Health Care

Imagine for a moment being involved in a sporting accident. You're taken to the Emergency Room, where they determine your tibia is broken. One of the ambulance attendants mentions that you're the "second broken leg they've gotten today." You complain to the nurse who's attending to you about the extreme pain you feel in your limb, and ask if something can be done about it. A few moments later she arrives with two tablets of prescription-strength acetaminophen. A half hour later the pills have done nothing for your excruciating pain. Meanwhile, it's been 20 minutes since you've heard the other individual with a broken leg moan, and he appears in fact to be asleep. Your parents arrive shortly before his do. You complain to them about the pain and your father goes to try to find the doctor. He returns and tells you that the doctor will soon be with you. You're all astounded when you overhear a nurse explaining to the other person's parents "we've given him a pretty large dose of morphine to quell the pain and make him feel more comfortable. He may or may not recognize you but you can talk to him..."

What's the difference between you and the other boy with a broken leg? For purposes of this writeup; he is white, age 21, sports short blonde hair and expensive sportswear. You are black, age 21, your long black hair is twisted into dreadlocks. You, too, are wearing fashionable sportswear. That's it. Don't worry, I'll attempt to explain this situation, and what's being done about it, herewith.
 

Why Are Emergency Rooms Allowing Minorities to Suffer Unnecessarily?

Many intelligent, progressive Americans can probably fill a blank sheet of paper with examples of overt racism in this country which remain alive and well in the new millennium. Incidents of racism which result in a civil rights action at law still, sadly, occur.

Racism becomes far more perplexing and frightening when a trend is identified such as one published recently in a report in the Journal of the American Medical Association. A team at the University of California San Francisco has concluded that despite efforts since 2001 to improve standards of pain management in various heath care settings nationwide, persons of color are less likely to be prescribed powerful pain killers, typically opiates, than white patients, despite presenting with exquisitely painful injuries/disorders which are virtually the same.

“Studies in the 1990s showed a disturbing racial or ethnic disparity in the use of these potent pain relievers, but we had hoped that the recent national efforts at improving pain management in emergency departments would shrink this disparity,” said Mark Pletcher, MD, a UCSF assistant professor of epidemiology and biostatistics and lead author of the study. “Unfortunately, this is not the case.”

This study was more of a data-collection exercise than an attempt to explain why the data proved yet another incidence of racism in modern American culture. Dr. Pletcher and his colleagues utilized data garnered from the National Hospital Ambulatory Medical Care Survey, which took place in cooperation with the U.S. Census Department, and lasted from 1993 to 2005. The report reveals that 42 percent of the 374,891 Emergency Room visits were pain related. For the duration of the study, 31 percent of white patients with pain received an opioid versus 23 percent of black, 24 percent of Hispanic and 28 percent of Asian/"other" patients. By 2005, the racial gap was still wide statistically; 40 percent of whites with pain received an opioid compared with only 32 percent of minority patients. Shockingly, the racial gap appeared no matter what the cause of the pain, and in fact the gap increased as a function of severity of pain.
 

Other Data on Race and Medication Are Similar

The American Journal on Obstetrics and Gynecology published a joint-agency survey of Medicaid patients in Georgia in 1998. This particular survey found very similar variations in the percentage of white women receiving epidural pain management in vaginal births as compared with the percentages of individual minorities and minorities as a whole.

The small-sample study came to the same conclusion that the UCSF study did:

The study subjects all had identical Medicaid insurance and met the same low-income Medicaid eligibility criteria, yet race/ethnicity was still a significant predictor of epidural analgesia after we had controlled for age, rural-urban residence, and availability of anesthesiologists. Further studies are needed to assess perceived benefits, risks, costs, and obstacles to epidural analgesia that are perceived by patients, physicians, nurses, and midwives.

No recommendations were made but for the need for further studies. Yet the data come out the same. This was in 1998 - and it bears repeating that causation was not one of the aims of the UCSF study, it merely examined existing healthcare data available, as did the Georgia study.
 

There Are Answers Available

Nearly 90 sources of data and opinion were used to create an enlightening book on the subject of race and healthcare. Perhaps the most thorough examination of differences overall quality of healthcare delivery analyzed by race of patient is a book published by the National Academy of Sciences: Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. This book is, mind you, a difficult read for the lay person. However, it's amazing how comprehensively it looks at the problem and seeks to find answers. Some suggested causations for the disparity in data are simple matters of education. Education of doctors, nurses, and healthcare workers. Education and empowerment of patients, particularly those for whom translation services are necessary. Finally, the book is also very candid about affirming certain stereotypes of patient behavior and recommending ways the health care system can overcome these stereotypes.

A few key ideas garnered from the abovementioned book and the UCSF study are listed here:

  • Generally, the medical community has been hesitant to properly manage pain.
     
  • Even following promulgation of NIH and CDC guidelines in 2001, physicians and physicians' assistants were hesitant about, and under-utilized proper pain management protocols. This despite the benefits of proper pain management outweigh the risks involved in utilization of opioids.
     
  • Several sources mentioned a general fear of authority leading to a loss of feeling of empowerment particularly in the case of black patients, leading them to understate their pain.
     
  • On the contrary, white patients were more outspoken and verbal about their pain management needs.
     
  • Several sources mentioned doctors' hesitance to prescribe commonly-abused pain medication to urban minority members for fear of addiction or abuse of the substances upon release from the health care setting.
     
