To the Editor: Bach et al. (Aug. 5 issue)1 present disturbingevidence on disparities in the training of physicians who treatblack patients and those who treat white patients and in accessto high-quality care by black patients and white patients. Thereason these differences occur is important, because it bearson how best to rectify an unacceptable situation.
One possibility is that patients with higher incomes see better-trainedphysicians and have better access to high-quality care thando patients with lower incomes, but that when whites and blackshave similar incomes, black patients are not disadvantaged.This finding would not render race-based differences in accessbenign, nor would it be a sign of differential treatment accordingto race within the medical sector. Rather, it would highlightone of the many reasons why it is important to reduce economicdisparities.
Another possibility is that even if one controls for income,blacks have poorer access to well-trained physicians and high-qualitycare than do whites. That finding would be even more disturbing.Can the authors shed light on whether the disparities resultfrom income inequality only or from inequality plus race?
Henry J. Aaron, Ph.D. Brookings Institution Washington, DC 20036 haaron{at}brookings.edu
References
Bach PB, Pham HH, Schrag D, Tate RC, Hargraves JL. Primary care physicians who treat blacks and whites. N Engl J Med 2004;351:575-584. [Free Full Text]
To the Editor: The article by Bach et al. is an important contributionto the literature on health care disparities because it empiricallydemonstrates that a health care system fashioned by the marketplaceleads to inequitable distribution of resources. Yet the studyhas the potential of doing harm if physicians find its conclusions,in the words of the accompanying editorial, "both reassuringand disturbing."1 That inequities in the distribution of resourcespartly explain disparities in health care outcomes is undoubtedlytrue. This study, however, does not invalidate the large numberof studies conducted in closed systems (such as the Departmentof Veterans Affairs2 or staff-model health maintenance organizations3)or single institutions4 that show that black patients receivingcare within the same system — with the same resourcesand physicians — as their white counterparts can and doreceive inferior care. Interpersonal bias is a consequence ofthe structural inequities described by Bach et al., and yetbias itself partly explains our society's tolerance of theseinequities. These are not competing hypotheses; rather, theyreinforce each other. Policies to address racial disparitiesin health care should address both structural and interpersonalcauses.
Alicia Fernandez, M.D. University of California, San Francisco San Francisco, CA 94110
Lauren Goldstein, A.B. Harvard Medical School Boston, MA 02115
References
Epstein AM. Health care in America -- still too separate, not yet equal. N Engl J Med 2004;351:603-605. [Free Full Text]
Petersen LA, Wright SM, Peterson ED, Daley J. Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction. Med Care 2002;40:Suppl:I-86.
Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM. Racial disparity in influenza vaccination: does managed care narrow the gap between African Americans and whites? JAMA 2001;286:1455-1460. [Free Full Text]
Peterson ED, Shaw LK, DeLong ER, Pryor DB, Califf RM, Mark DB. Racial variation in the use of coronary-revascularization procedures: are the differences real? Do they matter? N Engl J Med 1997;336:480-486. [Free Full Text]
To the Editor: Rather than impugn the abilities of the smallfraction of physicians who treat black patients, the resultsof the study by Bach and colleagues demand that we questionthe integrity of the majority of doctors — board eligibleor not — who do not treat black patients and the systemthat tacitly endorses segregated health care.
Margaret B. Wheeler, M.D. University of California, San Francisco San Francisco, CA 94110
The authors reply: Aaron asks whether our findings may be moreclosely linked to differences in the income of patients thanrace. As we reported, adjustment for the median income in theZIP Code of either the physician's practice or the patient'sresidence did not alter our findings. However, ZIP Code–basedestimates are imperfect surrogates for measures at the individuallevel, and as a consequence, we have probably underestimatedthe importance of the patients' socioeconomic status.1 If socioeconomicstatus partially explains our findings, we concur that thiswould not negate the importance of racial disparities in thequality of health care but, rather, would broaden the scopeof likely explanations.
Fernandez and Goldstein echo the belief of many that interpersonalbias, manifested by differential treatment of black patientsand white patients by individual physicians, is at the rootof health care disparities.2 Our study, by presenting evidencethat black patients and white patients are usually treated bydifferent populations of physicians who have different qualificationsand health care resources, raises some doubts about the primacyof the interpersonal-bias explanation. To determine the magnitudeof the contribution of physician bias to health care disparities,which our study did not address, investigators must determinewhether individual physicians actually treat their black patientsand white patients differently. In none of the landmark studiescited by Fernandez and Goldstein is it likely that the blackpatients and white patients were treated by the same physiciansin equal proportions,3,4 and in the case of the single-centerstudy from Peterson et al., the authors specifically reporta difference between the black patients and white patients andthe medical services through which they were treated.5 Moreto the point, in none of these studies did the authors concludethat interpersonal bias was responsible for the findings.
We appreciate Wheeler's frustration at what appears to be segregationin the health care system. However, our data do not supportthe conclusion that physicians are responsible. We demonstratedthat most primary care physicians in the United States see relativelyfew black patients, but we have no evidence that this reflectsa choice by the physicians. Rather, the distribution of blackpatients among physicians appears to be largely a result ofwhere black patients and white patients live. More generally,our results suggest that some underlying causes of disparitiesmay not be under the control of individual physicians at all— if, for example, the resources available to physiciansdiffer systematically between geographic areas. On a minor point,we showed that physicians who treat black patients are lesslikely to be board certified than are physicians who treat whitepatients. We did not examine board eligibility.
Peter B. Bach, M.D., M.A.P.P. Deborah Schrag, M.D., M.P.H. Memorial Sloan-Kettering Cancer Center New York, NY 10021
Hoangmai H. Pham, M.D., M.P.H. Center for Studying Health System Change Washington, DC 20024
References
Bach PB, Guadagnoli E, Schrag D, Schussler N, Warren JL. Patient demographic and socioeconomic characteristics in the SEER-Medicare database applications and limitations. Med Care 2002;40:Suppl:IV-19.
Smedley BD, Stith AY, Nelson AR, eds. Unequal treatment: confronting racial and ethnic disparities in health care. Washington, D.C.: National Academy Press, 2003.
Schneider EC, Cleary PD, Zaslavsky AM, Epstein AM. Racial disparity in influenza vaccination: does managed care narrow the gap between African Americans and whites? JAMA 2001;286:1455-1460. [Free Full Text]
Petersen LA, Wright SM, Peterson ED, Daley J. Impact of race on cardiac care and outcomes in veterans with acute myocardial infarction. Med Care 2002;40:Suppl:I-86.
Peterson ED, Shaw LK, DeLong ER, Pryor DB, Califf RM, Mark DB. Racial variation in the use of coronary-revascularization procedures: are the differences real? Do they matter? N Engl J Med 1997;336:480-486. [Free Full Text]
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