Bias in Medicine

What Is Bias?

According to the Merriam-Webster Collegiate Dictionary,

Bias: An inclination of temperament or outlook; especially: personal and sometimes-unreasoned judgment. (Prejudice)

Prejudice: injury or damage resulting from some judgment or action of another in disregard to one’s rights; especially: detrimental to one’s legal rights or claims. A preconceived judgment or opinion, an adverse opinion or learning formed without just grounds or sufficient knowledge.

Upon graduating from Medical School, physicians take what is known as the Hippocratic oath. A modern version, approved by the American Medical Association states:

You do solemnly swear, each by whatever he or she holds most sacred

That you will be loyal to the Profession of Medicine and just and generous to its members

That you will lead your lives and practice your art in uprightness and honor

That into whatsoever house you shall enter, it shall be for the good of the sick to the utmost of your power, your holding yourselves far aloof from wrong, from corruption, from the tempting of others to vice

That you will exercise your art solely for the cure of your patients and will give no drug, perform no operation, for a criminal purpose, even if solicited, far less suggest it. That whatsoever you shall see or hear of the lives of men and women which is not fitting to be spoken, you will keep inviolably secret.

These things do you swear, Let each bow the head in acquiescence And now if you will be true to this, your oath, may prosperity and good refute be ever yours; the opposite if you shall prove yourselves forsworn.

This is quite a lofty ideal and yet most physicians try to uphold it to the best of their abilities. However, in recent years a topic of concern has come up that concerns the medical field. It is called Bias. It affects race, gender, age, cultural, and social differences, and it is instrumental in denying certain people the type of care that they should receive, and is often responsible for the fatality of their respective diseases.

A study was published in the New England Journal of Medicine in February of 1999, revealing that racial and gender bias may still play a role in influencing health care providers’ decision-making. The study's authors report that women and blacks presenting with chest pain were almost two times as likely as white men not to be referred for cardiac catheterization.

Georgetown associate professor of Medicine Kevin Schulman, M.D., set out to address the question of bias in physician’s recommendations. The study used professionally produced and recorded multimedia presentations of interviews of patients with chest pain. The patients were eight actors, reading scripted descriptions of their symptoms. They were dressed identically, presented as having identical insurance and occupations, and directed to act identically in their presentations. The only variables were the age, sex, and race of the respective patients. The actors consisted of two black men, two black women, two white men, and two white women. The presentation was shown to 720 physicians attending one of two national meetings of organizations of primary care physicians. The physicians were asked to evaluate the patient's chest pain and whether they wished to order further cardiac evaluations. They were then shown the result of a thallium stress test and were asked whether they wished to refer the patient for catheterization. The results of the study revealed that when all the variables but race and sex are controlled, men and whites are more likely than women and blacks to be referred for catheterization, and that black women were significantly less likely to be referred for catheterization that white men.

Heart disease is the number one killer in the United States, for women as well as men, blacks as well as whites. The Schulman study showed, however, that recommended treatment for heart disease varied substantially based on race and sex.

Unfortunately, this study is not the first study to be conducted on this topic. There have been several studies done since the 1980’s that have repeatedly shown that there is sex and race bias in the treatment of heart disease. In 1987, in a study conducted by J. Tobin and S. Wassertheil-Smoller, “Sex bias in considering coronary bypass surgeryrdquo;, 390 patients were referred for nuclear exercise testing, 31% of the women and 64% of the men had abnormal results, yet only 4% of the women, compared with 40% of the men, were referred bye cardiologists for catheterization. For more than 25% of the women with abnormal nuclear scans, symptoms were diagnosed by the examining cardiologist as somatic or psychiatric, an explanation given for only 12% of the men.

In 1991, J. Ayanian and A. Epstein reported in the New England Journal of Medicine, the results of a retrospective examination by regression analysis of over 80,000 men and women treated for heart disease in Massachusetts and Maryland in 1987. They controlled for principal diagnosis, age, secondary diagnosis of congestive heart failure of diabetes, race, and insurance coverage. They found that women hospitalized for coronary heart disease underwent fewer major diagnostic and therapeutic procedures than men. In particular, they found that the odds of undergoing angiography were 15% to 28% higher for men than for women, and the odds of undergoing revascularization were 27% to 45% higher for men than women.

