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The Culture of Medicine and Racial, Ethnic, and Class Disparities in Healthcare Mary-Jo DelVecchio Good, Ph.D., Professor of Social Medicine Cara James, B.A. Byron J. Good, Ph.D., Professor of Medical Anthropology Anne E. Becker, M.D, Ph.D., Assistant Professor of Medical Anthropology Department of Social Medicine, Harvard Medical School INTRODUCTION Racial disparities in medical treatments and in health status have been documented in numerous studies over the past two decades. In a recent editorial in the New England Journal of Medicine, Epstein and Ayanian (2001) noted that “there is little evidence that racial disparities in medical care or in measures of health have substantially diminished.” Gary King (1996), in an insightful theoretical analysis of this research, argues that explanations of racial differences in medical care and of participation rates in medical research are grounded in institutional racism and in the pro- fessional ideologies of medicine and healthcare systems that lead to power imbalances between minorities and medicine’s elite professionals. King identifies three phases of research in this field, all of which have relevance to our project: (1) initial “exploratory research,” which documented dif- ferences between blacks and whites in medical care, utilizing quantitative data; (2) “contemporary” research, which focuses on coronary artery dis- ease and other specific diseases, using rigorous methods to investigate causes of disparities in treatment; and (3) most recently, “an incisive pe- riod in which researchers attempt to combine theory, methods and policy considerations.” King argues that to understand documented differences, one must come to understand covert as well as overt racism and the mul- tifaceted dimensions of institutional racism in medical and health institu- tions. His work and that of numerous other researchers who have docu- mented disparities in health and treatment for ethnic and linguistic minorities, in addition to examining black-white differences, raise ques- 594

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595 CULTURE OF MEDICINE tions about how we might best understand the mechanisms—attitudinal, structural, institutional, and ideological—that produce disparities in medical care and in health status. Our initial study questions for the Institute of Medicine (IOM) Group on Racial and Ethnic Disparities focused on the culture of medicine. How do the culture of medicine, the training of medical students and residents, and the organization and delivery of healthcare affect patient treatment in such a way as to produce obvious and documented disparities in thera- peutic action? Whether it is treatment for cardiac disease, asthma, kidney disorders, or mental illnesses, some Americans receive less than optimal or even standard best medical therapies. Two decades of research have documented that whether bounded by ethnic or racial identities, immi- grant status, English language fluency, educational attainment, poverty, low socioeconomic status (SES), or urban/ rural residence, minorities and the poor receive less care and poorer quality care than their middle-class and educated compatriots. The committee invited our group to address the question, “how could well-meaning people (healthcare providers) pro- vide inequitable care to minority and non-minority patients?” This question and the Committee’s initial larger query about the cul- ture of medicine and its contribution to patterning disparities in medical care and treatment have proved daunting to address. Empirical studies on medical training and racism appear scant in our literature searches. Our own research (B. Good, 1994; M. Good, 1995; Good and Good, 2000) on the socialization of medical students and on the culture of medicine, while suggestive, has not directly addressed disparities in care granted patients. However, in our studies over several decades, we found that “the medical gaze” soon becomes the dominant knowledge frame through medical school, that time and efficiency are highly prized, and that stu- dents and their attendings are most caring of patients who are willing to become part of the medical story they wish to tell and the therapeutic activities they hope to pursue. Nevertheless, we identified no clear rela- tionship between medical hierarchy, the culture of training, or profes- sional ideologies that would readily explain patterned disparities in care by race, SES, and ethnicity (such as the study group’s suggestion of a modeled preference for private rather than public patients although clearly such preferences may exist at many institutions). We contend that such relationships are multidimensional and subtle, and that to identify the production of disparities in care requires considerable additional criti- cal observation of our institutions of training and care. For example, dif- ferences in value of public and private patients may be conveyed not only in direct but in indirect and subtle process. In our own academic commu- nity, such distinctions may be demonstrated through a common but not hegemonic hierarchy of value. For example, many physicians regard

