A Case of Colorblind Care

The Wall Street Journal, August 6, 2004

By Sally Satel

At a certain point, it became possible to take a snapshot of America’s health, complete with vivid details and statistical portraits. Among other things, the snapshot revealed that blacks and whites experience different rates of diabetes, stroke, some cancers and other conditions — and different rates of diagnosis and treatment. And the reason? Plausible answers easily come to mind: genetics, discrepancies in insurance coverage, the availability of medical care and varying patient attitudes toward it. Two years ago, another reason was added: racism.

It was then that the Institute of Medicine (IOM) published “Unequal Treatment,” a much-heralded report arguing that doctors — acting deliberately or unconsciously — were giving their minority patients inferior care. The notion that doctors (and thus the workings of the entire health-care system) commit “bias,” “prejudice” and “stereotyping” — as the IOM report put it — is now conventional wisdom at many medical schools, philanthropies and health agencies. The Web site of the American Medical Association cites “discrimination at the individual patient-provider level” as a cause of heath-care disparities. Introducing a health bill last year, Sen. Tom Daschle cited the need to correct doctors’ “bias,” “stereotyping” and “discrimination.”

Skeptics of the biased-doctor model, and I count myself among them, do not dispute the troubling existence of a health gap. But we argue that the examining room is not the place to look for its origins. This is not to suggest that doctor-patient relationships are free of clinical uncertainty and miscommunication; they are not. But their relative importance is probably modest and remains hard to gauge, especially when compared with access to care and quality of care — both of which have undisputed and sizable effects.

This argument just got a big boost from researchers at Manhattan’s Memorial Sloan-Kettering Cancer Center and the Center for the Study of Health Care Change in Washington. They showed that white and black patients, on average, do not even visit the same population of physicians — making the idea of preferential treatment by individual doctors a far less compelling explanation for disparities in health. They show, too, that a higher proportion of the doctors that black patients tend to see may not be in a position to provide optimal care.

The dramatic finding, published yesterday in the New England Journal of Medicine, should incite a fundamental shift in thinking. Whether it actually does that is another matter, so entrenched are the pieties about America’s racist inclinations.

The research team, led by Dr. Peter Bach, examined more than 150,000 visits by black and white Medicare recipients to 4,355 primary-care physicians nationwide in 2001. It found that the vast majority of visits by black patients were made to a small group of physicians — 80% of their visits were made to 22% of all the physicians in the study. Is it possible, the researchers asked, that doctors who disproportionately treat black patients are different from other doctors? Do their clinical qualifications and their resources differ?

The answer is yes. Physicians of any race who disproportionately treat African-American patients, the study notes, were less likely to have passed a demanding certification exam in their specialty than the physicians treating white patients. More important, they were more likely to answer “not always” when asked whether they had access to high-quality colleague-specialists to whom they could refer their patients (e.g., cardiologists, gastroenterologists), or to nonemergency hospital services, diagnostic imaging and ancillary services such as home health aid.

These patterns reflect geographic distribution. Primary-care physicians who lack board certification and who encounter obstacles to specialized services are more likely to practice in areas where blacks receive their care — namely, poorer neighborhoods, as measured by the median income.

Dr. Bach and his colleagues suggest that these differences play a considerable role in racial disparities in health care and health status. They make a connection between well-established facts: that physicians who are not board certified are (a) less likely to follow screening recommendations and (b) more likely to manage symptoms rather than pursue diagnosis. Thus rates of screening for breast and cervical cancer or high blood pressure are lower among black patients than white, and black patients are more likely to receive a diagnosis when their diseases are at an advanced stage. Limited access to specialty services similarly put black patients at a disadvantage.

The Bach study is the first to examine physicians’ access to specialty care and nonemergency hospital admissions in light of the race of the patients they treat. As for the notion that that the capacities of doctors who treat black patients may account for some part of the health gap, earlier evidence for it has been hiding in plain sight.

For example, a 2002 study in the Journal of the American Medical Association found that physicians working for managed-care plans in which black patients were heavily enrolled provided lower-quality care to all patients. A report in the American Journal of Public Health in 2000 found that black patients undergoing cardiovascular surgery had poorer access to high-quality surgeons. Similarly, Dartmouth researchers have shown that African-Americans tend to live in areas or seek care in regions where the quality for all patients, black and white, is at a lower level.

It is important to recognize that many of the physicians working in black communities are hardworking, committed individuals who make considerable financial sacrifices to serve their patients. As Dr. Bach’s team notes, they deliver more charity care than doctors who mostly treat white patients and derive a higher volume of their practice revenue from Medicaid, a program whose fees are notoriously low. They are often solo practitioners who scramble to make good referrals for their patients but who are stymied by a dearth of well-trained colleagues and by limited entree to professional networks with advanced diagnostic techniques.

It is long past time to put aside the incendiary claim that racism plays a meaningful role in the health status of African-Americans. The health gap is assuredly real. But growing evidence suggests that the most promising course is to get well-trained doctors into low-income and rural neighborhoods and enable them to provide the best care for their patients — something they will do, it somehow needs to be said, without prejudice.

Dr. Satel, a resident scholar at the American Enterprise Institute, is the author of “PC, M.D.: How Political Correctness Is Corrupting Medicine.”