Controversial NEJM Study: Blacks treated by "lousier" physicians?

[Neuron]

An extraordinary study published in today's New England Journal of Medicine comes to the unsettling conclusion that, in the US, blacks are treated by a largely different group of doctors than those treating whites.

They hypothesize that one reason for the documented disparity in health care suffered by blacks may be that they are being seen by subgroup of physicians with "inferior qualifications".

It turns out that:

80% of visits by black patients were made to 22% of physicians. These 22% see very few white patients. This finding indicates that the care of black patients and white patients rests to a large extent in the hands of different physicians.

Resources
The 22% who see most blacks are more likely resource-challenged:
The physicians treating blacks were more likely to report having difficulties in accessing high-quality subspecialists, imaging, and nonemergency admission to hospitals.

Qualifications/Physician Charateristics
Where qualifications are concerned the study mainly touts this difference between the physicians seen by whites and blacks:
86% of physicians white people see are BC.
Only 77% of physicians black people see are BC.

If you look closely at the data, you also find that there are NO significant differences for the following:

Sex (both black and white patients have ~85% male docs)
Practice type (both mostly see docs in solo or two partner practices)
Location (both see mostly Urban docs)
PCP Specialty (both see about the same proportion of specialty type, IM v FP)
Education (no difference in number of USMGs v IMGs)​

The only other characteristic aside from board certification that was significantly different: blacks and whites see physicians of different races in different proportions.

22% of the doctors (650 out of 3211 pairs) seeing black patients were themselves black.
Whites saw virtually no black doctors (0.7%, or 370 out of 41,545 pairs). Whites get their health care from white and asian doctors, whereas blacks get theirs from blacks, whites and asians.

A higher % of the physicians seeing black patients were not "fully" qualified ie. not BC.

Of course, the questions that beg asking, and which on my cursory reading were not answered, are: who are these physicians? Are they predominantly black physicians? Is our medical education system failing black med students, and thus, indirectly, black patients? Why is it that more "less qualified" physicians are in the small subgroup of doctors serving blacks?

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[RLMD]

Actually, that 22% are predominantly non-black physicians since only 6-7% of ALL doctors are black. So most blacks are seeing non-black physicians.
This is one of the reasons for AA in medical school. Blacks make up 12% of the US population but only 6% of the doctors in the US are black. Blacks are going to non-black physicians and are getting worse treatment because of DISCRIMINATION, not because 9% less of these physicians are BCed. That doesnt look like a significant difference to me! This is nothing new to me.

 

[Neuron]

Actually, that 22% are predominantly non-black physicians since only 6-7% of ALL doctors are black. So most blacks are seeing non-black physicians.

You are merely repeating what I said. Yes, of course most black visits are to non-black (specifically, white) physicians. For black patients, 22% of visits are to black physicians, 59% to white.

Blacks are going to non-black physicians and are getting worse treatment because of DISCRIMINATION, not because 9% less of these physicians are BCed.

1. As I said, I did not see any data on the proportion of black doctors who are BC v white doctors who are BC in the NEJM paper.

It is known however that black physicians across all specialties are board certified at a lower rate compared to whites, 69% vs 79%. It is thought the percentage is even lower in primary care. Whether or not these "inferior qualifications" contribute to the poorer health care of blacks is an open question at the moment, so your statement denying it is without evidentiary basis.

I am inclined to believe it does play a role. We know that physicians ?whatever their race - who score poorly on their licensure examinations or who are not BC are less likely to follow screening recommendations and more likely to prescribe symptom-directed treatment, rather than diagnosis- directed treatment ? tendencies that may result in delayed diagnoses (see refs 31-35 of the NEJM paper).

Since blacks are seeing a higher proportion of non BC physicians, there is very likely an impact on their health.

 

[Neuron]

Blacks are going to non-black physicians and are getting worse treatment because of DISCRIMINATION?

That is a particularly vile accusation. I do not know of any study showing this. I think the poorer health status of blacks is multifactorial, and is impacted by socioeconomic factors, cultural factors, and also by the characteristics of the physicians they see - a higher proportion of whom are non-BC. I do not think there is calculated/systemic racism going on.

 

[Neuron]

This is one of the reasons for AA in medical school. Blacks make up 12% of the US population but only 6% of the doctors in the US are black.

This research does not concern AA, but I would be na?ve to think it wont be brought up. My thoughts on that:

1. I think it would be disastrous for the percentage of minority physicians (not just blacks, but hispanics, asians and others) to fall. This is because these patients tend to see physicians of their own race, as is amply demonstrated here for blacks. (To be fair, that may be as true for whites, but it is impossible to demonstrate because the physician workforce is overwhelmingly white). With the documented poorer healthcare minorities receive as it is, it would be awful if a proportion of them simply stopped seeing doctors at all because of physician imbalances.