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596 UNEQUAL TREATMENT practicing at a community clinic as less prestigious than practicing at an academic medical center, where private as well as public patients receive care. The diversity of medical professional communities also allows for “the saint” or hero physician, who is devoted to the care of the under- privileged or the poor. Professional careers are made in community- oriented medical service and in teaching “cultural competence” to one’s medical students and residents. Nevertheless, both the charismatic hero physicians who are leaders in social medicine (see Farmer, 1999), and the less publicly known academic and community physicians, who are to be commended for their commitment to improving the quality of care pro- vided to the underserved or to ethnic minorities, work within a biomedical knowledge frame. Although tempered with a social medicine perspective and interpretative sensibility, these physicians also employ the medical gaze in their daily clinical work and practice. Thus, we do not wish to underestimate the power of the medical gaze and the biomedical sciences that inform it to shape patterns of care and thus differences in care as well. In such a hierarchy of valued knowledge, psychological and social data are often regarded as inadmissable evidence by students who are learn- ing to hone their case reports and presentations to focus on the essence of “what medicine cares about” (M. Good, 1995). The social data may pro- duce patterns of care not otherwise critically examined, even for more practiced and socially concerned clinicians. This simple picture of “valued knowledge,” while the dominant model and underlying ideology in early medical training, hardly captures the complexities of contemporary medical education. In contrast to a singular biomedical model of training, which gives scant attention and value to the social aspects of medicine, many American medical schools over the past quarter-century have increasingly incorporated curriculum materials on diverse patient cultures. In addition, students have often been encouraged to engage in activities oriented to caring for underserved, poor and minority patients. Our observations of and engagement with medical education since 1976 have exposed us to social medicine-sensitive curricula even as we have contributed to it (Good and Good, 1980, 1981). Examples include the University of California at Davis, which in the late 1970’s and early 1980’s developed cultural courses that addressed “the health needs, beliefs, and practices” of California’s various ethnic popula- tions and immigrants (Asian, Mexican, Mexican American, Chicano, Viet- namese immigrants, and other refugees from Indochina—with a notable lesser emphasis on African Americans). Harvard Medical School’s com- mitment has flourished in the past two decades, increasing curricula in medical anthropology and social medicine, although the school has had a long tradition through the informal curriculum of encouraging students to participate in international as well as local community programs pro-

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597 CULTURE OF MEDICINE viding healthcare for the poor or marginally served ethnic groups. A third program, and among the most impressive, was begun when the Univer- sity of New Mexico established its medical school in 1968. The highly committed, state-sanctioned, and legislated programs of the University of New Mexico School of Medicine teach students about the state’s diverse populations and the healthcare needs of rural as well as urban ethnic com- munities. The school mandates practice training in underserved areas to provide care to the American Indian (Hopi, Navajo, Zuni, and others) and Hispanic rural populations. Many schools have produced formal and in- formal curricula, which on paper appear to be promoting cultural compe- tence. Rarely, however, does medical training focus on the culture of medi- cine itself; rarely do students have the time or the formal sanction to critically analyze the profession and institutions of care to examine how treatment choices, quality of care and research practices are shaped; or how medical culture may produce processes that evolve into institutional racism or aversive racism in clinical practice (King, 1996; Whaley, 1998). Theories about how professional elites and the imbalance of power pro- duce institutional racism, such as King’s, call for empirical documenta- tion. Why do racial and ethnic disparities continue to exist despite the two decades of documented research, of educational efforts to teach medical and health professionals “cultural competence” and social medicine, of programmatic efforts to attend to health needs of underserved communi- ties, and most recently of NIH/NCMHD and previous governmental ef- forts to redress the inequities in medical care and health status? Are edu- cational and research programs ineffective in changing clinician behavior and institutional and professional culture? Does the culture of medicine— as exemplified in the medical gaze and its underlying ideologies and po- litical economy of what constitutes legitimate medical knowledge, bio- science, and appropriate medical decision-making—too readily exclude patients whom clinicians assess as likely to pose “problems” and compro- mise the efficacy and efficiency prized by the medical world? Do profes- sionals’ concerns about patient compliance and community and patient trust at times serve as justifications for their employing different ap- proaches to treating minority patients, and thereby and perhaps naively, to their providing a lesser quality of care? Or are disparities in care in- grained in the social and economic inequalities that are rife in our larger society, feeding inequalities of treatment in America’s healthcare system? Clearly, differences in insurance coverage influence the kinds and quality of care patients receive. Do patients contribute to these disparities in care, and if so, how? We contend that multidimensional processes are at the root of different types of ethnic and racial disparities in health status and medical treatment. These processes are structural, economic, environmen-

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598 UNEQUAL TREATMENT tal, political and attitudinal. Individual behavior as well as institutional culture and practices are implicated. In the remainder of this essay, selected findings from studies docu- menting disparities are presented. In addition, exploratory qualitative data from recent interviews with physicians-in-training and with faculty attendings are introduced to suggest possible directions for a critical analysis of the culture of medicine and the political economy upon which it is based and from which it is produced. A cultural analysis of bias in mental healthcare is presented as one model suggestive for future research in other domains of medicine. In this case, differences in diagnosis and treatment by race and gender in psychiatry are examined, demonstrating how cultural and social analyses contribute to an explanation of racial and ethnic disparities in care and treatment. The conclusion draws on these materials and the wider literature documenting disparities in health- care, with the aim that future research findings and interpretations may contribute to formulating policies that will redress disparities in the qual- ity of care. The Culture of Medicine: Insights from Physicians in Academic Teaching Hospitals Clearly, the financing of healthcare coverage, type of health insurance, or accessibility to government programs, as well as lack of coverage, are relevant to understanding what happens within healthcare institutions and in the intimate exchanges that we characterize as clinical interactions, and how these interactions result in decisions that produce racial and eth- nic disparities in treatment. The Harvard Medical Practice Study analyzed over 32,000 records from New York State hospitals located in metropoli- tan/urban town/suburban/rural areas. The project found that patients who had no health insurance and who lived in poor urban areas were more likely regardless of race or ethnicity to experience an adverse event (Weiler et al., 1993). Where one receives healthcare, including how one enters a healthcare institution, via an Emergency Room or via a controlled appointment process, influences the type and scope of care provided. It may also influence how healthcare providers, from nurses and physicians to medical students and technologists, interpret who their patients are, what life experiences they carry with them, and what problems they may cause for those who will be delivering care. These processes, whether ste- reotyping, prototyping or profiling, clearly have consequences for treat- ment choices and medical decisions. Disparities in care and differences in therapeutic actions, regardless of provider race in certain cases (Chen et al., 2001), rest in part on these larger social processes within our complex medical institutions. The following discussion examines findings from

