising physicians.

Universities here typically reserve a set number of residency spots for those foreign doctors, with the Edmonton faculty training about a dozen in family medicine a year, said Szafran.

Her study does not specify countries of origin, but the top five sources of IMGs countrywide in 2012 were South Africa, India, Libya, the U.S. and Pakistan, according to a Canadian Medical Association report.

The Alberta team admit their research was “qualitative,” not an empirical study with statistically significant results. They conducted interviews or held focus groups with the doctors who supervise family medicine trainees, with nurses and other health professionals who work alongside them and with both Canadian and international residents.

IMGs are an important part of the system, not least because they help serve an increasingly multicultural patient population, said Szafran. But she said the study subjects were consistent in outlining an array of challenges they face.

The combination of thick accents and difficulties with the subtleties of English can undermine communication with patients, which “makes life difficult and diagnosis difficult and affects everything,” one physician-trainer told the researchers.

The linguistic barrier can be exacerbated by different types of body language — like refusing to make eye contact with patients, or invading their personal space.

Some have a more direct style of talking to patients. A Canadian resident recalled a foreign colleague telling someone: “ ‘You’re fat, that’s why your joints suck,’ and the patient started to cry because nobody says that stuff here.”

Participants in the study reported IMGs unfamiliar with common mental-health conditions like depression, addiction, anxiety and panic attacks — problems that patients never sought medical help for in their home countries.

The mix of genders is also an issue, with some foreign graduates refusing to shake hands with patients of the opposite sex, or recognizing that a female doctor could have authority over them, the paper noted. “They tend to walk over you a bit, and you have to stand your ground and push back and just remind them about gender equality,” one female physician told the researchers.

Foreign graduates often make “stellar” doctors, but some of the Alberta study’s findings do sound familiar, said the head of Canada’s biggest family-medicine program.

Dr. David White, interim chair of the University of Toronto’s department, recalled a highly motivated, hard-working and likeable male medical graduate from southwest Asia — who had never treated women or children.

It left him with “knowledge gaps you could drive a truck through,” but White said such shortcomings can be relatively easily fixed by, for instance, teaching how to conduct a pelvic exam.

More difficult, he said, is to unlearn the mindset of a different medical culture. White cited a resident from a central Asian republic who had the doctor-knows-best attitude long since discouraged in Canada, and “a very reserved approach that did not come across as very empathic or warm.”

But White questioned whether formal cross-cultural training is necessary. So long as teachers understand the challenges faced by IMGs, such issues can be addressed on an individual basis, he argued.

Source: From language troubles to the female body, foreign doctors training in Canada can face challenges: study | National Post

Doctors Struggle With Unconscious Bias, Same As Police

Not surprising but some good examples of how these can play out:

Even as health overall has improved in the U.S., the disparities in treatment and outcomes between white patients, and black and Latino patients, are almost as big as they were 50 years ago. A growing body of research suggests that doctors’ unconscious behaviors play a role in these statistics, and the Institute of Medicine has called for more studies looking at discrimination and prejudice.

One study found that doctors were far less likely to refer black women for advanced cardiac care than white men with identical symptoms. Other studies show that African Americans and Latino patients are often prescribed less pain medication than white patients with the same complaints.

“We know that doctors spend more time with white patients than with patients of color,” says Howard Ross, founder of management consulting firm Cook Ross.

He’s developed a new diversity training curriculum for health care professionals that focuses on the role of unconscious bias in these scenarios.

Doctors and nurses don’t mean to treat people differently, Ross says. But, just like police, they harbor stereotypes that they’re not aware they have. Everybody does.

“This is normal human behavior,” Ross says. “We can no more stop having bias than we can stop breathing.

Unconscious biases often surface when we’re multitasking or when we’re stressed. They come up in tense situations where we don’t have time to think. Like police on the street at night who have to decide quickly if a person is reaching for a wallet, or a gun. It’s similar for doctors in the hospital.

“You’re dealing with people who are frightened, they’re reactive,” Ross says. “If you’re doing triage in the Emergency Room, for example, you don’t have time to sit back and contemplate, ‘why am I thinking about this,’ You have to instantaneously react.”

Doctors are trained to think fast, and to be confident in their decisions.

“There’s almost a trained arrogance,” Ross says.

This leads to treatments prescribed based on snap judgments, which can reveal internalized stereotypes. A doctor sees one black patient who doesn’t take his medication, perhaps because he can’t afford it. Without realizing it, the doctor starts to assume that all black  patients aren’t going to follow instructions.

Doctors Struggle With Unconscious Bias, Same As Police | State of Health | KQED News.

Tightening of foreign worker rules affecting supply of doctors – The Globe and Mail

A small part of the Temporary Foreign Workers program that most Canadians would not have problems with but nevertheless affected by the changed rules:

A tightening of the rules in the last three years – including the most recent overhaul, announced last month – has convinced some recruiters to give up on the TFW program altogether.

“Many, many, many recruiters that were doing this work back in 2011 have dropped off,” said Joan Mavrinac, head of the regional physician recruitment office for Essex County, which includes the border city of Windsor, Ont.

“Then, with the changes in 2013, we’ve become far fewer and now the changes in 2014, I think, are going to effectively kill the program [for doctors.]”The TFW program had been under fire for more than a year when Employment Minister Jason Kenney and Immigration Minister Chris Alexander announced sweeping reforms designed to prevent unscrupulous employers from importing low-wage foreign workers to displace Canadian employees.

The reforms include a 10-day turnaround time to process applications for highly skilled, high-wage workers, but they do not address any of the unique concerns of doctors, many of which stem from the fact MDs are generally self-employed.

Tightening of foreign worker rules affecting supply of doctors – The Globe and Mail.