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)