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599 CULTURE OF MEDICINE our pilot interviews and seeks to raise what we believe are some reasons disparities persist. Our past research on medical education and the socialization of medi- cal students was carried out at Harvard Medical School in 1986-1991, and addressed how medical students and physicians-in-training learn to see, present and write up patient cases (B. Good, 1994; M. Good, 1995; Good and Good, 2000). Students come to embody the medical gaze as they learn to see what is relevant data and to speak the language of medicine. Early in training, they enter the molecular worlds of disease and thera- peutic interventions and the world of medical practice and medical cul- ture. They also learn socially acceptable behaviors—when to speak, how to listen, and what is relevant to the clinical task. Students struggle to learn “what medicine cares about.” Students are also socialized to attend to social and economic issues in healthcare; some embrace the “social medicine” perspective even as they come to speak and be in the molecular medical world. Those who do so incorporate into their studies projects in international health, urban health, and volunteer work providing basic healthcare for poor or immigrant or minority populations. These social medicine projects become less central in students’ education as they move into clinical clerkships and become responsible for the clinical care of patients and for decisions of therapeutic consequence. Other research on medical education from the classic work of Robert K. Merton’s Student Physician (1957) to Howard Becker et al. Boys in White (1961) to more contemporary projects such as Fred Hafferty’s Into the Valley: Death and the Socialization of Medical Students (1991) document similar experiences, suggesting historical depth and continuity in the culture of medical edu- cation. This continuity of medical educational culture persists despite a sea change in the gender, and to a lesser extent, the racial and ethnic profile of medical students. In addition, extraordinary developments in medical technology, biomedical science and the political economy and financing of medicine and delivery of healthcare appear to be subsumed into this culture and way of learning medicine. Scholars interested in narrative analysis such as that provided by Katherine Hunter (1991), as well as many physicians interested in medical narratives, have all explored ways physicians present and speak about patients. Narrative forms of the culture of medicine are ingrained; they have historical depth and substance and make for continuity of profes- sionalism despite changes in practice environments. They are reinforced by the modeling that occurs through the hierarchy of medicine, through interactions between students and interns, interns and residents, and resi- dents and attendings. What is important in medicine is learned through daily interactions with peers and with the hierarchy, and students are rewarded as they come to behave as competent, reliable, and responsible

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600 UNEQUAL TREATMENT clinicians who have learned appropriate professional behavior. How does this professional socialization affect physician behavior so as to have an impact on the treatments offered to patients of different social groups? First, the culture of medicine emphasizes the dismantling of patient life narratives and the reconstitution of patient concerns and experiences of illness and associated social context into medically meaningful narra- tives that allow physicians to determine a diagnosis and formulate plans for therapeutic actions and procedures. In our research, patient life issues were often regarded by students and attendings, as “inadmissible evi- dence”; senior clinicians modeled for juniors how to streamline medical narratives and to edit out data irrelevant to the clinical decision or task currently at hand. Patients are not ignored, however. As students and residents mature as clinicians they learn to create clinical narratives for patients; these clinical narratives are biomedical stories through which physicians explain to patients about their disease diagnoses and processes, therapeutic options, and treatment courses and goals. Good doctors en- gage patients in these clinical stories, teaching and guiding and helping patients own what is happening. Some clinicians describe this very sim- ply as empowering patients, while others reflect little but work hard at fitting patients into the medical world of treatment, helping patients un- derstand and accept what may be difficult treatments for frightening and life threatening diseases. These narratives smooth the working of what one of our junior colleagues calls “the medical machine” (personal com- munication, Herskovits, 2001). Disruptions in the Medical Machine Recent interviews with attending physicians, residents, and medical students in the Boston area suggest several ways the medical gaze may lead to disparities in healthcare. Interviews were carried out with physi- cians who were both men and women and were from Euro-American, Asian and African-American backgrounds. A second year medicine resi- dent at a major teaching hospital who had recently completed a Ph. D. in medical anthropology made the following observations as we explored what might lie behind the reasons for disparities in healthcare for minori- ties, immigrants, and lower class patients. She had been thinking about these issues, in large measure due to publication of recent research on health disparities and to the publicity of NIH minority research activities: “People who don’t fit into the medical machine” are ones who may not get of- fered the latest therapeutic interventions. Here at [x hospital] is a medical ma- chine—we are all cogs in it, not just the docs, but the patients too. And the more we fit into our role, the smoother the machine runs. In internship—it is relearn- ing to listen to patients without listening to them. It is painful, because it is the

