MINORITY HEALTH: Study Confirms Heart Test ‘Bias’

      Doctors are significantly less likely to recommend cardiac catheterization for blacks and woman than for white men with identical complaints of chest pain, according to a study published in today's New England Journal of Medicine. Lead author Kevin Schulman of Georgetown University Medical Center found that for actor-patients with scripted identical health insurance, jobs, address and gestures, "blacks and women with chest pain [were] 40% less likely than whites or men to be referred by physicians for cardiac catheterization," the best diagnostic tool for heart disease (Rubin, USA Today, 2/24). Based solely on their symptoms, Schulman said, "all of the patients should have been referred for catheterization." In the study, 720 primary care physicians were shown videos of the actor-patients being examined by doctors and then asked to fill out surveys offering their own recommendations for care. Ninety-one percent of white males were referred for catheterization, "compared with 85% of blacks and women," with black women accounting for most of the difference (Burling, Philadelphia Inquirer, 2/25).

Who Me, Biased?
      Shulman concluded that while the bias "may represent overt prejudice on the part of physicians ... more likely, [it] could be the result of subconscious perceptions rather than deliberate actions or thoughts" (Schulman et al., NEJM, 2/25 issue). The study effectively puts to rest assertions by many in medicine that treatment biases are due to factors such as insurance coverage or socioeconomic status, the Inquirer reports. Schulman said, "I thing we have to challenge physicians to begin to say they are part of the problem and to move forward to say they are part of the solution" (2/25). Newsday reports that Shulman believes the study "is a small window into a larger problem of how biases affect the care patients receive." Dr. Luther Clark, chief of cardiology at SUNY Downstate Medical Center, noted, "Many faulty perceptions have developed over time about blacks and women." He said for years it was "believed that blacks did not develop coronary artery disease and severe chest pain in women was a manifestation of hysteria." The study also found that doctors perceived the black patients to be of lower socioeconomic status than the white patients, even though their addresses, occupations and insurance coverage were identical (Ricks, 2/25).

Fallout
      ABC's Peter Jennings reported that the study "is bound to make waves, political waves" because it is the first to illustrate "that prejudice among doctors causes a gap in the quality of health care between blacks and whites." Columbia University's Allan Rosenfield said, "I think the medical profession is going to be embarrassed by this. ... I don't understand the difference in any way except there has to be some form of subconscious or just-below the surface bias" ("World News Tonight," ABC, 2/24). U.S. Surgeon General Dr. David Satcher called the problem "serious" and joined Schulman in a call for medical schools and residency programs to train "future doctors to confront racial sensitivity in the same way that many other industries have." But bioethicist Arthur Caplan of the University of Pennsylvania added that such an effort will prove difficult. He said, "Some schools are teaching courses on race and sex and gender, ... but because many doctors and nurses come to medicine with the values, presumptions and biases that are in our society, you don't have to be consciously racist to see the influence of race and gender playing out in treatment" (Goldstein, Washington Post, 2/25). Nonetheless, Walter McDonald, executive vice president of the American College of Physicians-American Society of Internal Medicine, predicted, "We're going to go to school on this study" (Philadelphia Inquirer, 2/25).