the color of health care

September 23, 2007 § Leave a comment


By Shankar Vedantam
The Washington Post
Monday 13 August 2007

Long before word recently broke that white referees in the National Basketball
Association were calling fouls at a higher rate on black athletes than on white
athletes, and long before studies found racial disparities in how black and
white applicants get called for job interviews, researchers noted differences
in the most troubling domain of all – disparities in survival and health among
people belonging to different racial groups.

Black babies, according to the federal government’s Centers for Disease Control
and Prevention, have higher death rates than white babies. Black women are more
than twice as likely as white women to die of cervical cancer. And in 2000, the
death rate from heart disease was 29 percent higher among African Americans
than among white adults, and the death rate from stroke was 40 percent higher.

The trouble with all these numbers, as with the NBA study – which was conducted
by researchers Justin Wolfers and Joseph Price – is that they do not explain
why such differences exist among racial groups.

Some studies have shown, similar to the NBA analysis, that diagnoses and
treatments offered by physicians vary between racial groups, for diseases as
dissimilar as heart disease and schizophrenia. But does this reflect physician
bias, or the possibility that patients from different backgrounds present
themselves differently? Could race be a marker for some other variable that
really matters, such as health insurance status?

A new study by researchers at Massachusetts General Hospital and other
institutions affiliated with Harvard University provides empirical evidence for
the first time that when it comes to heart disease, bias is the central problem
– bias so deeply internalized that people are sincerely unaware that they hold

Physicians who were more racially biased were less likely to prescribe
aggressive heart-attack treatment for black patients than for whites. The study
was recently published in the Journal of General Internal Medicine.

The research finding cannot be automatically extrapolated to the NBA or other
domains, but it does suggest a mechanism by which disparities emerge. No
conscious bias was apparently present – there was no connection between the
explicit racial views of physicians and disparities in their diagnoses. It was
only when researchers studied physicians’ implicit attitudes – by measuring how
quickly they made positive or negative mental associations with blacks and
whites – that they found a mechanism to explain differences in medical

“Physicians who had higher biases against blacks were less likely to recommend
thrombolysis for blacks,” said Alexander R. Green, the study’s chief
investigator and a faculty member at the Disparities Solutions Center at
Massachusetts General Hospital.

Thrombolysis is a clot-busting technique given when doctors suspect that a
patient is having a heart attack. It is not to be given lightly, which is why a
physician’s judgment is crucial in telling patients who are merely having aches
and pains apart from patients at death’s door.

Green had 287 physicians at four academic medical centers in Boston and Atlanta
take a psychological test for bias. He followed it up by providing a case study
of a 50-year-old man called “Mr. Thompson,” a smoker with a history of
hypertension, “who presents to the emergency department with chest pain. He
appears to be in a lot of pain describing it as ‘sharp, like being stabbed with
a knife.’ ”

The patient was described to some physicians as white and to others as black.
Physicians were asked to decide whether the pain was the result of coronary
artery disease and whether to prescribe clot-busting drugs.

Doctors were more likely to think “Mr. Thompson” was having a heart attack when
he was black than when he was white. But they did not prescribe treatment to
reflect this – physicians who thought a black Mr. Thompson was having a heart
attack prescribed thrombolysis less often than when they thought a white Mr.
Thompson was having one.

Green said numerous other studies are underway to evaluate the utility of
psychological tests for bias to explain disparities in medical domains. “We
have reason to suspect you can measure unconscious bias among physicians and
show it has an impact on treatment decisions,” he said.

Mahzarin Banaji, a co-author and Harvard psychologist who helped develop the
Implicit Association Test used in this study, said the racial bias unearthed by
the study is at odds with conventional views of bigotry – and perhaps more
insidious. Rather than harboring deliberate ill will, she said, the physicians
had apparently internalized racial stereotypes, and these attitudes subtly
influenced their medical judgment without their even realizing it.

The study of physicians had one hopeful note, Banaji said: Doctors at least
were willing to open their subconscious minds for inspection, which is
something that many other professionals – judges, police officers and NBA
referees – rarely are willing to do.

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