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601 CULTURE OF MEDICINE opposite of anthropology. You learn to do a better job by not listening to your patients. We become different types of subjects, disciplined (after Foucault), to fit into the machine. Or Fordist. The machine model breaks down when patients don’t get referred into high tech medical therapies, the most cutting edge of medicine. When physicians experience difficulties in interacting with patients, it befuddles the doctor, and derails them. In ER shifts, there is the discipline of time, and when a patient derails you, it is glaringly obvious. In the ER, you have an immediate problem—what do I do with this person—the faster you make a decision the better you are as an ED doctor; it is a different yardstick to figure out what is troubling them. Patients derail physicians when they present with what an attending described as “socially complex problems.” The notions of the medical machine, of derailment and befuddlement, are relevant to explaining why disparities exist. The comments of a cardiac specialist, who has practiced in community clinics as well as in a major teaching hospital, highlight similar issues. He remarked: “One needs to attend to the more mundane aspects of doctoring.” In today’s practice environment, “we need coop- erative patients because of the tightness of time.” Another attending noted how language problems and family issues can disrupt practice flow and influence choice of therapeutic options. Her work with patients at a community mental health clinic became most dif- ficult when she found that many of her patients of color had social situa- tions that were “so dismal that it far outweighed the clinical problems” she was expected to address. She remarked that her work over the four years at this clinic led her to re-evaluate why I became a clinician… when patients would ask for disability papers when I thought they should have a job and structure; when I had to turn in many patients for abusing their children. I felt I was in an adversarial role that I did not want to be—court papers, reports, and people needed social interventions and no one was offering it. In the past, clinicians had the luxury of time to teach and do paper work, now they are scheduling brief therapeutic sessions instead of 50 minute sessions to allow time for insurance paperwork. A fourth year medical student had experienced similar pressures of time that the attending and resident discussed. He explained: a measure of success (as a student) is extracting a history of illness and develop- ing a treatment regimen that allows you to discharge the patient with some improvement. Things that interfere with the above make physicians uncomfort- able. If you have a minority patient who allows you to do the history and treat- ment plan (in a timely fashion) then the interaction is not problematic for the most part. I am of course speaking for myself.

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602 UNEQUAL TREATMENT When we discussed if he detected any bias in the curriculum or in modeled behavior by attendings or residents that might have an impact on how minority patients were treated he reflected: One modeled message currently about hospital care is rapid assessment, effi- ciency, and treatment. One thing about minority, indigent, low-income patients, is that their social situations are complex in negative terms and not fixable by any intervention that can happen in the hospital. As a result, one becomes almost discouraged to begin to explore these things. With some people you work with a translator and even when not, there is a reluctance rather than an incli- nation to get a good social history and explore the social roots of the illness. When I asked whether he observed any differences by racial or ethnic groups in terms of their trust in the medical system he remarked that he had not interacted with that many African Americans but his impression was that Absolutely. African-American patients do not come into the hospital expecting to be treated well. White lower class patients, for example at the MGH, expect to be and they have been treated well. Asians—so many different kinds. New im- migrants versus academics. This very thoughtful student and I discussed how readily one distin- guished different groups of Asians, some difficult to care for because of language barriers and social situations, others more similar in educational status and class to the medical community and easy to communicate with but that it was easy to slip into grouping African-American patients into one category. A resident also noted the stereotype of African-American patients as being “dreadfully sick and their social life is so disorganized that they are ‘non-compliant’ and living in a state of chaos, with a disorganized house- hold, or that they are socially isolated. And incredibly sick and incredibly difficult to manage.” In these cases “it is really hard to make progress and take care of patients,” if for example diabetes is out of control and vague symptoms are difficult to manage. The resident concluded, however, that she did not have experiences that fit the stereotype she had just elabo- rated; her experiences were more varied. When asked if she had stereo- types for Asian patients, she noted that she did not have any, although she thought of East African patients (Somalians) as different from African Americans and Asians. This resident reported that she and her colleagues have a profile for young Hispanic women with total body pain—”they hurt everywhere” and “you simply cannot interview them. You take it on their terms or abdicate helping them. Some people work with them, I use the notion of nervios with patients, and it speaks to the political and do-

