In a famous 1999 study, 700 physicians were given a simple case-study task. Each watched a video of a patient-actor describing chest pain and were given basic test results for that patient. Each doctor was then asked whether they would recommend the patient for cardiac catheterization, an additional diagnostic procedure. The patient cases varied in terms of type of chest pain, stress test results, and heart history, influencing the physician’s eventual decision. But when all of those clinical factors were controlled for, two other factors remained: race and sex. With everything else equal, black patients and female patients were 40 percent less likely to be recommended for catheterization; black, female patients were 60 percent less likely to be sent to advanced care.
“People assume that when physicians take the Hippocratic oath that somehow there is a miraculous, magic process that makes us free from any inherent stereotypes or biases that we may have had through our whole lives,” said Monica Peek, assistant professor of medicine in her MacLean Center for Clinical Medical Ethics seminar. “We want to be good physicians and give good care and be unbiased in our assumptions. But there’s not really any magic that happens just because you get a medical degree.”
Many studies of the health effects of discrimination focus on the world outside the doctor’s office, where the cumulative effects of sexism and racism negatively affect clinical measures such as hypertension and cardiovascular disease. Less attention is paid to discrimination within the healthcare system, Peek said, the often subconscious biases that physicians and other caregivers may use to make snap judgments about patients. Discrimination in this setting might directly affect preventative measures such as vaccination or screening, lower adherence to prescribed medications, and decrease patient satisfaction.
One way to combat discrimination within healthcare is to elevate the patient’s role in their treatment, creating a patient-centered and shared decision-making model. Research suggests that when the patient is an active participant in their care rather than a passive recipient of doctor’s orders, measures of trust, understanding, and satisfaction improve – and chronic disease measures such as glucose levels and blood pressure are better controlled. But for many African-Americans, shared decision-making in a healthcare setting is a foreign concept.
A 2008 focus group study led by Peek found that many African-American patients wanted to be involved in the decision-making process with their doctor, but many told stories that showed a less than equal relationship:
- “We make decisions together and she gives me what I’m suppose to take and she knows what I’m suppose to take.”
- “She told me I need to go to the dermatologist … Now the lady up there at the check out desk. I told her that I didn’t want to go.”
- “See, when the doctor tells me what to do, then I can make up my mind whether or not to do [it].”
“Basically African-Americans…wanted shared decision-making as much as their non-hispanic white counterparts when we adjusted for class and education – and maybe a little more so,” Peek said.
One way to help action meet expectations is to teach patients how to become more effectively involved in their medical care. To that end, Peek and colleagues in the Urban Health Initiative and Finding Answers have developed several interventions to empower patients, including videos, training sessions, and interactive uses of technology. In one program, diabetic patients received regular reminders via text message to check their blood sugar. Some were so excited to receive some form of daily interaction about their health, they wrote back thank you messages to the automated service.
“They loved the idea that somebody in the health care system cared about them,” Peek said. “The idea that somebody cared really resonated with a lot of our patients. These are patients who have a hunger to have a positive relationship with the healthcare system.”
[Each academic year, the MacLean Center for Clinical Medical Ethics organizes a series of lunchtime seminars by physicians, biologists, economists, social scientists and other experts covering the biggest questions in health care and ethics. This year’s theme is “Health Disparities: Local, National, Global,” and the series was put together with the Urban Health Initiative, the Global Health Initiative, and Finding Answers. ScienceLife will carry regular coverage of this unique series, and video of the lectures will be posted when available.]