Hidden in the World of Medicine, Discrimination and Stereotypes

June 19, 2001, Tuesday

CASES; Hidden in the World of Medicine, Discrimination and Stereotypes

By SANDEEP JAUHAR, M.D.

It is obvious from even a cursory look at history that doctors sometimes act with prejudice. Consider that as recently as the early 1960's, before major civil rights and Medicare legislation, black women were housed in separate maternity wards. Or that 10 years ago, in some places, AIDS patients could not find a surgeon.

Fortunately, blatant discrimination has declined in American medicine, as in other sectors of American life. But bias persists in subtle, more camouflaged forms.

Last year, an obese middle-age man was admitted to my hospital after a small heart attack. He underwent a coronary angiogram, a procedure that uses X-rays and dye to visualize the arteries supplying blood to the heart, but the pictures came out fuzzy because of the fat around his chest. Still, there appeared to be significant arterial blockages that were depriving his heart muscle of adequate blood flow.

Cardiologists tried opening one of the blockages with a balloon catheter, but the procedure failed because of the poor view. So the patient was transferred to the wards for medical management, which means drugs but no further invasive procedures.

What he really needed was bypass surgery. A surgeon was consulted, but he said heart surgery was too risky. Since the patient was already almost totally immobilized by his weight, wound healing and physical rehabilitation would be prohibitively slow. Another surgeon agreed. So surgery was shelved, his drug regimen was tuned up, and the patient was sent home.

Several months later, he was back after a protracted bout of chest pain. He said he was not doing well. His angina was becoming more frequent and more severe, and it was often accompanied by an oppressive sensation of breathlessness. He was regularly popping nitroglycerin. Surely something, I thought, even risky surgery, would be better than waiting for the time bomb in his chest to go off.

I spoke with his cardiologist. Conceding that medical management had failed, he said he was going to consult the surgeons again; perhaps now they would see things differently. I was skeptical. The surgeons had been firm and persuasive in their arguments, and I didn't expect them to change their minds.

''Still, I wonder if the surgical option was dismissed too quickly,'' the cardiologist said. ''Sometimes we look at a patient like this and make a judgment that isn't always fair or rational or even medical.'' The comment and case stayed with me. Had we discriminated against this patient because of his weight?

It did not appear that our prejudice, if it existed, had been conscious. Granted, the patient's obesity had been on our minds in deciding on his treatment. But had we been hypersensitive about his obesity, to his detriment? Had we made a value judgment that because of his weight, surgery would be wasted? Or worse, that he was somehow less deserving of surgery because he was unable or unwilling to control his weight?

Doctors can be a judgmental sort. In fact, it can be argued that making judgments is the essence of what doctors do. That elderly man in the intensive care unit: should we treat the patient aggressively or pull back? Should that alcoholic with liver failure get a transplant? These are medical judgments but moral ones, too.

Judgments about personality, character and worthiness are reflected in all aspects of the doctor-patient relationship, from the language doctors use to describe patients (hysterical, difficult, nice, solid) to the attitude we take into the examination room.

Every day, in clinics and emergency rooms, doctors encounter drug addicts with endocarditis, smokers with lung cancer and others seemingly bent on self-destruction.

To treat them with perfect equanimity, without any trace of moral or value judgment, would be impossibly Zen. But to act upon these judgments, to allow them to alter treatment, would be violate fiduciary responsibility.

Personal judgments, however, can lead to prejudgments and prejudice. Recent studies on health outcomes in various patient populations suggest that subtle prejudice may be widespread in health care.

For example, a recent study in The New England Journal of Medicine showed that blacks not only waited longer than whites for kidney transplants, but that they waited longer to get on a kidney transplant waiting list, even though they disproportionately suffered from kidney failure. Why do doctors delay?

There is more: Compared with whites, black women are twice as likely to receive inappropriate treatment for ovarian cancer, and they have a worse prognosis; blacks with lung cancer are less likely to receive possibly curative surgery; and blacks with heart disease get fewer cardiac angiograms and bypass operations, have worse outcomes after a heart attack and are less likely to receive standard drugs like aspirin and beta blockers. Not long ago, The New England Journal of Medicine reported that the difference in angiogram rates was independent of the doctor's race. These differences persist even after correcting for disease severity, insurance status, geography and income.

The disparities are not limited to race. Women with heart disease get fewer cardiac angiograms and catheter procedures than men, and they are more likely to die from heart attacks and unstable angina. A recent study showed that women with chest pain waited longer than men did for emergency room examinations. Perhaps influenced by behavior stereotypes, doctors may be more likely to minimize symptoms in women and attribute them to emotions.

The list could go on, encompassing gays, the elderly and other groups. These and other studies suggest systemic discrimination in medicine, though it is hard to draw any firm conclusions from them.

Why does it take longer for doctors to put black patients on the kidney transplant list? Is it racism, or is it because blacks have a higher rate of transplant rejection?

Why are doctors more likely to withhold artificial ventilation, dialysis and surgery from seriously ill elderly patients than from their younger, equally ill counterparts, even after preferences regarding aggressive treatment are accounted for? Is it discrimination, or rational and merciful medicine? (In Britain, age is routinely used as a criterion for rationing treatments like dialysis and heart surgery.) Bias, unconscious or not, may account for these disparities, but it is camouflaged; the difficulty of identifying bias is perhaps why it is so hard to root out.

After almost three years of medical training, I am no longer surprised by the small injustices I see in the hospital. Ours is a multitiered system, and the tiers can be defined any which way. Frankly, what is surprising are the rare doctors who treat the Bowery bum with the same care as the Madison Avenue socialite. They are the kind of doctors who seem untouched by bias, or at least recognize their biases and fight to disentangle them from medical decisions. Like their colleagues, they appear unaware of their behavior and how much it matters.

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