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603 CULTURE OF MEDICINE mestic violence in their lives, if I think it makes sense; a sense of culture bound category. Everybody calls them crazy including Hispanic doctors.” In this case, the resident’s advanced degrees in medical anthropology have added to her ability to bridge cultural gaps between this population of patients and the medical world. Race and ethnicity continue to define responses of clinicians. Assump- tions are often made that may have inadvertent influence on how treat- ment interventions are offered to patients and how disease etiology is explored. One mode of profiling racial groups is through case formula- tions—the way certain diseases are discussed in relationship to certain minorities. Examples include African-American patients who are associ- ated with hypertension and diabetes; Asian patients with hepatitis; poor Hispanics, Puerto Ricans, and Mexicans or Central Americans with diabe- tes and obesity; or working-class Irish with alcoholism. Case examples may follow an epidemiological pattern—diseases more prevalent in cer- tain groups will be described in terms of patient demographics associated with those groups. Thus, though in a subtle way, race, ethnicity and class become part of the world of the medical gaze and the standard patient formulation. Does this lead to explicit racism or bias in what is offered to patients in terms of medical interventions? An African-American attend- ing psychiatrist noted that in his consultations on psychotropic medica- tions he often finds that primary care physicians prescribe less current drugs for their black patients. When he asks them why, they are baffled and unaware. Current antipsychotics and psychoactive drugs are not only an improvement over older medications in treating mental disorders, but also are better tolerated than older drugs. The Bias of Efficacy All physicians we spoke with expressed concern about how effective their interventions will be when patients may be “train wrecks”—the student’s term for victims of complex social problems—the term used by residents and attendings. The following example recounted by a resident suggests how complex responses by clinicians may be and how clinicians may take actions to offset the perceived bias: Last night I had an elderly African-American woman [in the ER], ‘the classic invisible cardiac patient who does not get referred to cath.’ I was trying to make a strong case that she needed to get cathed, to see if blockages [were the cause of] her intermittent episodes of shortness of breath. Her story was fuzzy in the way it came out. We push people to answer questions in a format we phrase for them. We guide and teach them how to answer the questions. If we try to coach them and they don’t respond to it or submit, it throws us off. Her job was to put her words into mine.

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604 UNEQUAL TREATMENT The attempt was successful. The resident commented on a second patient, with whom she was having less success. She had grown familiar with her through the patient’s many visits to the ER. I was thinking about how to help these patients and figure out what was wrong with them. I had another African-American lady, a huge part of her problem is chaos in her life, with teenagers living in her house who use drugs. She does not have keys to her own apartment, the kids stole the keys, she has to be let in. I got the social workers to impose their external presence to intimidate the kids, and get them out of the house. She [the patient] comes less often into the ER. I also gave her a tranquilizer. I feel bad about dosing a social problem. If chaos is in their life, patients such as this woman don’t get referred to high tech care, to cath, because they have a “difficult social situation.” There is a danger of quickly moving to that interpretation and physicians are biased in looking at the patient and saying ‘oh, difficult social situation’ and sure black physicians do this, too. Some people do this and some don’t—it needs to be documented. Political Correctness, the Medical Machine, and the Meaning of Bias In the clinical contexts we discussed, political correctness appears to be the normative order in public discussion. Medical students with whom we spoke note they never hear overtly negative racist comments in the hospital or among classmates. This sensitivity is new to the late twentieth century generation of medical students and faculty in our study area. However, when race is not a category of response, certain groups of pa- tients are fair game for jokes and occasional expressions of dismay and amazement about discrepancies in expectations, behavior, and their treat- ment of physicians. Patients from the former Soviet Bloc—Russians and others—are in particular maddening for physicians. Because “race” is not part of the package, physicians feel freer to comment on what they regard as strange behavior inappropriate in our society’s wider medical culture. Examples that are perceived as disrespectful behavior toward physicians and the healthcare system include not showing up for appointments and not notifying the clinics, calling in the middle of the night for minor prob- lems, choosing to go on vacation instead of keeping surgical schedules, and demanding particular treatments when paying, without regard for physician recommendations and expertise. “No-shows” are calculated into the time schedules for many community clinics and ambulatory care units; surgical units and surgeons are aware they may have problems with such patients as well. These problems are also encountered with other new immigrants, many of whom do not speak English. The community clinics with large immigrant non-English-speaking populations appear to be scheduled differently than are units at the teaching hospitals.

