An Examination Of Healthcare Quality---with A Focus On Physician-rendered Care

An Examination of Healthcare Quality— With a focus on physician-rendered care Teri Abel 1999

Copyright  1999. All rights reserved. No other uses without express author permission.

Note: Following is the original contents page. Subsequent pages represent selected excerpts written exclusively by Teri Abel from the original co-authored forty-two paged document, assembled and edited to present adequate context for purposes of public viewing.

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Contents

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The definition of quality in the health care sector: the need for clarification 1.1

Perspectives on quality in the health care sector

1.2

Benefits and limits of each approach and the need for integration

2

The introduction of quality measures to improve health care performance

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Physician autonomy and physician-delivered care: problems with the medical perspective 3.1

Physicians’ education

3.2

The impact of group distrust for healthcare systems on physician-rendered care 3.2.1

The biology of sociology—American-style: race as a demarcation line for

differentials in health status 3.2.2

The sociology of the biology: The Under-representation of Groups in

Clinical Trials and Clinical Training 3.3

Bias in the medical perspective: Variances in treatment across patient groups

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… 3.2.2 …

The Under-representation of Groups in Clinical Trials and Clinical Training General medical recommendations and treatment standards are generated in great part

from clinical training and clinical trials. If a given set of standards is biologically and statistically less relevant to African American disease progression vs. Caucasian American disease progression, for example, then either African Americans are not adequately represented in clinical training and trials, or if they are adequately represented, their health status is not charted in a way that is attentive to systematic variations across race. For different reasons, patient populations can be alienated from the healthcare system. For example, to the degree that there is distrust by a group for the healthcare system, that group stands to be less available to and represented in clinical training and trials. Consequently, the clinical training and trials can be expected to return conclusions and recommendations that may not be maximally applicable to the underrepresented group. Even if an underrepresented group abides by the scientific conclusions of certain clinical training and trials, health benefits may not be perceptible in them. Whatever the reason for under-representation by groups in clinical training and trials, potential differences in the physician’s perception of beneficial treatment outcomes during the physician-patient encounter can effect an impression upon the physician of a disconnect from or disregard for medical advice by the underrepresented group. Such can potentially alter the advocacy which physicians do for these patients’ improved health status, and can undermine their energetic care-rendering, thereby promoting a differential in the quality of care rendered across patient groups. After all, the scientific method that encourages and rewards the physician’s confident care-rendering to the represented group, is the same scientific method by which she perceives the underrepresented group’s systematic failure to reap the benefits of clinical training and trials. In this event, the working assumption on the physician’s part is that 3

variances in beneficial outcomes for the underrepresented group are due to perhaps sociological rather than biological factors. This issue is illuminated by a long-standing puzzle and set of assumptions confronted by researchers at the George Washington University Hospital, who were investigating differences in breast cancer survival rates between African American and Caucasian American women. According to Dr. Robert Siegel, director of the university’s cancer center, statistics show black women are less likely than whites to get breast cancer; but five-year survival rates are 63 percent for black women compared with 76 percent for whites. Researchers had long believed that the discrepancy was due to socioeconomic factors and the quality of delivered care, or to black women’s “delay” to go to the doctor. In his study of six years of breast cancer data, Siegel found that even when black women's breast cancer is discovered at the same stage as whites -- and even when the treatment is the same -- the cancer in African-American women shows "more aggressive behavior."1 "The bottom line is black women are getting more aggressive cancers at an earlier age."2 According to Siegel, there were "clear biological differences" between the cancers found in whites and blacks. Regardless of the tumor size or whether the cancer had spread, black women were more likely to have breast cancers that grew faster, contained more malignant cells and did not respond to hormone treatments:

"For some reason -- and I have no idea what the explanation is -- black women have cancers that look worse under the microscope."3 1

Detroit News, Washington Bureau, “Investigating a medical mystery: Why do African-American women with breast cancer have much lower survival rates than whites?”,1995. 2 Ibid., Siegel, R. 3