Ayanian, et al, disclosed further evidence of how widespread the differences are between heart disease care for whites and blacks. They retrospectively examined the treatment of more than 27,000 Medicare enrollees between the ages of 65 and 74 who were treated for coronary heart disease in 1987 at 1429 U.S. acute care hospitals that provided coronary angiography. Because these patients had Medicare A, were of the same age, and had already been examined by angiography by a heart specialist at an acute care hospital, many of the explanations suggested in prior studies were eliminated. This study revealed that white males were most likely to receive revascularization and black women were the least likely to receive revascularization.

In a study published in 1993 in the New England Journal of Medicine, by J. Whittle, et al, it was found of 822,930 coronary heart disease patients, treated between 1987 and 1991 at U.S. Veterans Affairs Hospitals that whites were 50% more likely than blacks to undergo angioplasty and 122% more likely to undergo coronary bypass surgery.

This matter of race and gender bias has become such an important issue that over the past two years, the Centers for Disease Control and Prevention (CDC) has funded 40 programs for communities in states attempting to eliminate health disparities. Congress increased the National Institutes of Health (NIH) budget by $2.8 billion.

In 1990 the Department of Health and Human Services (DHHS) Office of Prevention and Health Promotion released a health agenda, called Healthy People 2000. This program encompassed 300 national health objectives in 22 categories that included physical activity, nutrition, tobacco use, substance abuse, occupational safety, unintentional injury, sexually transmitted diseases, and other disease-specific categories, all aimed at increasing the life span of individuals. The goal of Healthy People 2010, while hoping to increase years and quality of life, also focuses on eliminating racial and ethnic disparities in healthcare. Healthy People 2010 can be found on the Internet at: http://www.health.gov/healthypeople/.

In his plenary address presented at the Society of General Internal Medicine (SGIM) 24th Annual Meeting, on May 2, 2001, David Satcher, MD, Surgeon General of the United States provided an overview of where and how the present administration is using federal resources to eliminate health disparities among different racial and ethnic groups. He recommended an overall plan of attack for decreasing disparities that included:

Access to quality care.
Mental Health; the second highest disease burden according to the Global Burden of Disease Study, conducted by the World Health Organization, the World Bank, and Harvard University.
Environment
Lifestyles

In closing, Dr. Satcher called for physicians to continue to address these four areas on the local, state, and national levels to eliminate existing disparities in care.

Unfortunately, there were only 1600 individuals registered which was a record breaking number of attendees, and while the agenda is a good start, it still does not address the fact that race and gender attitudes of treating physicians significantly affect the treatment of patients, as was established in the Schulman study.

Charles R. Lawrence III, in his article, The Id, the Ego, and Equal Protection: Reckoning with Unconscious Racism, offered this observation:

Racism is part of our common historical experience and…culture. It arises from the assumptions that we have learned to make about the world, ourselves, and others as well as from the patterns of our fundamental social activities.

The Schulman study not only requested treatment recommendations but also inquired about physician’s perceptions of the actor-patient’s personal characteristics. The results showed that physicians regarded the black patients as more hostile, less self-controlled, less knowledgeable, less independent, and less likely to comply with treatment than the white patients. Doctors assessed the female patients as being less intelligent, less self-controlled, and more likely to over report symptoms than the male patients. Physicians assessing white male patients as compared to black female patients saw white men as more friendly, more intelligent, more self-controlled, more communicative, more independent, and happier than the black women. These findings are consistent with surveys of white attitudes about blacks generally. The Schulman results strongly suggest a link between the stereotyping that permits physicians to view actors reading lines in terms of commonly attributed race and gender differences and the physicians treatment recommendations, which favor white men while disfavoring blacks and women, and especially black women.

In order to start changing these medical practices, one must come to terms with the reality of the data, and then forge a determined commitment that where race and gender differences are rooted in stereotype rather than in symptom, they have no place in medical practice. Developing new awareness that these stereotypes affect the judgments and perceptions of even the most well intentioned people, and rigorous retraining of judgments and perceptual vigilance will go a long way towards rectifying this problem.