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615 CULTURE OF MEDICINE tent findings of bias, and that “bias is also consistently revealed in diagnos- tic judgments of Black and White patients” (1989:191). He finds little evi- dence to date for bias toward Hispanic patients. Lopez concludes from his review that “systematic errors in judgment based on patient variables may pertain to all clinicians and not just to those clinicians with prejudicial atti- tudes,” and that “investigators should give careful consideration to the symptoms or disorders used as their clinical stimuli” (1989:194). Support for these conclusions comes from an interesting study, con- ducted by Loring and Powell (1988). Loring and Powell mailed question- naires to psychiatrists, stratified by gender and race, asking them to par- ticipate in a study of the reliability of DSM-III by making diagnoses of two case vignettes. Two hundred ninety psychiatrists responded. The case narratives, written in the style of the DSM-III Casebook, included clear- cut diagnostic criteria to support diagnoses of undifferentiated schizo- phrenic disorder (an Axis I diagnosis) and dependent personality disor- der (an Axis II diagnosis). Descriptors identifying the gender and race of the case, or excluding such characteristics, were randomized, allowing the researchers to analyze how diagnosis is influenced by race and gender of both psychiatrist and patient. Findings are suggestive. First, “correct” diagnoses were given for only 38 percent and 45 percent of the two cases, respectively. Correct diagnoses were most often given when no identify- ing characteristics of the client were provided. Second, a highly complex pattern of interaction between race and gender of psychiatrist and race and gender of the case emerged. For example, white female psychiatrists diagnosed the first case as brief reactive psychosis 50 percent of the time when the client was identified as a white female, and paranoid schizo- phrenic disorder 53 percent of the time when the client was identified as a black male. No single interpretation of the overall response pattern can be given. However, black patients were given significantly more severe diagnoses, and black psychiatrists shared in this pattern of rating. How- ever, one clear pattern emerged. Black male clients were diagnosed with paranoid schizophrenic disorder in 43 percent of the first cases (compared with 6 percent, 10 percent and 12 percent for white males, white females and black females, respectively), and with paranoid personality disorder in 50 percent of the second cases (compared with 26 percent for the total sample). As the authors conclude, “clinicians appear to ascribe violence, suspiciousness, and dangerousness to black clients even though the case studies are the same as the case studies for the white clients” (p. 18). Whaley (1998) provides an insightful, complementary perspective on sources of racism in mental health services. Providing a comprehensive view of social-cognitive models of racism, Whaley elaborates a theory of “aversive racism,” which may be relevant. Drawing on the work of Gaert- ner and Dovidio (1986), he ascribes aversive racism to “low prejudice” white

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616 UNEQUAL TREATMENT subjects who hold negative stereotypes of black people. He argues that “whites who identify with a liberal political agenda (e.g., endorse public policies that promote racial equality and combat racism, view themselves as nonprejudiced and nondiscriminatory, and sympathize with blacks’ his- tory of victimization) but who harbor negative perceptions of black people” will experience “prejudice-related conflict” rather than hostility or hate, expressing “discomfort, disgust, uneasiness, or fear” indirectly or in situa- tions that do not threaten their liberal self-image (Whaley, 1998:49). He cites evidence that liberal whites are as likely as conservative whites to dis- criminate against blacks in situations that do not implicate racial prejudice as the basis for their actions, then goes on to examine how such “aversive racism” might function in mental health settings. Whaley focuses particular attention on research that identifies “bias in mental health professionals’ judgments associated with the racial stereo- type of blacks as violent” (1998:51). He reviews evidence that African Americans are likely to be sent to local correctional facilities, while white patients with similar levels of psychopathology and violent behavior are more likely to be referred to a mental health hospital. He interprets the Loring and Powell (1988) study cited above as evidence that black patients are more likely to be given a more severe diagnosis “because they are ste- reotyped as more dangerous.” And he links this specifically to the litera- ture on over-diagnosis of schizophrenia for black patients. However, since violence is not among the diagnostic criteria for schizophrenia, he is forced to make an indirect argument, saying that “The racial stereotype of violence may set off a chain reaction in the mental health evaluation and treatment process for black persons seeking help” (1998:52). He cites evidence that a diagnosis of psychotic disorder “is associated with fewer sessions with a primary therapist, greater likelihood of being treated with medication, less likelihood of being in outpatient treatment, and a lower chance of being in treatment with a professional therapist (Flaskerud and Hu, 1992),” arguing that “severe diagnoses and restrictive interventions,” both forms of “thera- peutic social control,” are linked to the view that mentally ill persons are dangerous. “Thus, the stereotype of violence is the common denominator in perceptions of black individuals and the diagnosis of schizophrenic dis- orders,” accounting for both the over-diagnosis of schizophrenia for Afri- can-Americans and a “chain reaction in the mental health evaluation and treatment process for black persons seeking care” (Whaley, 1998:52). Race, Perceptions of Violence, Involuntary Commitment, and Diagnosis of Schizophrenia Lower socioeconomic classes and minority persons, and in particu- lar African Americans, are over-represented in public mental health in-