Ibid. 4

If there are biological reasons explaining why certain diseases are more common or aggressive in blacks, the medical system may be unfairly suspecting African Americans for delaying prevention and treatment. Moreover, because certain diseases appear to behave differently in blacks and whites, the medical system may actually be doing African Americans a disservice by recommending prevention strategies, screening schedules and treatment options developed from studies of ‘white’ disease progression.4 Siegel further thinks the medical community should consider revising its age recommendations for screening mammographies -- based on a patient's race. The American Cancer Society currently recommends women 40-49 years old have a mammogram every one to two years, and women age 50 and over should have yearly mammograms: "One potentially reasonable idea is that the guidelines for screening mammographies should be earlier for black women."5 In a 1995 study published in the Journal of the American Medical Association it was found that prostate cancer may follow a different biological course in blacks and whites, too. The study of 1,606 military men found that even when they all got the same screening, prostate cancer was diagnosed in blacks at a younger age and at a more advanced stage. Moreover, researchers found the disease grew faster in blacks, even when they underwent the same treatments as whites. This study confirms the suspicions of Dr. Isaac Powell, a urologist at Harper Hospital in Detroit, who was one of the early advocates of screening African-American men for prostate cancer at an earlier age than white men: "We think the biology of progression may be different in blacks.” 6 4

Ibid.

5

Ibid.

6

Ibid. 5

Until recently, the American Cancer Society recommended annual prostate-specific antigen blood tests, or PSAs, to screen for prostate cancer in men beginning at age 50. But based on research showing that blacks tend to get prostate cancer earlier than whites, the American Cancer Society now suggests annual PSA testing for African-American men beginning at age 40. According to the Detroit News story, Powell applied for a federal grant to study whether doctors should use different standards to evaluate the PSAs of African Americans. Whereas most doctors recommend further treatment for men whose PSAs measure four points and higher on a 10-point scale, Powell would like to see the treatment threshold lowered to two points for black men. Henry Ford Hospital cardiologist Fareed Khaja is one of eight researchers nationally working on five-year grants awarded by the National Heart, Lung and Blood Institute to investigate possible biological causes for higher heart disease rates in blacks. Working with 23 Ford cardiologists, Khaja is investigating why African Americans are more likely to suffer from a thickening of the heart muscle than whites, and whether the condition explains why blacks are less likely to survive heart attacks. Asthma is another disease that appears to more severely impact African Americans than whites. In early 1995, researchers at the Henry Ford Health System began investigating why African Americans had more emergency visits for asthma than whites. In previous studies, researchers speculated that African Americans were forced to use emergency rooms because they did not have the money or health care coverage to obtain regular medical care, or because of a fundamental alienation from the health care system. But by comparing asthma patients enrolled in health maintenance organizations, who had the same health coverage and access to medical care, Henry Ford researchers found that African Americans may actually suffer from a more

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severe form of the disease. Researchers at Henry Ford have received a grant from the National Institutes of Health to study whether biological differences explain the increased severity of asthma in African-American children. If biology is found to be the culprit, researchers may recommend more aggressive treatment for African-American children with asthma. Based on its research, Henry Ford's medical effectiveness center is one of four programs nationally that has been awarded a grant to study the effectiveness of medical treatments in minority populations. While all of these findings have obvious implications for the way doctors treat breast and prostate cancer, and asthma in blacks, they also incline us to question long-held assumptions about the reasons African Americans have higher death rates for a host of other diseases. A review of source integrity for the “original” medical recommendations in the above cases seems warranted; for example we can inquire about the process and science that produced a recommendation of PSA screening commencement at 50 years in age for all men before the corrective of 40 years for black men specifically---a difference in age of 20%, which would be well discernible in ideal studies or data sets that included African American men. It seems debatable whether there has been a greater evolution of this process or of disease progression across groups in the patient population.

