Book Review

Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations

N Engl J Med 2007; 357:626-627August 9, 2007

Article

Medical Management of Vulnerable and Underserved Patients: Principles, Practice, and Populations
Edited by Talmadge E. King, Jr., Margaret B. Wheeler, and Andrew B. Bindman, with four others. 454 pp., illustrated. New York, McGraw-Hill, 2007. $41.95. ISBN: 978-0-07-144331-9

Many physicians consider the care of vulnerable and underserved patients to be an unsatisfying and often frustrating endeavor, but this new book offers an optimistic and evidence-based approach to the care of such patients. The editors define medically vulnerable populations as “those that are wounded by social forces placing them at a disadvantage for their health.” The book serves as an important reminder that many of the issues it raises are relevant to the broader landscape of American health care. The authors elicit the voice of the patient to explain and offer guidance on some of the difficult clinical and societal issues that physicians face in practice, including behavioral change, noncompliance, health literacy, health disparities, and the plight of the hidden poor. The book should become an essential primer for teachers, physicians-in-training, and practicing physicians because it offers important tools for teaching, critical concepts, common pitfalls, core competency concepts, and discussion questions for each chapter.

A challenge for the editors and authors of this kind of book is to emphasize the importance of the physician's own attitudes and practices toward vulnerable patients without being preachy. The editors' decision to use the patient's voice and a strong, evidence-based orientation helps them meet this challenge. The first part of the book, “Principles,” includes a chapter on the theoretical groundwork and context for understanding care of complex patients. There are also excellent reviews of disparities in health and health care and of the financing and organization of health care for vulnerable populations. Other chapters are excellent primers on legal and ethical principles and are written by respected leaders in the field.

There is a remarkable focus on what health care providers and systems can actually do to improve care and reduce disparities. The chapters in the second section of the book, “Practice,” contain important insights on behavioral change, cross-cultural communication, health literacy, home visits, group visits, interactive health technology, quality improvement, case management, and care in the context of community. The author of a superb chapter on cross-cultural communication emphasizes the importance of assessing one's own values in order to improve care and communication. A chapter on behavioral change offers some practical tools to use with patients who have resistant behaviors in the context of cultural and financial pressures. The authors of the chapter on medication adherence make the case that this problem is not unique to vulnerable populations, and they offer some common-sense approaches. The chapter on limited health literacy should be required reading for all medical students and physicians. The role of interactive health technology in filling in safety-net gaps is emphasized, with real-life examples of how health information technology has been transformative in the care of vulnerable patients facing language and cultural divides.

The third section of the book deals with a variety of vulnerable populations that need special consideration when they seek care. The chapters on many different population groups stand on their own and offer important lessons for the care of patients who often are not mentioned in standard medical textbooks. These groups include patients with a history of incarceration, patients with limited English proficiency, immigrants, patients with disabilities, patients who have been victims of domestic violence, patients with chronic pain, and patients with substance-abuse problems. The information is provided in a nonjudgmental manner on the basis of strong evidence and with practical guides for improving care. The chapters on immigrant health and language barriers offer useful guidance, such as advice on how to work with interpreters, that could help to bridge divides. The authors of chapter 20, “The Hidden Poor: Care of the Elderly,” emphasize functional assessment, elder abuse, and the limitations of prescription-drug coverage for the elderly. Several chapters in the third section serve to remind us to consider care in the context of family and community, such as chapter 19, “The Family as the Context for Care,” and chapter 38, “HIV/AIDS: Impact on Vulnerable Populations.” Chapter 40, “Caring for Oneself While Caring for Others,” offers important insights on reducing clinician burnout.

This book is an ambitious and important contribution to the care of our most wounded patients. For those of us who regularly care for vulnerable patients, it provides an excellent resource and supportive guide. However, it should also become part of the standard library for all medical students and practicing physicians. All physicians have much to learn from the practical, evidence-based approaches to the societal issues we all face in practice. Ultimately, this is a book that could help all clinicians take better care of all patients, especially those who may need extra help and support as they navigate our complex health care system.

Helen Burstin, M.D., M.P.H.
National Quality Forum, Washington, DC 20005
hburstin@qualityforum.org