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617 CULTURE OF MEDICINE stitutions. However, perhaps even more troubling is a consistent find- ing that African Americans are over-represented among those who are committed involuntarily. After an extensive review, Lindsey and Paul (1989:172) conclude that after individuals “have reached the public sys- tem for admission, Blacks have been and continue to be even more over- represented in comparison with Whites among those who are involun- tarily committed. Such over-representation appears across all periods of data collection and all areas of the country, without regional differ- ences (e.g., North vs. South).” Recent accounts by patients and patient advocates provide reminders that involuntary commitment is still often associated with abusive treatment and abrogation of human rights (Nordhoff and Bates, 1989), and those experiences of coercion influence inclination to participate in treatment (Lidz et al., 1995). (There is a large literature on elevated rates of schizophrenia among Afro-Caribbeans in Britain, as well as higher rates of involuntary confinement. See Coid et al., 2000 for a recent example.) Involuntary commitment is linked in part to assessment of severity of a person’s illness and to diagnosis, suggesting an added reason for con- cern about misdiagnosis and its over-representation in minority commu- nities. However, involuntary commitment is also linked to assessment of “dangerousness,” formally defined as the likelihood that an individual will use violence against self or others. The study of actual rates of vio- lence among persons identified as suffering mental illness has recently been the focus of research and sharp debate. Analysis of data from the NIMH Epidemiological Catchment Area studies found that the claim that the mentally ill are no more likely to be violent than those who are not ill is untrue (Swanson et al., 1990; Link, Andrews, and Cullen, 1992; Monahan, 1992). However, research also indicates that “excess risk for violence among mental patients is modest compared to the effects of other fac- tors,” in particular when compared with the effects of alcohol and drug abuse, and “only patients with current psychotic symptoms have elevated rates of violent behavior and it may be that inappropriate reactions by others to psychotic symptoms are involved in producing the violent/ille- gal behavior” (Link, Andrews, and Cullen, 1992:290). The sources and types of risk of violence among persons suffering mental illness and those who engage in substance abuse, as well as the implications for mental health services and involuntary commitment, are significant issues in on- going research (Link and Stueve, 1995; Junginger, 1996). Although Lindsey and Paul (1989:179) conclude that “empirical data to date provide no direct assistance in narrowing the range of explana- tions proposed for the over-representation of Blacks” among those who are involuntarily committed, the data are consistent with Whaley’s theory of aversive racism discussed above. Both epidemiologic and ethnographic

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618 UNEQUAL TREATMENT research are needed to understand how this explanation fits with other social and institutional factors, and to extend the analysis to other minor- ity groups. Detailed ethnographic and clinical research will be required to identify how assessment and commitment processes function in par- ticular settings and with particular populations—for example, rural Indi- ans jailed for drinking, African Americans apprehended by the police, or persons assessed in psychiatric emergency rooms of general hospitals or state institutions. Findings from such research would have important implications for improving mental health services in community settings, correctional institutions, and psychiatric institutions, and for eliminating racial and ethnic bias in assessment and treatment. For the purposes of this review, the linking of perceptions of violence, psychiatric diagnosis, and involuntary confinement may provide a model for understanding how clinical judgments and treatment decisions that have discriminatory impact, resulting in disparities in health services, may be made by persons who are not overtly racist and by persons who are strong advocates for minority communities and patients. The linkages in this case are highly specific, rather than a result of generalized attitudes or tendencies to discriminate. Indeed, because good care requires assess- ment of levels of dangerousness to self and others, the role of stereotyping those who are to be considered “violent” may well “slip under the radar” of efforts to provide training to support “cultural sensitivity” or culturally competent care. To be useful, this model needs to be verified in research and extended to other types of ethnic stereotyping. For example, research suggests that Asians may receive inadequate levels of psychotropic medi- cations precisely because they are viewed as relatively free of emotional and mental health problems. And rather than hypothesizing attitudes such as “aversive racism,” research should be directed at measuring them. Cautions: Health Systems Issues and the Complexities of Mental Health Phenomena It is important to temper the hopes that a single line of reasoning, such as that outlined above, is adequate to fully explain disparities in mental health services. We have not yet mentioned disparities in access to health insurance, or the tendency for persons who belong to ethnic and racial mi- norities to be over-represented among those who are poor and homeless and to grow up in settings where violence is a part of the routine social environment. No mention has been made as to how managed care, or “managed behavioral health services,” is affecting the relationships formed between patients and clinicians. Yet we know that health insurance is closely linked to access to mental healthcare. McAlpine and Mechanic (2000) recently demonstrated that for a sample of persons with severe men-

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619 CULTURE OF MEDICINE tal illness, who are disproportionately African American, unmarried, male, less educated, and low income, almost three-fifths received no specialty mental healthcare in a 12-month period, one in five were uninsured, and only 37 percent were insured by Medicare or Medicaid. Because “persons covered by these public programs are over six times more likely to have access to specialty care than the uninsured,” any explanations that ignore formal mechanisms for access to care are likely to be extremely partial. Furthermore, privatization of mental health services has led to disbanding of clinics devoted to the care of high risk children, youth and families. There- fore, psychiatrists have far fewer visits to develop relationships with pa- tients that allow them to move beyond initial stereotypes—on the part of both the clinician and the patient—and to develop truly therapeutic and understanding relationships than is true under other forms of mental health services. Thus, great care should be taken in developing explanations that focus on decision-making processes of individual clinicians. Finally, in the specific case discussed here—the apparent “over-diag- nosis of schizophrenia” among African Americans—the robustness of the phenomenon remains in question. Because there is no gold standard or biological marker for diagnosing schizophrenia, one line of research at- tempting to determine reasons for higher rates of schizophrenia among hospitalized African Americans has compared diagnoses using standard- ized diagnostic interviews with recorded hospital or emergency room di- agnoses. The best such study, carried out by Neighbors et al. (1999), found that use of a standardized diagnostic interview reduced the percentage of black patients diagnosed with schizophrenia in a Michigan hospital from 58 percent to 39 percent. However, the study found that white patients diagnosed with schizophrenia were reduced from 49 percent to 31 per- cent, and that levels of “misdiagnosis” (assuming the research diagnoses were correct) for white patients were somewhat higher for whites than for blacks. Misdiagnosis in this study was shown to be as high for whites as blacks, and even the most carefully designed study continued to find higher rates of schizophrenia among hospitalized African Americans than among hospitalized white Americans. Thus, although mental healthcare provides an important model for how to approach the issues to be ad- dressed in this review, it remains a particularly difficult domain to make claims with great certainty. Concluding Questions The multidimensionality of reasons for disparities in healthcare and medical treatment for racial and ethnic minorities, along with the lack of data focused explicitly on the role of the culture of professionals and health institutions in producing these disparities makes it difficult to fully

