D. Discrimination

      The final barrier to care is discrimination.  Discrimination is the differential and negative treatment of individuals on the basis of race, ethnicity, gender, or other group membership.   In health care delivery there are three possible causes of discriminatory treatment: (1) bias or prejudice, (2) stereotyping, and (3) uncertainty in communication and clinical decision-making.” Prejudice is conscious behavior defined as an “unjustified negative attitude based on a person's group membership.” In contrast, stereotyping can be conscious or unconscious. Stereotyping is the “process by which people use social categories (e.g., race, sex) in acquiring, processing, and recalling information about others.” Uncertainty in communication and clinical decision-making is a result of the dissonance that results from intergroup communication. Here, physicians might provide less than appropriate treatment, because they must make diagnosis and treatment decisions in a short amount of time with limited or inaccurate information, including missing or misinterpreting patients' verbal and nonverbal communications.

      Discrimination in the health care system is merely a reflection of the discrimination that exists in American society.  Racial discrimination persists in several important aspects of American life, such as mortgage lending, housing, employment, and criminal justice.   Access to quality health care is no different.  For example, a recent study published in the February 25, 1999 New England Journal of Medicine found that the race and sex of a patient independently influence how physicians manage cardiac care and the use of cardiac catheterization.   The hypothesis of this study was to evaluate how a patient's race and sex influenced a physician's recommendation for cardiac catheterization.   The study also controlled the effect of differing socioeconomic status on the physician's treatment decision to avoid challenges to the study, based upon the argument that socioeconomic status was the basis for differing treatment decisions between the races.

      The conclusions of the New England Journal of Medicine study were supported by a study on physicians' perceptions about patients.  This study, by van Ryn and Burke, surveyed physicians to assess their perceptions of white and African American patients following a hospital visit.   The study found that a patient's race and socioeconomic background influence physicians' perceptions.   According to the study, physicians rated African American patients “as less intelligent, less educated, more likely to abuse drugs and alcohol, more likely to fail to comply with medical advice, and less likely to participate in . . . [treatment] than white patients.”

      The van Ryn and Burke Study reveals that an obvious consequence of a physician holding negative perceptions about ethnic minorities is that the doctor is less likely to recommend treatments, or less likely to put effort into discerning the true nature of the patient's problems.   The study also shows that a physician's stereotypical expectations may cause the doctor to engage in behavior toward the patient that causes the patient to respond in a way that confirms the negative perception held by the health care provider.

      Health care professionals, like many individuals, are reluctant to believe that they themselves engage in discriminatory behavior.  While minority communities have asserted for years that racial discrimination affects health care, the health care profession as a whole has refused to believe or admit it.  In 1998, two major reports by the United States Department of Health and Human Services, one of which was the Department's Response to the President's Initiative on Race, failed to acknowledge racial discrimination as a substantial cause of disparities in health care.   These reports merely listed (1) level of education, (2) environment, (3) income, and (4) type of occupation as substantial causes of the disparities.  Similarly, the Institute of Medicine's recent report on Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, assumes without direct evidence that the vast majority of health care providers finds “prejudice morally abhorrent and at odds with their professional values.” However, this assumption brings little comfort to minority patients when the survey also finds that well-meaning whites, not overtly biased or prejudiced, typically demonstrate “unconscious, implicit negative racial attitudes.” Thus, from the minority patient's point of view, it does not matter whether the health care provider subconsciously or consciously engages in racial or ethnically discriminatory behavior, because the effect on the patient is the same: receipt of health care that does not meet the patient's needs.