  • Doctors, although being highly educated and therefore perhaps less apt to subscribe to racist behaviors, are taken to task for the commission of acts of racism, both overt and by way of miscommunication. The gravity of racism on the part of doctors ranges from out-and-out prejudice, to beliefs or stereotypes held by healthcare professionals about patients' behavior or health.
     
  • Anecdotal information relayed enough data for a whole chapter of the book published by The National Academy of Sciences. "To many observers, the mechanism behind disparities that comes most immediately to mind is provider prejudice: doctors and other providers might have a lower regard for minority patients and treat hem less well. Prejudice is the least subtle of the mechanisms likely involved in clinical disparities, and does not require a sophisticated understanding of doctor-patient interaction to see how it might work" a conclusion reads.
     
  • The clinical experience is brief and the physician under enormous pressure and also time constraints with regard to the treatment of patients. Often, difficulty in communication with healthcare workers, due to inability to understand medical terminology, will increase the caution with which a physician approaches a particular case. Additionally, lack of communication about pain may lead a physician to mistakenly assume that a mere complaint of "pain" rather than one which is better described is a warning sign for drug-seeking on the part of the patient.
     
  • Given, again, the limited amount of time and information the doctor may spend with a patient, particularly in the Emergency Room setting, and the cognitive pressure placed on the physician, although the physician may never, upon direct inquiry, admit to stereotypes about certain patient behaviors, the physician may unconsciously act using that perspective on certain patients.
     
  • Patients who may perceive the physician as "aloof" or "arrogant" will react negatively to such behaviors, compounding the negative response of the physician, as well as other caregivers, to the patient. This is again amplified by a high-pressure setting where staffing and resources may be limited. A study of approximately 200 doctors performed in 2000 found, however, that by a panel of 60 percent white and 40 percent black physicians, that with all things constant but for a "post angioplasty interview" given to "patients" who were actually well-prepared actors, black 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.
     

Recommendations

Of course, it's difficult to combat overt racism, despite how much "sensitivity training" and the like is given to healthcare professionals. The hope is that as racism declines and is found more and more socially abhorrent by the public at large, the problem will decrease.

The good news is that racial differences in pain treatment caused by non-overt reasons are much more easily rectified. Fixes include simple enhancement of communication, re-writing of patient questionnaires, and enhanced pain management techniques (checking for pain more and more often, and utilizing various scales which may be more understandable or comfortable for the patient to relate to).

What YOU can do is find out what is being done in their community about racial differences in health care. Read your local hospital's plan for progressive healthcare. Ask local advocates for minorities what can be done. And petition the authors of the study at the University of California San Francisco what their organization's next steps are by way of finding causation for the data they've accumulated and analyzed. You can also read the book Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care for free at http://www.nap.edu/openbook.php?record_id=10260&page=R1.
 

In conclusion, the recently published UCSF study is the tip of the iceberg with regard to equality of health care. Remember, only one point — pain management and variance by race — is touched upon. It is not the purpose of this writing to engage in hand-wringing nor amplifying evidence of racism by way of being inflammatory. The good news is that as clinical interaction between doctor and patient is analyzed, researchers come up with information that benefits all of us. For instance, pain management was once a difficult subject for doctors to address and they'd err on the side of "not enough." The holistic benefits of pain management despite the use of powerful, potentially addictive substances, have been proven to be far more effective than to not use them. Beside, patients who are treated with opioids in a hospital setting are rarely sent home with the drugs, and far more rarely are found to try to seek them out illicitly after a hospital stay. Health care litigation reforms have been legislated, enabling doctors to provide proper patient comfort without the worry of somehow being accused of malpractice.
 

SOURCES:

DigitalJournal: http://www.digitaljournal.com/article/248266/ER_Doctors_Show_Racial_Bias_in_Prescribing_Painkillers (Accessed January 5, 2008)

"Minorities Less Likely to Get Powerful Painkillers in ER" by Randy Dotinga, Healthday http://www.healthfinder.gov/news/newsstory.asp?docid=611342 (Accessed January 5, 2008)

"Racial Gap in ER Opioid Use Still Persists" Reuters News Service Article included in Scientific American Online http://www.sciam.com/article.cfm?id=racial-gap-in-er-opioid-u (Accessed January 5, 2008)

"Racial and Ethnic Disparities in the Provision of Epidural Analgesia to Georgia Medicaid Beneficiaries During Labor and Delivery" George Rust, MD, MPH; Wendy N. Nembhard PhD; Michelle Nichols MD; Folashade Omeole MD; Patrick Minor MS; Gerrie Barosso MPH, MS; and Robert Mayberry, PhD; American Journal of Obstetrics and Gynecology, Volume 191, Issue 2, August 2004, Pages 456-462 (Accessed at www.sciencedirect.com on January 5, 2008)

"Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care" Brian D. Smedley, Adrienne Y. Stith, and Alan R. Nelson, Editors, Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care, Board on Health Sciences Policy, Institute of Medicine of the National Academes www.nap.edu (Accessed January 5, 2008)

"Drug Bias Seen In ERs: Whites Likelier to Get Potent Painkillers" (Combined Wire Services, January 2, 2008) The Hartford Courant, http://www.courant.com/news/health/hc-painkillers0102.artjan02,0,6599843.story (Accessed January 5, 2008)

"Blacks, Hispanics Less Likely to get Strong Pain Drugs in Emergency Rooms" (Press Release) by Wallace Ravven, UCSF News Office, University of California, San Francisco http://pub.ucsf.edu/newsservices/releases/200801021/ (Accessed January 5, 2008)

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