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620 UNEQUAL TREATMENT respond to the charge given to these authors by the IOM Committee. “Cul- ture counts,” as Satcher’s report notes. Until recently, when cultural analy- ses were proposed, the focus was largely on patient culture. Burdens of difference were on patient communities, and medicine and health profes- sionals were expected to learn to be culturally competent in attending to the diverse populations that make up American society. When we are challenged to examine the culture of medicine and of our healthcare insti- tutions, we are also challenged to bring a critical perspective that has largely been ignored by most research to date or that has circumscribed cultural inquiry to the differences between patients’ and physicians’ “be- liefs.” Disparities in medical treatment are not simply matters of differ- ences in “beliefs.” Clearly, political and economic factors that shape our medical commons and our larger society are implicated in the production of these disparities. Physicians interviewed as well as research reviewed indicate that societal racism and persistent inequalities may be respon- sible for many of the differences, now so widely documented. In a recent study sponsored by the Robert Wood Johnson Foundation, Hargraves et al. (August 2001) found that minority physicians who were more likely to be in solo practice were also less likely to obtain referrals to specialists and had greater difficulty admitting patients to the hospital. Given that minority physicians care for a greater proportion of minority patients, differences in high-technology care may be related to environmental prac- tice factors. As Hargrave et al. (2001) note, “Minority physicians’ inability to arrange important medical services for their patients may be positively associated with problems minority patients have with access to care.” Minority physicians in this study included Hispanic and African- American physicians. (See also Gray and Stoddard, 1997 and Komaromy et al., 1996.) Minority physicians also feel there is discrimination in peer review, hospital promotions, Medicaid and Medicare reimbursement, malpractice suits and private insurance oversight (Byrd et al., 1994). Bias appears in the awarding of managed care contracts as well, with dispari- ties between white and minority, in particular Asian, physicians docu- mented in a national survey (Mackenzie et al., 1999). These complexities of bias and practice environment clearly indicate that differences are found not simply in cultural diversity or in practice “beliefs.” In sum, we recommend the following approaches to further under- standing of reasons for disparities. 1. Attend to a critical analysis of the culture of medicine in its broad- est meaning and in different practice and training environments and geo- graphical regions. The dimensions of time, efficiency and efficacy and the medical gaze may be useful starting points, but analyses should examine

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621 CULTURE OF MEDICINE behavioral modeling and hierarchical relationships that may influence patterns of care and choice of treatments as well. 2. Examine the political economy of cultural practices in medicine, from the arrangement of healthcare delivery systems to the financing of biomedical innovations and practices, to the justification for choice of treatment and care. 3. Examine the practice arrangements of minority physicians by ethnicity, age, and region (urban/rural and state). 4. Explore how the sea change in the ethnicity and race of medical students, physicians, nurses, and healthcare staff affects provision of care to ethnic and racial minorities, new immigrants, and the poor. 5. Identify interventions and programs that have been successful in medical and nursing education and have influenced the way care is pro- vided to ethnic and racial minority patients. 6. Assess the success of programs directed to redress imbalances in care such as minority outreach programs and clinics; what are positive lessons, negative if unintended consequences and avoidable difficulties? These are elementary suggestions, and the questions with which we began this chapter are but partially addressed. Unfortunately, we have not been able to conclude with a clear set of findings. Clearly, more work focused explicitly on these questions is required, and such research will have to include depthful, qualitative work—observations; in-depth confi- dential interviews with health practitioners, including those in training; and similar in-depth interviews with patients from diverse minority groups about their experiences in healthcare. In terms of policy responses to eliminate racial and ethnic health disparities, these will not only have to come from innovative research and programs in the medical commons and the healthcare arena, but as David Williams suggests, from larger societal changes (Williams and Rucker, 2000). And such responses will have to use new and innovative understandings of culture, ethnicity and racism to develop multidimensional results. Acknowledgments Appreciation to Giuseppe Raviola HMS IV and Elizabeth Herskovits for interviews and analyses of contemporary academic hospital culture; to Jennifer Clark for data analysis, charts, and maps; to Naomi Ko for research assistance, and to Martha MacLeish Fuller for bibliographic assistance.

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