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Physician autonomy and physician-rendered care: problems with the medical perspective For all the variations in definitions of quality among American patients, physicians,

health management organizations, health policy experts, and public health agents, there is a unifying concession worth recalling before engaging in a perspective-specific focus on quality.

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In particular, quality is regarded as something fundamentally discernible, which lends itself to not only outright description, but to calculable and systematic reproduction. ... 3.1

Physicians’ training Toward the end of understanding certain disruptions in quality at the level of physician

autonomy, it is informative to consider a generic American model of physician training. Such begins as a rigorous academic process culminating in clinical experience and training. Arguably, few other disciplines have a breadth of intellectual uniformity and consensus comparable to that found in the hard sciences which ground all medical training: students of hard science not only establish allegiance with a singular modern cell theory, a singular fossil record and Darwinian evolution, Mendelian genetics, or a singular atomic theory, as examples, but their references to such lack the subjective inflection regularly harbored outside of science. This is different from economics, for example, where theories and antagonistic counter theories indefinitely reside quite credibly and seriously together: Keynesian economics vs. Friedman economics. It is different from jurisprudence, where legal code interpretations can be affirmed in one court only to be reversed within the same justice system in the appellate court. It is different from fine arts, where two artistic movements may be contemporaneously celebrated as each the superior aesthetic contribution. The body of science hinges on a perpetual process of evidence-based consensus-making, representing a culmination of repeatable and peer-reviewed experimental outcomes, explanations that lack counterexamples, and a growing residual of intelligence from iterations of the scientific method. Over the course of the physician’s professional development, a substantial piece of their knowledge base and default mode of critical analysis, is indelibly imprinted by the scientific

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method. While medical practice is assuredly part art, there remains significant similarity in medical recommendations, given physician consensus about a particular obstruction to a patient’s better health status, which permits medicine to yield a discernible quality. For example, if it is accepted that a presenting patient is infected with the influenza virus and is suffering from its symptoms, physicians will not prescribe antibiotics as a pharmaceutical address or expectation to specifically eradicate the influenza virus from the body. This is a direct consequence of an intellectual consensus attendant with the physicians’ academic and clinical training: antibiotics do not eradicate viral diseases. While simplistic, this example can be extended to a multitude of other health problems. It is precisely because there exist streams of intellectual consensus in medicine, that nonrandom departures from such are not only discernible and represent risks to the consistency and quality with which medicine is practiced, but are departures worthy of analysis. … 3.3

Bias in the medical perspective: Variances in treatment across patient groups In the February 25, 1999 issue of The New England Journal of Medicine, the conclusions

of a study titled “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization” [Schulman, et al.] read:

“Our findings suggest that the race and sex of a patient independently influence how physicians manage chest pain.”7 This controlled experiment, using multivariable logistic-regression analyses, aimed to assess physicians’ treatment recommendations to patients who presented with different types of chest pain. Scientists who conducted the study hypothesized that patient race and sex 7

Schulman, K.A, The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization, The New England Journal of Medicine, Vol. 340, p. 618. 9

independently influenced physicians’ recommendations regarding cardiac catheterization. The degree to which physicians were responsible for variations in recommendations according to race and sex had not been captured by previous studies. In the discussion of the study, researchers reported:

“We found that the race and sex of the patient affected the physicians’ decisions about whether to refer patients with chest pain for cardiac catheterization, even after we adjusted for symptoms, the physicians’ estimates of the probability of coronary disease, and clinical characteristics. Our findings are most striking for black women…Our finding…may suggest bias on the part of the physicians…Bias may represent overt prejudice on the part of physicians or, more likely, …subconscious perceptions rather than deliberate actions or thoughts. Subconscious bias occurs when a patient’s membership in a target group automatically activates a cultural stereotype in the physician’s memory regardless of the level of prejudice the physician has…[Our findings] suggest that decision making by physicians may be an important factor in explaining differences in the treatment of cardiovascular disease with respect to race and sex.”8

