Law 803 Health Care Malpractice
Professor Vernellia Randall
The University of Dayton School of Law

Racial Disparities as Medical Error

 

01: Introduction
02: Sickness and Quality
03: Medical Error
04: Provider Obligation
05: Hospital Obligation
06: Contractual Relationship
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Sidney D. Watson

Excerpted from: Sidney D. Watson, Race, Ethnicity and Quality of Care: Inequalities and Incentives , 27 American Journal of Law and Medicine 203-221, 205-210 (2001)(131 Footnotes Omitted)

As was my custom, I moved from one exam room to the next with a fluidity that comes from years of practice, yet I was stopped in my tracks when Mr. North rose to his feet to greet me. His deep ebony, six foot>three>inch frame dwarfed my pale, five>foot>three presence. The tremendous hands on his 260 pound body grabbed my own outstretched right hand and shook it .... I glanced at his face, trying to see through my initial discomfort, only to be greeted by my own face staring back at me from the silver, reflective sunglasses he wore beneath a baseball cap that covered his head and any hair that might have been growing on it. His huge chest was tightly wrapped in a black T> shirt that, even in its largest version, couldn't stretch comfortably to encompass his pectoral girth .... Mr. North became one of my favorite patients ... I like him because I realize how hard I have had to work all of my life to overcome the racist feelings that made me fear him when we first met and that never allow me to act completely naturally in his presence. . . . There is absolutely no doubt that Mr. North is treated differently than my white, middle>class patients. The echocardiography lab where he had an appointment sent him home because he was ten minutes late, having to stop every block to rest in the walk from his home to the hospital on a particularly windy day. The pharmacy refused to refill his insulin syringes without a written prescription, even though he had been getting them at the same pharmacy for the past two years. I try to help in every way I can. Every time I send him to a new consultant, I call ahead with an introduction. I tell them how smart Mr. North is, how compliant he is with every aspect of his treatment, and how he knows so much about his medical condition and the medications he takes. I hope that my introduction will enable them to see my patient as I see him now, not as I saw him the first time we met. He needs that help in order to get the medical care he requires and deserves.

Race matters. A plethora of studies and reports document that the patient's race makes a difference in the care received. Race and ethnicity are consistently linked with different and poorer patterns of health access and treatment.

Minority Americans have significantly higher rates of cancer, stroke, heart disease, AIDS, diabetes, and other severe health problems than white Americans. However, even though minority Americans are generally in worse health than white Americans, they have fewer doctor visits, receive less primary care and fewer preventive procedures even when they have the same insurance coverage. Insured Blacks and Hispanics are less likely than whites to have private physicians and are more likely than whites to rely on hospital emergency rooms and outpatient clinics for primary care. As a result, Black, Hispanic and Native Americans are hospitalized more often than whites.

Moreover, health care professionals provide different>>and generally less>> care to their minority patients. When hospitalized, African>Americans receive fewer surgical interventions, diagnostic tests, medical services, and less optimal interventions than whites>>even when their diagnosis, symptoms, and source of payment are the same. The findings for African>Americans are consistent for every service studied: cardiology and cardiac surgery, obstetrics, general medicine, kidney transplants, hip replacements, mammograms, oncology and leg sparing surgery for peripheral vascular disease. All told, African>Americans get only about three>quarters the high technology interventions prescribed for whites. They are more likely to be discharged in an unstable condition and more likely to have longer hospital stays.

Outpatient care is no different. African>American patients are less likely to be prescribed antidepressants for major depression and anti> retroviral therapy for HIV infection. They are also less likely to get adequate treatment for cancer>related pain.

While less is known about access and treatment for other minority Americans, the few available studies confirm that Hispanic and Native Americans suffer from similar treatment disparities. Both Hispanic and Native Americans are significantly less likely than whites to receive cardiac bypass surgery and angioplasty, and Hispanics are less likely to receive other major therapeutic procedures. Hispanics are also less likely to get adequate treatment for cancer>related pain, and are twice as likely as white patients to receive no pain medication when treated in the emergency room for bone fractures.

These race>based treatment differences raise concerns about the quality of medical care for minority Americans. They are not the result of biology, age, gender, clinical condition, severity of disease or insurance status. Contrary to popular belief, the gaps cannot be attributed to insurance status or income: significant differences exist even when these factors are controlled for. Although most studies merely document disparities in the rates of procedures based upon the patient's race and ethnicity, those that examine the actual quality of care provided to patients tend to confirm that minority patients not only receive less care, but poorer quality care.

Thus, race>linked disparities signal some kind of error. Some may be mistakes in judgment>>the result of a wrong belief or misapprehension about the disease or patient's race, ethnicity or class. Other disparities may be the result of ignorance, carelessness or oversight. Many are likely the result of poor communication. Some may be transgressions of law. All are colored by America's history of slavery and segregation.

Minority patients do not always trust white caregivers or the medical care system. Caregivers may carry deep>seated, often unconscious stereotypes about patients of other races and ethnic groups. Class differences are likely to accentuate and complicate racial and ethnic differences. Cross cultural and cross>class communication can be difficult not only when the participants speak different languages, but even when they appear to share a tongue. Individual institutions and the health care system retain vestiges of a formerly segregated system that compound the problem. Residential and geographic segregation mean that health care providers do not locate their practices where large numbers of minority patients, particularly poor minority patients, live.

In America, race is not just a skin color, and ethnicity is not just culture. Race and ethnicity are social categories that reflect differential access to power and social resources. Throughout American history, law and custom have relegated minority groups to different>>and inferior>> treatment. Medical care is no exception. Understanding racial disparities in medical care requires an appreciation of the history of racism, segregation and civil rights in medicine. Today's health care is rooted in the past.

 

 
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Home ] 01: Intro to Medical Malpractice ] 02: Defining Sickness and Quality ] 03: Medical Error ] 04: Obligation to Provide Care ] 05: Hospital Obligation ] 06: Contractual Relationship ]
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Professor Vernellia R. Randall
Institute on Race, Health Care and the Law
The University of Dayton School of Law
300 College Park 
Dayton, OH 45469-2772
Email: randall@udayton.edu

Last Updated:
 01/17/2004

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