In 2002, the Institute of Medicine published an oft-cited and controversial report entitled Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. The report concluded that members of minority groups, even when fully insured, tend to receive substandard care from their doctors. It cited disparities in how often whites and minorities received even routine medical procedures, as well as how often they underwent specific operations, such as coronary artery bypass surgery.
The resulting headlines were sensational—“Is Your Doctor a Bigot?” asked one. And there soon followed fulsome denunciations of the report’s conclusions, notably by Dr. Sally Satel and Jonathan Klick of the American Enterprise Institute. In their 2006 book, The Health Disparities Myth, Klick and Satel claimed that “[n]ot only is the charge of bias divisive, it siphons energy and resources from endeavors targeting system factors that are more relevant to improving minority health.”
Today, both sides in this debate have refined their positions and can point to new information. Professor David R. Williams of the Harvard School of Public Health still criticizes Satel as “coming at it from an ideological perspective.” But, he adds, “I will say one thing in her defense. At the time of the IOM report, our conclusion about the role of unconscious discrimination was based on circumstantial evidence.”
That changed in 2007, when the Journal of General Internal Medicine published the results of a study of residents at four academic medical centers. Participants were asked to review the medical record of an imaginary patient complaining of chest pain. For half the participants, the record included a picture of a middle-aged black man; for the rest, a middle-aged white man. Participants were asked to rate on a scale of 1 to 5 whether they thought the patient suffered from coronary artery disease, and, if so, whether they believed that the patient should receive a drug treatment known
The study also asked participants to complete what are known as Implicit Association Tests, or IATs. These tests are designed to uncover unconscious bias by, for example, asking test takers a series of questions about whether they associate the word “happiness” with the word “white” or with the word “black.” In this instance, the test also asked the residents whether they associated black patients with being more or less cooperative with a doctor’s orders.
The study found that participants who scored high for antiblack bias on the IATs were less likely to recommend thrombolysis when the black man’s picture, rather than the white man’s, was included in the medical record, presumably because they believed the black man would be a less cooperative patient or perhaps less able to pay. The study’s authors concluded that the “[r]esults suggest that physicians’ unconscious biases may contribute to racial/ethnic disparities in use of medical procedures such as thrombolysis.”
While few now dispute that some doctors may consciously or unconsciously treat patients of color differently, both the nature of that bias and its importance in explaining racial disparities in health care are highly disputed. For example, in focus groups organized by researchers to assess the role of race in medical practice, black doctors were far more likely than white doctors to say that a patient’s race is a medically relevant factor in determining the best treatment. As one black physician in a Philadelphia focus group put it, “I think being an African American is a risk factor in and of itself. And, I think that when you see an African American then you need to often be more aggressive than you would, and use different standards than you would for the general white population.”
Black doctors were also more likely than white doctors to say that they pay close attention to whether a patient can afford the prescriptions they write, and to consider what the circumstances of their patients’ lives are like outside the examining room. In contrast, white doctors in these focus groups tended to dispute that there is any reason to pay attention to a patient’s race in recommending a course of treatment, and even to warn other doctors against racial stereotyping.
But perhaps in this way the white doctors were showing insensitivity to racial realities that black doctors know better and that are indeed medically relevant. As the organizers of the focus groups concluded, since African Americans as a whole are far more likely than whites to suffer from hypertension and diabetes, it may be appropriate for doctors to take into account at least some population-based probabilities of disease when deciding protocols of treatment to follow. Color-blind medicine isn’t necessarily the best medicine.
The picture also looks different when researchers pan back and look at how widely medical practice varies in different areas of the United States. From this perspective, it is place, not race, that overwhelmingly determines what specific treatments patients receive for specific ailments. Blacks tend to live in parts of the country that have a disproportionately large share of low-quality providers. But as researchers from Dartmouth Medical School have demonstrated, within poor-quality hospitals, which include not just inner-city “St. Elsewhere”s but often well-known academic medical centers, both whites and blacks tend to be equally mistreated, often by being subjected to unnecessary surgery and unproven treatments. Moreover, there are some predominantly black cities, such as Raleigh, North Carolina, and Birmingham, Alabama, that have a long history of institutionalized segregation but where the researchers did not find racial disparities in treatment, and there are others, such as Jackson, Mississippi, where racial disparities in care are apparent.
More recently, researchers associated with the Dartmouth Atlas Project have concluded that “where patients live has a greater influence on the care they receive than the color of their skin.” Reform efforts, they argue, should therefore be focused not on the headline-grabbing issue of racial disparities, but on improving the quality of the U.S. health care delivery system in every region where it is poor.