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February 23, 2006,
8:11 a.m.
Biased Doctors?
Don’t rush to pull out the race card.
Dr. Foreman to African American patient: Your blood pressure’s a little high. I have something new that should help you out. Combines a nitrate with a blood pressure pill. It’s targeted to African-Americans.
Patient: Targeted?
Foreman: Yeah, well, see we tend to have nitric oxide deficiencies. The studies show this drug counteracts that problem. It’s the first drug to—
Patient: Ah…I’ve had white people lying to me for 60 years.
…
The patient rejects that drug, returns the next day, and finally leaves satisfied when another doctor tells him, “I’ll give you the same medicine we give Republicans.”
This exchange between a black doctor and his black patient took place on House, Fox’s medical drama. The idea that a physician (black or white) will give his white patients better care than his black patients has, alas, found its way into mainstream, primetime television.
This “biased-doctor” model, as we call it, is a woeful misimpression of reality, but one that has become a staple of the “health disparities” campaign now underway at schools of medicine and in the American Medical Association, the Association of American Medical Schools, and health-care philanthropies.
To the extent that the drive against health disparities seeks to improve health of minorities — and there is no question that, as a group, they suffer worse health and receive poorer quality care than whites — its goal is worthy.
But effective solutions depend on an accurate understanding of the causes of race-related differences in treatment. And we have no evidence to support the idea that racially biased doctors are a cause of poor minority health — a proposition almost impossible to prove in any case.
The notion of physician bias was popularized in 2002 by a report from the Institute of Medicine called “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care.” It concluded that an important dynamic in race-related treatment differences were “bias,” “prejudice,” and “discrimination” within the doctor patient relationship. A year later former-Senator Tom Daschle cited the need to correct doctors’ “bias,” “stereotyping,” and “discrimination.” Last year the American Public Health Association issued a call for “Research and Intervention on Racism as a Fundamental Cause of Ethnic Disparities in Health.”
This is not to suggest that doctor-patient relationships are free of clinical uncertainty and miscommunication. But their relative importance, as a function of race, is probably modest and hard to gauge, especially when compared with access to care and quality of care — both of which have undisputed and sizable effects. Two factors in particular have considerable influence on the quality of care an individual receives, irrespective of race: the doctor pool available to the patient and where the patient lives.
Peter Bach of Memorial Sloan Kettering Cancer Center and colleagues showed that white and black patients, on average, do not visit the same population of physicians — making the idea of preferential treatment by individual doctors a far less compelling explanation for disparities in health. Notably, though, the doctors frequented by black patients were often not in a position to provide optimal care.
Bach’s study, which appeared in the New England Journal of Medicine in 2004, found that the vast majority of visits by black patients — 80 percent — were made to a small group of physicians — 22 percent of all those in the study. These physicians were less likely to have passed a demanding certification exam in their specialty than the physicians treating white patients. They were more likely to answer “not always” when asked whether they had access to high-quality colleague-specialists, such as cardiologists or gastroenterologists, to whom they could refer their patients, or to non-emergency hospital services, diagnostic imaging, and ancillary services, such as home health aid.
Along the same lines was a 2002 study by researchers at the Harvard School of Public Health. The study found that physicians working for Medicare managed-care plans in which black patients were heavily enrolled provided lower-quality care to all patients, regardless of race. Specifically, their patients were less likely to receive the four clinical services the authors measured — mammography, eye exam for diabetics, beta-blocker after myocardial infarction, and follow-up after hospitalization for mental illness.
Similarly, a team at the Center for Studying Health System Change in Washington, D.C., assessed the abilities of a random sample of physicians to obtain medically necessary services for their patients. According to the survey, black physicians were more likely to report difficulties admitting patients to hospitals than white physicians, and Hispanic physicians were more likely to report having a poor specialty-referral network than white physicians (is this racism on the part of hospitals?).
The second important factor in treatment disparities is that access to quality care, irrespective of the race of the patient, is tied to geography. With most health care delivered locally — and with racial and ethnic groups not evenly scattered about the country — it is imperative that researchers account for geography in evaluations of health disparities. When they do, they discover that geographic residence often explains race-related differences in treatment better than even income or education.
Consider the effects of location on health disparities in infant mortality rates. Jeannette Rogowski and colleagues at Rand used the rich Vermont-Oxford network dataset to examine the effects of hospital quality on the mortality rates of very low-birthweight babies, controlling for condition of the baby at birth as well as other characteristics such as gestational age, race, method of delivery, birth defects, and prenatal care. The authors found that black and white babies were not delivered at the same kinds of hospitals. Black babies were significantly more likely to be born in government-run hospitals that served a relatively high proportion of Medicaid patients, and where doctors spent less time with patients, mostly due to high patient volume. Further, the hospitals where black babies were born were significantly less likely to have neonatal intensive care units or to perform neonatal cardiac surgery.
Thus, if physicians cannot fairly be accused of bias, does this shift the charge of bias to the health-care system? In other words, do black patients receive poorer care because they are black or because they have disproportionately lower incomes and social capital (for example, less capacity for negotiating complex systems) than whites — and are thus disproportionately mired in systems that are underfinanced?
The most recent report from the Agency for Healthcare Research and Quality suggests this is so. It examines, separately, quality by race and quality by income. It says that “remote rural populations” receive poor care, and “many racial and ethnic minorities and persons of lower socioeconomic positions” receive suboptimal care. In short, white people who live in these areas get bad care too; conversely black people living in majority white areas tend to get good care.
Much has been made of the need for greater sensitivity in the doctor-patient relationship. Common sense dictates that patients benefit when they trust their physicians and interact with them productively. But the remedies for unsatisfactory doctor-patient relationships do not reside in racial sensitivity training for health-care professionals, affirmative action in medical-school admissions, or the specter of Title VI (civil-rights) litigation — all avenues of redress that have been advocated.
Since class makes a much greater contribution to heath care and health status than does race, sound solutions should target all underserved populations. Low-income patients benefit from many factors: a strong safety net provided by the federally funded community health-care system (guaranteeing a usual source of care); grassroots outreach through black churches, social clubs, and worksites; patient “navigators” to help negotiate the system; language services; and efforts to get more good doctors into distressed neighborhoods. Seemingly simple innovations, such as clinic night hours, mobile clinics, and more extensive use of school nurses, could be a great boon to patients with hourly wage employment who risk a loss of income, or even their jobs, by taking time off from work for doctor’s appointments.
Words such as “prejudice,” “bias,” and “discrimination” are charged and divisive. Civil-rights advocates talk about the lingering shadow cast on the health-care system by troubled race relations. Yet, paradoxically, health campaigns that seek to educate about alleged bias of physicians will only inflame the mistrust of black patients like the one on House.
— Sally Satel M.D. is a resident scholar at the American Enterprise Institute. Jonathan Klick, a health economist and lawyer, is the Jeffrey A. Stoops Professor of Law at Florida State University. The authors just published The Health Disparities Myth: Diagnosing the Treatment Gap.
