Not me! Doctors, Decisions, and Disparities in Health Care

Abstract and Introduction

Racial and ethnic disparities in health have been well described, with data showing that minority Americans suffer disproportionately from cardiovascular disease, diabetes, asthma, cancer, and human immunodeficiency virus/acquired immunodeficiency syndrome, among others. Several factors lead to these disparities, including the fact that minority Americans suffer from adverse social determinants (such as poverty and lower levels of education) at greater rates and are more likely to be uninsured. A recent Institute of Medicine report has also highlighted that minorities tend to receive lower-quality care even when they have insurance and access to the health system.The Institute of Medicine report identified various sources that contribute to racial/ethnic disparities in health care; among them was health care providers' susceptibility to stereotyping minority patients, leading to disparate clinical decision making. This review dissects the process of clinical decision making—and the environment in which decisions are made—to present a model for understanding how even well intentioned physicians may be susceptible to stereotyping and unknowingly contribute to racial/ethnic disparities in health care. Several strategies to counteract this process, both systematically and individually, are also described.

Racial and ethnic disparities in health have been well described, with data showing that minority Americans suffer disproportionately from cardiovascular disease, diabetes, asthma, cancer, and human immunodeficiency virus/acquired immunodeficiency syndrome, among other illnesses.^[1] Several factors lead to these disparities. First, research has demonstrated the adverse effect of social determinants such as lower levels of education, inadequate and unsafe housing, higher levels of unemployment, and overall lower socioeconomic status on the health of minorities.^[2,3,4,5,6] Second, minorities tend to be uninsured at greater rates than majority Americans, which also leads to poorer health status.^[7,8] The prolonged effect of historical segregation and racism, both in society and in the health care system, also contributes to this problem.^[9,10]

Within the past few decades there has been a focus on racial/ethnic disparities in quality of care for those patients with access to the medical system. Research has demonstrated that minorities, compared with whites, receive fewer cardiac diagnostic and therapeutic procedures,^{[11,12,13,14,15]} less analgesia for pain control when in an emergency department with long bone fractures,^[16,17,18] less surgical treatment of operable lung cancer,^[19] fewer referrals to renal transplantation when on hemodialysis,^[20] poorer quality of care when hospitalized for pneumonia and congestive heart failure,^[21] and have lower use of general services covered by Medicare (i.e., immunizations and mammograms)^[22] even when controlling for insurance status, income, age, comorbid conditions, and symptom expression, among other possible confounders.

As a result of these findings, the Institute of Medicine (IOM) was commissioned to study the issue of racial/ethnic disparities in the health care system and released the report, Unequal Treatment: Confronting Racial/Ethnic Disparities in Health Care^[23] in March 2002. In addition to finding that racial and ethnic disparities in health care exist and are associated with worse health outcomes, the report states that many sources—including health systems, health care providers, patients, and utilization managers—may contribute to racial and ethnic disparities in health care.^[23] In addition, the report states that bias, stereotyping, prejudice, and clinical uncertainty on the part of health care providers may contribute to racial and ethnic disparities in health care.

In discussing this last point, the IOM report describes that sociocultural differences between patients and health care providers, in addition to other nonmedical factors, directly influence communication and clinical decision making.^[24,25] The failure of health care providers to take this into account may lead to stereotyping of patients, and in the worst cases, biased or discriminatory treatment based on a patient's race, ethnicity, culture, or class.^[23]

Several studies were presented in the IOM report to support this claim; three are described here. First, a study by van Ryn et al.^[26] attempted to identify physicians' perceptions of both African-American and white patients (i.e., personal characteristics such as intelligence, likelihood to comply with recommendations) following a postcardiac catheterization visit. The study found that physicians tended to associate African Americans and patients of low socioeconomic status as being less intelligent, more likely to engage in risky behaviors, and less likely to adhere to medical regimens, even when controlling for the patients' true socioeconomic status, personality attributes, and degree of illness. A study by Weisse et al.^[27] presented physicians with vignettes of African-American and white patients suffering from identical symptoms of kidney stone pain, low back pain, and sinusitis, then examined prescribing of pain medication. The authors found that male physicians (80% white) tended to prescribe more pain medication for whites than for African Americans. Schulman et al.^[14] assessed physicians' recommendations for management of chest pain after viewing videos of patients (who varied in race, but whose age, gender, socioeconomic status, and level of education were equally matched) describing cardiac symptoms. The authors demonstrated differential referral patterns for cardiac catheterization based on race and gender, with African-American women being referred least for the procedure compared with white men. In all of these cases, a variety of hypotheses for the findings were presented and ranged from discrimination to stereotyping on the part of physicians.

What do these studies—and these hypotheses—mean for the majority of doctors in practice, who when presented with this data and the results of the IOM report tend to say, "Not me! I don't contribute to disparities—I treat all my patients the same." The goal here is to dissect the process of clinical decision making—and the environment in which decisions are made—to present a model for understanding how even well intentioned physicians may be susceptible to stereotyping and may unknowingly contribute to racial/ethnic disparities in health care.

Cardiovasc Rev Rep. 2004;25(3) © 2004 Le Jacq Communications, Inc.

Cite this: Not me! Doctors, Decisions, and Disparities in Health Care - Medscape - May 01, 2004.