In the near decade since we published the first edition of this book, research has firmly established that populations of lower socioeconomic status and from minority racial and ethnic backgrounds have worse health and often receive a lower standard of health care. Worse health out comes attributed to inequity in distribution of resources, initially termed disparities in health and health care, are now more aptly and pointedly referred to as inequities in health and health care. These inequities are attributed to broad social forces that shape the way we live and how medicine is practiced. With this perspective, a person's and a community's health and the health care they receive are measures of social justice.
As clinicians, there is perhaps no more distressing medical research than that which suggests that health-care workers and the health-care system contribute to inequities in health for vulnerable populations. Studies reveal that health-care workers continue to feel ill prepared when caring for vulnerable patients, especially those who are chronically ill, the elderly, addicted, mentally ill, victims of violence, or from minority or disadvantaged backgrounds. Hence, health-care workers may be the third factor in a "triple jeopardy" vulnerable patients face when it comes to health care: not only are these patients more likely to be ill and to have difficulty accessing care, but when they do, the care they receive is more likely to be suboptimal. Fortunately, training health-care workers to care for vulnerable patients makes a difference. With training, they are more willing to work with these populations and provide better care.
We hope the second edition of our book will be part of an ongoing process of improving our professions' ability to discharge its obligation to enhance social justice by both delivering comprehensive care for all patients and challenging the policies that undermine health for underprivileged patients and health-care access and delivery. Although grounded in health care as it is practiced in the United States, we draw from evidence and practices worldwide and believe that the concepts and approaches are relevant to medical practice globally.
The purpose of this book is to offer the theoretical background and practical knowledge required to teach clinicians to care for vulnerable, underserved patients both at the individual and system levels. In this book, we aim to illuminate the complexities of caring for vulnerable, underserved patients. We provide both an appreciation of the need to address inequities at multiple levels and practical suggestions for how to improve the care of vulnerable populations. We aim to "enable" health-care workers, students, and other interested parties to contribute to the solution. We focus on issues of patient care that are common among underserved patients and suggest ways to use our materials as teaching tools for health professions trainees in both didactic and clinical settings.
Our book is intended as a basis for teaching the core principles and skills required to care for our most complex patients—the vulnerable and underserved—where our clinical skills must be the most astute. Our text is appropriate for students, residents and practitioners (medical students, nurses, pharmacists, physician's assistants, public health, and other health-care practitioners) both in clinical, community, or social medicine classes and in practical experiences, including, but not limited to, primary care rotations and clerkships in family medicine, pediatrics, internal medicine, women's medicine, and psychiatry. As teaching hospitals are the major providers of care to uninsured, poor, and minority patients in the United States, the book is also intended as a resource for teachers and trainees who practice in these settings as well as public health-care settings internationally. Post-graduate trainees (e.g., residents and fellows) from all disciplines could use this text for didactics in behavioral and clinical medicine, and quality improvement. Finally, it can also serve as a rapid, yet comprehensive reference for all practitioners.
The book is organized into three sections: Principles, Practice, and Populations. Chapters in each section discuss ways in which both the individual practitioner and the health-care system may be more responsive to patients with these characteristics to assure they receive accessible, high-quality care, thereby reducing the inequities in health care that are both causes and consequences of vulnerability. We present clinical approaches to many issues that complicate caring for socially vulnerable patients. Many chapters feature both Key Concepts and Common Pitfalls, and end with a Core Competency highlighting important concepts and skills for quick and easy referencing.
Putting together a book of this scope and magnitude was no easy task and involved making certain decisions that not all readers may agree with. For example, while trying to keep the length of the book as manageable as possible, we were forced to exclude some relevant topics and decided to allow some overlap of content in those areas that are most critical. In addition, we welcomed differences of opinion among authors, provided the issues were clearly stated and the reasons for the author's opinion documented.
The first section, entitled Principles, lays out the theoretical groundwork of the book. Topics discussed include overview of the concepts of medical vulnerability and inequities in health and health care; financing and organization of health care for vulnerable populations; laws and regulations governing the care of medically underserved populations in the United States; and ethical dilemmas that arise in the clinical care of medically underserved populations. We also present chapters on engaging communities, on a global health-care perspective and promoting physician advocacy. The second section, Practice, considers overarching themes and skills necessary to care for patients. In particular, this section concentrates on population medicine and systems approaches to improving care to vulnerable patients. Topics discussed include the importance of building a therapeutic alliance and assessing for vulnerability; supporting health behavior change and adherence; principles of effective communication when cultural or literacy barriers may exist; models of care delivery to improve the effectiveness of medical care, such as the patient-centered medical home, group medical visits, and use of interactive health technologies; as well as quality improvement and case management programs. The third section, Populations, examines particular conditions or social circumstances that can lead to worse care. Chapters consider approaches to patients with histories of trauma, mental illness, intimate partner violence, and addiction, for example. Care of patients with limited English proficiency, history of incarceration, gay, lesbian and transgender patients, children, adolescents, and the elderly are subjects of others. In addition, this section addresses common situations that uniquely complicate the care of vulnerable populations such as environmental and occupational illnesses; the care of socially complicated hospitalized patients; end-of-life health care; chronic pain management; dental health; the care of patients with HIV/AIDS; and patients with disabilities. We end with a chapter that addresses the prevention of practitioner burnout.
We are deeply appreciative to the authors for their outstanding contributions to both editions of the book. Although the authors of some chapters have changed, we wish to acknowledge the influence and contribution of those who laid the foundation in the original chapters. We would also like to acknowledge the support and patience of the staff at McGraw-Hill. We especially wish to recognize the efforts of James Shanahan for believing in the project since its inception and to Amanda Fielding, Kim Davis, Laura Libretti, and Kritika Kaushik for bringing it to fruition. Finally, we are forever grateful to our patients for allowing us to participate in their care, our students for inspiring us to do better, and our families for their generous support.
Talmadge E. King, Jr., MD
Margaret B. Wheeler, MS, MD
Andrew B. Bindman, MD
Alicia Fernandez, MD
Kevin Grumbach, MD
Dean Schillinger, MD
Teresa J. Villela, MD