Introduction

Reviews

How Your Race Gender and Age Can Affect What the Doctor Recommends

Timothy B. McCall, M.D.

When deciding whether to have a particular test or treatment, you may want to consider whether subtle (and sometimes not-so-subtle bias) could be influencing what the doctor tells you. Consider the effects of race uncovered in a 1993 study in the American Journal of Public Health.

Researchers from the University of Pennsylvania in Philadelphia examined whether there were differences in the rates of various medical procedures in blacks and whites. The following table summarizes some of their findings. The rates show the number of operations per 10,000 people.

Procedure	White Rate	Black Rate
Heart bypass surgery	30.6	8.1
Balloon angioplasty	9.9	3.2
Carotid endarterectomy	17.3	5.8
Heart catheterization	85.6	43.1
Hip replacement surgery	22.5	9.5
Knee replacement surgery	18.2	8.9
Hernia repair	33.7	16.5
Glaucoma surgery	8.0	17.9

Whites were more likely than blacks to receive 23 of the 32 procedures studied. Whites had especially greater use of newer, higher-technology services. Rural blacks, almost all of whom live in the South, were much less likely than urban blacks or rural whites to receive services. Urban whites, for example, were 2.5 times as likely as urban blacks to have an angioplasty but rural whites were more than 20 times as likely to have one than rural blacks. Racial differences were found in all areas of the country but were greatest in the South.

Part of the racial difference in intervention rates may be due to the fact that more whites are well-off and have private insurance which reimburses doctors well for procedures. But money isn’t the whole story. Consider a study of a system where money has nothing to do with who gets care and who does not.

Researchers from the Veterans Administration examined the number of heart procedures done on black and white heart attack victims. The V.A. is in some ways the perfect place to look for racial differences in care because treatment does not depend on the ability to pay. The researchers, whose results were reported in the Journal of the American Medical Association (JAMA), found that blacks were 33 percent less likely to have a heart catheterization, 42 percent less likely to have an angioplasty and 54 percent less likely to undergo bypass surgery. Despite having fewer procedures, a significantly higher percentage of blacks were alive one month after their heart attack. There were no differences in survival rates one and two years later.

And this proves the point we have made in the last few columns: More intervention doesn’t necessarily mean better care. Procedures in which physician discretion plays a big role may be precisely those that are often unnecessary or inappropriate. Blacks may have benefited by avoiding procedures they did not need (even if many doctors would recommend them!).

The elderly, too, may be discriminated against when it comes to medical interventions. Consider the results of a UCLA study that looked at how women of different ages with breast cancer were treated in seven southern California hospitals. The appropriate treatment of breast cancer involves various combinations of surgery, hormones, chemotherapy and radiation therapy depending on the cancer. The researchers found that the care was inappropriate 16.6 percent of the time in women aged 50-69 but 32.6 percent of the time in women over 70. Even when elderly patients were vigorous and healthy, their doctors were less likely to provide optimal treatment.

The situation for women is more complex. Overall, women receive more medical care than men. They visit doctors more often, have more lab tests done and receive more drug prescriptions. According to the Journal of the American Medical Association, however, they have lower rates of heart catheterizations, kidney transplants and certain other procedures that cannot be explained by a lower incidence of disease.

Next: When Less is More