Military medical care affected by rank and race, new study finds

HSenior military officers receive more resources and better care than lower-ranking military officers, analysis of 1.5 million military ER visits shows published Thursday in the journal Science.

The study also showed that white physicians spent less effort on black patients, even when rank was taken into account: Senior black officers received care from white physicians that was comparable to that of lower white officers.

“Simply being Black significantly reduces the efforts of white physicians,” wrote the authors, who used a large dataset of health contacts in the Military Health System, which provides care to active-duty service members, their families and military retirees, to examine both the means as the time doctors spend with patients. (The study did not include data from the Veterans Administration, which serves veterans and their families.)

The study, which examines what the authors call the “long shadow” of power, uses real-world data to explore an issue that has been largely invisible until now: how power differentials and race can influence time and resources who patients receive, and how those patients rate afterwards. The results, the authors say, require attention – and may also apply to civilian healthcare.

“This finding that white physicians prefer to prioritize the care of white patients over black patients, regardless of power status, underscores the need for continued efforts to address implicit bias and systemic inequities in the health care system,” the wrote authors, Stephen Schwab, an organizational health economist and assistant professor at the University of Texas, San Antonio, and Manasvini Singh, a health economist and assistant professor at Carnegie Mellon. “Of course we are concerned,” Singh said at a news conference describing the results. “Are we surprised? No.”

Overall, higher-ranked patients received 3.6% more physician effort and resources, such as tests, imaging or procedures, prescriptions for opioids, or the use of more complex treatments, and were 15% less likely than lower-ranked patients. a bad outcome.

Lower-ranking patients seen by doctors simultaneously treating higher-ranking patients were 3.4% more likely to experience worse outcomes, such as a hospital stay or the need to return to the emergency room within 30 days, it found from the study. The study found that the greater the difference between the rank of the doctor and the patient, the less effort and resources the doctor spends.

Schwab, a retired Army lieutenant colonel who previously worked as chief financial officer at a military hospital, said conversations with health care providers revealed that providing better care to people of higher status was an open secret within the hospitals.

“When a colonel comes in, they get a text message from a superior or a colleague saying, ‘Know that a colonel is coming in, make sure he doesn’t wait,’” Singh said. Schwab said a nurse midwife told him that spouses of wealthier officers also received preferential treatment. “They know this is happening,” he said.

He said Military Health System leaders were very supportive of the study, provided the data and said they hoped the research would help reduce health disparities. “They said, ‘Yes, this is an important question and we really want to know the answer, even if it’s something we don’t necessarily like. But we can’t do anything about it unless we know the answer,” he said, adding that he was speaking for himself and not on behalf of the military. “Everyone I’ve talked to has said, ‘Yes, we know, but we don’t know what to do about it.'”

When asked about the investigation, a spokesperson for the Defense Health Agency, which oversees the health care system, did not directly comment on the findings but said the agency is “committed to providing the highest quality of care to all of our patients, regardless of their rank. , race, color, sex, gender identity, religion, age or any other demographic group. We always expect the same high standards to be applied exceptionally to every patient, anytime, anywhere.”

Studies have shown that while there are health disparities within military care, this is also the case in general less than that in the general population.

The research was conducted within a military context, where rank is an obvious way to measure power, but the authors said the findings could be generalizable to health care outside military contexts. They speculated that the disparities may be greater in populations that are generally less healthy than active-duty service members and who receive care in settings that lack service members’ sense of kinship and shared mission, which may explain some of the power differentials that exist in the military. research has been observed could mitigate. .

As evidence, the authors pointed to care in the New York University emergency room, where doctors felt pressure to give VIP patients preferential treatment, whose donations or relationships with hospital administrators were noted in electronic health records. “The prevalence of ‘VIP patients’ and ‘concierge’ or ‘red carpet’ care for the wealthy and influential in civilian health care suggests that the gap between military and civilian institutions is smaller than expected,” the authors wrote.

Schwab said he suspected the same findings from the military study would extend to the general public, since the military reflects that public. “In a military composed of the general public, the same general social problems exist,” he said.

The study highlights “systemic injustices” related to power and racial disparities that exist across medicine, including among non-white patients report poorer care When she was seen by doctors who did not match their race or ethnicity, Laura Nimmon, an associate professor at the University of British Columbia who studies the effects of social networks within health care, wrote in a accompanying editorial.

Lisa Cooper, a researcher and physician who directs the Johns Hopkins Center for Health Equity, told STAT she was not surprised by the findings. Her research, and that of others, has shown that when doctors and patients share a racial background, they receive better care and achieve better outcomes. She said the research reflected findings from the civilian world, including that patients with less education are often treated worse, adding: “It is worrying that we continue to see disparities in the way patients are treated based on their social status and their race.”

The differential treatment of patients due to their social status or race may have gone largely unnoticed because a myth persists that “the doctor is a completely altruistic agent for the patient” and is not corrupted by power, the authors suggested .

They pointed to several ways to address healthcare disparities, from diversifying the medical workforce to finding ways to shift tasks away from overburdened physicians. Blaming doctors for bias is not the solution, the researchers said. “They do incredibly difficult tax work. Let’s not make it harder for them by holding them to an impossible standard, and then be surprised when they exhibit extreme human behavior that we are all susceptible to,” Singh said.

The study revealed some new findings regarding gender and race. Female doctors were less likely to be affected by a patient’s rank, and male doctors provided more resources to female patients than female doctors, possibly the authors said, because they generally provide more “kitchen sink” care such as pregnancy tests and pelvic exams than female doctors doctors. It also showed that male doctors responded better to high-ranking female patients than female doctors.

Black doctors were found to treat lower-ranking patients equally, regardless of race. However, they made “extraordinary” efforts for high-ranking black patients, possibly, the authors said, because of an emotional reaction to the lower number of black individuals in positions of power in the military. Previous studies have shown this Black patients do better in general when treated by black doctors and that the presence of black doctors improves the health of the population in the provinces where they work.

Cooper said the study helps show that “diversification of the health care workforce across race, social class and lived experiences could reduce health care disparities and improve care for all.”

In her editorial, Nimmon noted that the response to power begins early in medicine; one study showed first-year medical students preferred white and high-status individuals. She asked whether medical students were “supported to confront entrenched systems of power in the clinical encounter.”

More research is needed, she said, including examining how other racial and ethnic groups, including Hispanic, Native American and Asian patients, fare under the military’s power dynamics, and whether doctors feel “moral distress” when they are forced to prioritize high priority. status of patients.

This is part of a series of articles examining racism in healthcare and medicine, funded by a grant from the Commonwealth Fund. Us financial supporters are not involved in decisions about our journalism.