Friday, January 4, 2008

Physician Bias =-Doctor Bias

The perfect is the enemy of the good.


To be perfectly blunt, I tire of searches for the perfect doctor - perfectly balanced, perfectly equitable, perfectly consistent. I weary of stories about physician bias against blacks, ethnic groups, the poor, and the uninsured. I dread commentaries saying no bias was intended but must be considered.

“Nobody’s perfect,” goes the cliché, and doctors don’t pretend to be. We don’t change stripes between patients. We evaluate, diagnose, and treat patients we meet.

Part of the attitude that a bias lies under every medical rock dates back to a 2002 Institute of Medicine Report “Unequal Treatment Confronted: Racial and Ethnic Disparities in Health Care.” Of the report, Alan Flieschman, MD, senior VP of New York Academy of Medicine, said this in a 2002 NYT letter to the editor:

Doctors, hospitals and the institutions that represent the medical profession must be held accountable for correcting those parts of this problem that are within their control. Medical racism is unacceptable.

Realizing that preconceived notions about others exist in all of us is critical to eliminating social stereotyping and the resultant disparities in medical services. The overt or unconscious bias that a physician may bring to a patient encounter must be recognized and eliminated.

I concur, in theory. But the crusade against “overt and unconscious bias” can be overdone. Much of this so-called “bias” may simply be a sampling problem
Consider the following, based on three medical journal aritcles, and widely reported in the media.

• The January 2 Hartford Courant ran a story “Drug Bias Seen in ERs.” It says whites are more likely to get narcotics for pain than blacks and other ethnic minorities, and is based on a January 3 JAMA article ( Pletcher, el, “Trends in Opioid Prescribing by Race/Ethnicity for Patients Seeking Care in US Emergency Departments “ The JAMA study indicated narcotics were prescribed for 31% of whites, 28% of Asians, 24% of Hispanics, and 23% of blacks. For blacks, the reporter speculated, doctors feared, presumably due to “social stereotyping, “ that blacks were more likely to be addicts and to feign pain. Maybe the doctors were right. Maybe black addicts visit ERs more often to get fixes because they’re unknown to ER personnel whereas private doctors might be more suspicious of feigned pain.

• The January 3 issues of both the NYT and the WSJ carried articles citing a NEJM article indicating too many American hospitals take more than 2 minutes to respond to sudden cardiac arrest ((Chan, P. et al: “Delayed Times to Defibrillation after in-Hospital Cardiac Arrest, “ NEJM, January 3, 2008). When response times exceeded 2 minutes, survival plunged. Response times were slow when hearts stopped at night or on weekends, in patients with non-cardiac diseases, in hospitals with fewer than 250 beds, units without cardiac monitors, and in blacks. The NYT reporter was careful to point out that racial bias may not have been a factor because blacks tended to be in smaller hospitals. Still, the NEJM authors felt compelled to say,

“The association of black race with delayed defibrillation is not intuitively obvious and raises potential issues of disparities in care. Further studies are warranted to determine whether such variations are due to geographic differences in access to hospitals with more resources (such as more monitored beds) or whether they reflect actual differences in practice patterns according to race.

• The January 3 Boston Globe features “Drug Distribution System Faulted.” The article says doctors distribute more free drug samples to the “wealthy and insured” than to the “poor and uninsured.” The reporter, citing an article in February issue of The Journal of Public Health, is, in my opinion, is subconsciously using the phrases “wealthy and insured” and “poor and uninsured” pejoratively . He implies doctors are systematically biased against the disenfranchised. However, The lead author Sara Cutran, MD, is carefully and correctly points out,

“Doctors are truly trying to target samples to needy patients, but their individual efforts failed to counteract society-wide factors that determine patient care.”

These factors, of course, include the reality that the insured tend to see doctors in their offices, while the uninsured more often go to ERs and hospital clinics, where free samples aren’t usually distributed. The faulty distribution, therefore, is not due to doctor bias, but to society factors beyond doctor control.

To conclude:

Some insist doctors harbor an ingrained bias,
Against blacks, so critics in the main decry us,
I say doctors can only treat
Patients they see or meet,
To say otherwise is overly pious.

Give doctors a break. In this imperfect world, inequality may depend on clinical and social circumstances, not on bias.


rlbates said...

Thank you for saying what I wish I could have put into words.

Happy New Year!

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