Are doctors prejudiced? According to the media’s coverage of a new report by the Institute of Medicine called “Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care,” the answer is yes. In the days after the report’s release, headlines across the country sounded the alarm: “Color-Blind Care Is Not What Minorities Are Getting,” declared Newsday; “Fed Report Cites “Prejudice” in White, Minority Health Care Gap” the Boston Herald charged; “Separate and Unequal,” said the St. Louis Post-Dispatch.
Virtually every story ran the triumphant remark of Dr. Lucille Perez, president of the National Medical Association, which represents minority physicians: “It validates what many of us have been saying for so long — that racism is a major culprit in the mix of health disparities and has had a devastating impact on African-Americans.” Only CNN elicited comments from physicians who questioned the bias charge.
The truth is far less inflammatory than Dr. Perez and the press would have us believe. The institute’s case for prejudice in the March 20 report is weak. Its own conclusion tells the story: “Some evidence suggests that bias, prejudice and stereotyping on the part of health care providers may contribute to differences in care.” “Some,” “suggests,” and “may” — these are all the kinds of words authors use when the data are flimsy and reputations are at stake.
A look at the 191-page report shows why IOM authors hedged their bets so carefully. Congress asked the IOM to assess the extent of racial differences in receipt of treatments with a special emphasis on “evaluating . . . the role of bias, discrimination and stereotyping” in explaining those differences. To meet its charge, the IOM examined data on the frequency with which white and minority patients underwent certain procedures and received specific treatments. The report also reviewed evidence aimed at measuring doctor bias, discrimination and stereotyping.
Evaluating the evidence had to be extremely difficult. In reviewing the substantial literature of academic studies comparing treatment of white and black patients, the IOM selected studies that accounted for obvious reasons for differential care, such as insurance status, income or age. But because these studies contained data already collected for other purposes, such as patient billing, even the best of them were limited. Depending on the nature of data amassed, investigators could not obtain details vital to understanding why patients might be treated differently.
Newspapers especially cited a 1999 New England Journal of Medicine study of lung cancer treatment by Peter Bach and colleagues at Memorial Sloan Kettering Cancer Center as an example of unfairness. Dr. Bach looked at records of over 10,000 Medicare patients who received diagnoses of operable lung cancer. Seventy seven percent of white patients underwent surgery compared with 64% of black patients. Five years later, one-third of the white patients, but only one-quarter of the black patients, were still alive.
Those numbers understandably arouse concern, but many unanswered questions remain. Did black patients refuse surgery more often than whites? Did black patients have higher rates of other conditions like poor lung function that would have prohibited surgery or contributed to an earlier demise? Were fewer black patients married? (Married men usually fare better after surgery than unmarried ones.) Although substandard treatment solely based on their race could have possibly — maybe — perhaps played a role in the lower rate of surgery among the black cohort, the available evidence does not make the case.
The part of the IOM report that focused on doctors’ attitudes toward patients relied on studies that are even more difficult to interpret. Doctors were asked their impressions of a hypothetical black or white patient and then to make judgments about the financial status of the patient, his ability to cooperate with treatment and so on. Such studies offer negligible evidence that doctors’ impressions led them to offer shoddy care.
To be sure, physicians base their clinical decisions on experience and statistical norms — these are sometimes influenced by race (or sex or class, for that matter). If a physician thinks that a patient will not comply with triple therapy for HIV, he might either forgo the medication or prescribe it while monitoring the patient especially closely.
To the extent that a physician does the former, the IOM report serves a consciousness-raising function, prompting doctors to ask themselves whether they are giving every patient the opportunity to benefit from treatment. But to elevate the phenomenon of making clinical generalizations to the level of “potential civil-rights violations,” as the IOM report does, is a large, questionable leap.
Unfortunately little research exists comparing the care that black patients receive from white or black doctors. A group of Yale cardiologists, in one of the rare studies assessing this, found that black patients underwent catheterization at the same rate regardless of the race of their doctor.
All the hype surrounding this study is most disturbing because it diverts us from the far more important causes of the health gap: access to care, health literacy, and attitudes toward health. We can do much to improve the health of African- Americans. Inciting their distrust of the medical profession with misleading claims about physician prejudice can only hurt.