However, Bias is not just relegated to women and minorities. It has also affected LGBT’s (Lesbians, Gays, Bisexuals, and Transgenders). LGBT’s make up at least 10% of the population. LGBT patients have an increasing risk of suicide, eating disorders, substance misuse, breast cancer, and anal cancer.

Fear and lack of knowledge by both health care providers and patients lead to sub optimal care or no provision of health care, and there is a limited amount of information available within the LGBT population concerning health care risks.

Fear of stigmatization prevents patients from revealing their sexual orientation, and as many as two-third’s of health care providers don’t ask the sexual orientation of their patients.

According to a report form the Secretary of the Department of Health and Human Services Task Force on Youth Suicide in 1989, Gay youths accounted for 30% of completed suicides. Forty percent of LGBT youths have attempted or seriously considered suicide.

In a recent study, it was reported that only 54% of lesbian and bisexual women had been given a cervical smear within the past year, and 7.5% had never had a pap smear. This is partially due to the misconception that lesbians are not at risk for cervical cancer.

According to the Associated Press, doctors and insurers have only recently started to support organ transplants in patients with HIV, and many are still skeptical and question whether the operations are warranted in people who have shorter life spans and more health problems than other patients. In 1999, the United Network for Organ Sharing received five reports of organ transplants for HIV-positive patients, a number that grew to 11 in 2000.

However, owing to the differences in how states report operations involving HIV-positive patients, those numbers have a high probability of being incomplete.

In a report put out by the Planetout.com network, researchers in San Francisco are organizing the largest-ever clinical trial for HIV-patients who need organ transplants. It was also noted that the medical center at the University of California, San Francisco, plans to recruit as many as 15 hospitals for a clinical study of organ transplants in patients with HIV.

Also according to this report, Empire Blue Cross and Blue Shield are making it easier for HIV patients to get transplants. Dr. Alan Sokolow, Empire’s Chief medical officer, was reported to have stated that, The previous policy basically said that HIV was too significant a risk factor for consideration of transplants. Now that we know more about how HIV and transplants interact, it’s possible to consider certain situations of HIV infection to be acceptable conditions for transplant.

Gender-biased differences may emanate from a biomedical (genetic, hormonal, anatomic, physiological); psychosocial (personality, coping, symptom reporting); epidemiological (population based risk factors), or even a more global perspective. The latter analyses large-scale cultural, social, economic, and political processes that ultimately produce differential health risks for women and men.

Women’s healthcare is affected by:

Their unequal status in society
Lower levels of political participation
Higher levels of poverty
More often being the single parent who is underinsured or uninsured
Limited resources to health care
Making up the majority of the elderly and disabled

Are Outcomes Improving?

The most recent analysis from the National Registry of Myocardial Infraction-I confirmed that while women with acute MI continue to be older than men, (56% of women experiencing their first MI do so after age 70), women still have higher mortality rates even when controlled for age.

In an Article in the Archives of Internal Medicine: Journals of AMA (vol. 160 no. 20, November 13, 2000) Differential Access in the Receipt of Antiretroviral Drugs for the treatment of Aids and Its Implications for Survival it was stated that there is a need to investigate why women are less likely to receive antiretroviral drug therapies than men.

The bottom line in health care today appears to be this:

Disregarding gender, age, race/ethnicity, the patients’ responsibility seems to be seeking the best care available for him/herself.

This would include:

Using all avenues available, i.e. the internet, the library, second opinions, and book stores to find information about one’s condition

Informing the healthcare provider of all information that is pertinent to one’s condition
Making sure that they have been satisfied as to the care they have received and if not, then seeking care elsewhere

On the other hand, the healthcare provider’s duties and responsibilities remain the same as they have always been:

Making sure that they are giving their patients’ the most up to date treatment that is available
Asking patients pertinent questions, including their sexual preferences
Not discriminating according to age, gender, or race/ethnicity
If unable to give the needed care, making sure to refer the patient to someone who can give the needed care

Bias in Medicine will continue to be an issue in healthcare until healthcare providers can identify and put aside said bias, treating each and every individual to the best care available according to the healthcare provider’s ability, and until patients become more involved with their own healthcare by demanding the best care, even at the political levels.

Web page generated by Nick Zymaris.
Page created: November 10, 2001
Last modified: November12, 2001