Unequal Treatment Confronting Racial and Ethnic Disparities in Health Care (2003) / Chapter Skim
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4. Assessing Potential Sources of Racial and Ethnic Disparities in Care: The Clinical Encounter
4. Assessing Potential Sources of Racial and Ethnic Disparities in Care: The Clinical Encounter
Pages 160-179
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From page 160... ...
When these encounters systematically produce racial and ethnic disparities, they may constitute discrimination. As noted in Chapter 1, the study committee defines discrimination as differences in care that emerge from biases and prejudice, stereotyping, and uncertainty in communication and clinical decisionmaking.
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MEDICAL DECISIONS UNDER TIME PRESSURE WITH LIMITED INFORMATION In the process of healthcare, doctors and other healthcare providers often must reach judgments about patients' conditions and make decisions about treatment without complete and accurate information. Moreover, they frequently must do so under severe time pressure and resource constraints.
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From page 162... ...
That is, physicians use clusters of information in making diagnostic and other complex judgments that must be arrived at without the luxury of the time and other resources to collect all the information that might be relevant. These conditions of time pressure and resource constraints are common to many clinical encounters, and map closely onto those identified as producing negative outcomes due to lack of information, to stereotypes, and to prejudice (van Ryn and Burke, 2000; van Ryn, 2002~.
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From page 163... ...
demonstrated that had the study authors calculated the relative chance of referral using risk ratios, rather than odds ratios, the probability of African Americans being referred for cardiac catheterization was only 7% lower than for whites. In addition, Schwartz et al.
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From page 164... ...
and gender of the "patient" was manipulated. The authors found that male physicians prescribed higher doses of hydrocodone for white "patients" than black "patients" suffering from back pain and renal colic, while female physicians prescribed higher doses of analgesic for black "patients" than white "patients." In both cases, findings were robust: male physicians prescribed twice as much hydrocodone to white patients than black patients, while female physicians prescribed the reverse.
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From page 165... ...
The authors found that students were more likely to provide a diagnosis of "definite" angina for the white male patient than the black female patient, but rated the health status of the black female patient as lower than that of the white male. Thus, these subjects assessed the while male patient's cardiac symptoms to be more severe, yet perceived the black female patient's quality of life to be lower, despite objectively similar presentations from the two "patients." Minority students, however, did not rate the health status of the black female patient as significantly different than that of the white patient.
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From page 166... ...
The results supported the authors' hypotheses that patient race and socioeconomic background do influence physicians' perceptions, even when controlling for differences in patients' socioeconomic status, personality attributes and degree of illness. African-American patients were rated as less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to fail to comply with medical advice, more likely to lack social support, and less likely to participate in cardiac rehabilitation than white patients.
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In other words, is it possible for physicians and other healthcare professionals to act in a racially biased manner without knowing it? To begin to address this question, the following section offers a hypothesis about clinical uncertainty, and how it may affect healthcare providers' decision-making, and ultimately influence the care provided to minority patients.
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From page 168... ...
White doctors may simply understand pain reports better from members of their own racial group. When the white male talks to the doctor, the doctor relates easily to the patient's report; when the Latino tells his story, the doctor follows less well, and picks up fewer implicit clues.
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Humans are social animals, and people tend automatically to classify others into important, essential social categories, typically relating to dimensions such as age, gender, and skin color. These
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Other studies reveal that among people who endorse egalitarian principles, racial bias may be expressed in subtle and indirect ways that can be rationalized on the basis of factors apparently other than race, or in the form of discomfort and uncertainty in interactions involving racial and ethnic minorities (Dovidio, 1999~. Other studies of social categorization reveal that when people or objects are categorized into groups, actual differences between members of the same category tend to be perceptually minimized and often ignored in making decisions or forming impressions (Fiske, 1998~.
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A number of studies demonstrate just how powerfully mere social categorization can influence differential thinking, feeling and behaving toward in-group versus out-group members. Mackie, Devos, and Smith (2000)
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Stereotypes and Healthcare Disparities Negative stereotypes about minorities, held explicitly or implicitly by physicians, can contribute to healthcare disparities in a number of ways. In some cases, healthcare providers may be consciously aware of their negative stereotypes of minorities, but may nonetheless view these stereotypes as accurate, functional, and appropriate for their clinical work.
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Stereotypes may also reflect well-meaning, but nonetheless harmful judgments on the part of healthcare providers. For example, physicians may be less aggressive in seeking minority patients' consent for certain medical procedures, out of a heightened (but nonetheless stereotyped)
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PATIENT RESPONSE: MISTRUST AND REFUSAL As noted above, racial and ethnic minority patients' responses to healthcare providers are also a potential source of disparities. Little research has been conducted on how patients may influence the clinical encounter.
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Therefore, future analyses of patient attributes that may be related to healthcare disparities must carefully consider the roots of these attitudes in historic and contemporary social and cultural forces, in and outside medical practice, that play a role in minority patients' perceptions of healthcare institutions. In the absence of careful study as to how patients may influence the clinical encounter and contribute to disparities in healthcare, the committee is reluctant to speculate on how and to what extent such processes occur.
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From page 176... ...
To summarize the evidence presented in this chapter and the previous two chapters that provider prejudice, stereotyping, and biases may influence clinical care: 1. With increasing sophistication, several recent studies of racial and ethnic disparities in receipt of health services have controlled for possible confounding variables or other possible explanations for racial and ethnic differences in care, including patient preferences, overuse of services by whites, health insurance status, type of health system, patient income and education, severity or stage of disease, co-morbidity, hospital type, and
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From page 177... ...
Minority race or ethnicity is found to be associated with generally more negative evaluations or lower rates of referral for clinical services, even when "patients" present with the same clinical condition. In addition, a survey of physicians following actual clinical encounters demonstrates that physicians endorse stereotypes about their African-American patients (who were characterized as "less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to fail to comply with medical advice," and less likely "to be .
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From page 178... ...
These streams of evidence lead the committee to conclude that bias, stereotyping, prejudice, and uncertainty on the part of healthcare professionals cannot be ruled out and indeed, appear among the many patient-level, system-level, and clinical encounter-level factors to contribute to racial and ethnic disparities in healthcare. Finding 4-1: Bias, stereotyping, prejudice, and clinical uncertainty on the part of healthcare providers may contribute to racial and ethnic disparities in healthcare.
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From page 179... ...
A small number of studies suggest that racial and ethnic minorities are slightly more likely than whites to refuse treatment, but this research has yet to distinguish the sources of minority patients' higher rates of refusal (i.e., general mistrust of healthcare providers, real or perceived experiences of discrimination in healthcare settings, or patient treatment decisions based on incomplete information from providers)
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