This study promotes contemplation on at least three critical issues in the care-rendering process: it implies some complexities attendant with the arguably unique American challenge of rendering quality care to a particularly heterogeneous American patient population by a relatively homogeneous American physician population; it identifies one way that current medical education, medical ethics, existing regulatory regimes, physician autonomy, and personal aims for professional integrity leave care-rendering qualitatively different across groups; and it introduces clear questions around the very nature of physician professionalism. For American professionalism, the Schulman study renders some profound implications: for it suggests that even in perhaps the oldest and most esteemed of our traditional professions where the most critical goal of sustaining life and health resides; even given a training methodology that incentivizes intellectual weddedness to the evidence-based, consensus-building 8

Ibid., p. 623-24. 10

process of the scientific method; even after the lengthiest apprenticeship program for any of our professions; even given the regulatory apparatus of licensing requirements and board certifications; even including the deterrent of an ever increasing personal tax in the professional’s compensation profile in the form of a malpractice insurance premium; even amidst the threat of lost reputation---expensively and doggedly won---from a failure to practice evidence-based medicine; and even as the physician population itself credibly purports to represent a subset of the population intrinsically interested in the welfare of others; the Schulman study says that somehow, at the end of this dense array of preparedness and quality control and professional surveillance----somehow, at the ultimate event of physician care-rendering, the cloak of professionalism that distinguishes the medical profession can be systematically set aside. Biology succumbs to sociology. On the matter of health status for American populations, we can wonder what systematic variances in health status are maintained over time for disparate patient populations who seek physician-rendered care. On the matter of professionalism generally and other contracted relationships residing outside of the traditional professions, an expanded concern is this: the likelihood of similar disparities in other arenas of professional conduct for which the academic and apprenticeship training is far less a function of intellectual consensus, less regulated, less rigorous, and shorter. We can speculate about comparable professional lapses between attorney and client; judge and defendant; teacher and pupil; police officer and citizen; and corporate boards and consumers and workforces. While a unique study, the results from the New England Journal study which suggests the existence of independent racial and gender influences upon physician-rendered care are not in isolation. In a 1993 study of the influence of ethnicity upon patient-controlled analgesia (PCA),

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researchers concluded that narcotic prescriptions for post-operative pain were correlated with patient ethnicity.9 According to a study reported in the 1994 Journal of the American Medical Association, poor and black patients do appear to receive systematically different (inferior) treatment. In the Journal of the American Medical Association the study reported that gravely ill Medicare patients who are black and poor receive worse care than other equally sick Medicare patients in every type of hospital in America. The finding suggests that the quality of medical care may vary tremendously with a patient's race and not, as other studies have suggested, with whether a person has insurance.10 On the one hand physician autonomy is a central component of high quality physician-rendered care. It is also the arena in which data suggests that physicians face a curious challenge. They must not abandon the scientific critical analysis that has enabled their role as an informed professional for pressures from sociology, and must nonetheless, be attentive to the sociology that is relevant to their act of rendering care. …

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“Using a retrospective record review, we examined data from all patients treated with PCA for post-operative pain from January to June 1993. We excluded patients who did not have surgery prior to the prescription of PCA or were not prescribed PCA in the immediate post-operative period….While there were no differences in the amount of narcotic self-administered, there were significant differences in the amount of narcotic prescribed among Asians, Blacks, Hispanics, and Whites…The ethnic differences in prescribed analgesic persisted after controlling for age, gender, pre-operative use of narcotics, pain site, and insurance status. Patient's ethnicity has a greater impact on the amount of narcotic prescribed by the physician than on the amount of narcotic self-administered by the patient.”-Ng B., Dimsdale J.E., Rollnik J.D., Shapiro H, Department of Psychiatry, University of California at San Diego, La Jolla. 92093-0804, USA. Pain. 66(1):9-12, 1996 Jul. 10

Blakeslee, S. reported in New York Times (Late New York Edition).Apr. 20 '94 p. B9 12

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