2. Whether or not the best way of doing this is through AA is debatable, but it is the most practical way at present, since the system is already in place.

3. An equally serious problem is to bridge the ?performance gap? between black and white/asian doctors. Why is it so many more blacks are unable to be BC?

 

[tofurious]

Blacks are going to non-black physicians and are getting worse treatment because of DISCRIMINATION, not because 9% less of these physicians are BCed.

WHy am I not surprised that any research like this will be used as proof that racism and discrimination are causing all the problems this society faces? Assuming the white physicians who see blacks to be incompetent (or discriminatory) is as racist as assuming the 6% black physicians to be incompetent. I guess logic is just not part of affirmative action argument.

 

[RLMD]

You are merely repeating what I said. Yes, of course most black visits are to non-black (specifically, white) physicians. For black patients, 22% of visits are to black physicians, 59% to white.



1. As I said, I did not see any data on the proportion of black doctors who are BC v white doctors who are BC in the NEJM paper.

It is known however that black physicians across all specialties are board certified at a lower rate compared to whites, 69% vs 79%. It is thought the percentage is even lower in primary care. Whether or not these "inferior qualifications" contribute to the poorer health care of blacks is an open question at the moment, so your statement denying it is without evidentiary basis.

I am inclined to believe it does play a role. We know that physicians ?whatever their race - who score poorly on their licensure examinations or who are not BC are less likely to follow screening recommendations and more likely to prescribe symptom-directed treatment, rather than diagnosis- directed treatment ? tendencies that may result in delayed diagnoses (see refs 31-35 of the NEJM paper).

Since blacks are seeing a higher proportion of non BC physicians, there is very likely an impact on their health.

I dont know since I cant see the article you are referring to, but if you see a resident, is that not the same as seeing a non-BC doc? Couldnt there be other factors for this lower number of BC doctors being seen by african americans? And I really dont think the 9% difference is very significant, honestly. It doesnt fully account for the large difference in healthcare minorities receive. People tend to simplify the issue to understand it better. It isnt simple and there are no simple answers. I wish there were, but there arent.

 

[RLMD]

That is a particularly vile accusation. I do not know of any study showing this. I think the poorer health status of blacks is multifactorial, and is impacted by socioeconomic factors, cultural factors, and also by the characteristics of the physicians they see - a higher proportion of whom are non-BC. I do not think there is calculated/systemic racism going on.

I do know of studies showing this. Like I said, this is nothing new, I have heard about this for years. Minorities are more sensitive to the issue because it effects them directly. If you believe discrimination does not exist, you are naive. If you believe doctors are "above" discrimination because of their place in society, you are even more naive.
Studies have shown that all else being equal (socioeconomic status, insurance, ability to pay, symptoms, SAME DOCTORS, etc.), african americans get worse treatment (delayed treatment, outdated medication, etc.) than whites. And the majority of blacks see white doctors. Sounds like prejudice to me. I am not suggesting that it is anything malicious or even a conscious act, its just the way it is.

 

[RLMD]

This research does not concern AA, but I would be na?ve to think it wont be brought up. My thoughts on that:

1. I think it would be disastrous for the percentage of minority physicians (not just blacks, but hispanics, asians and others) to fall. This is because these patients tend to see physicians of their own race, as is amply demonstrated here for blacks. (To be fair, that may be as true for whites, but it is impossible to demonstrate because the physician workforce is overwhelmingly white). With the documented poorer healthcare minorities receive as it is, it would be awful if a proportion of them simply stopped seeing doctors at all because of physician imbalances.

2. Whether or not the best way of doing this is through AA is debatable, but it is the most practical way at present, since the system is already in place.

3. An equally serious problem is to bridge the ?performance gap? between black and white/asian doctors. Why is it so many more blacks are unable to be BC?

I completely agree.
The answer to your last question is, once again, not simple. It is multifactorial as you said. I wish I or anyone else had the answer. I can say this: the problem is more deeply rooted and older than the individuals medical school education.

 

[iwantrad05]

Neuron, it seems as if you are pretty stirred by this "extraordinary study". It is as if you have not been aware of the fact that there is something in America called lack of access to appropriate care. Something that all races of AMerican citizens fall victim to. It is not a breakthrough that Blacks visit Black physicians at a higher rate. It has been the case for over one hundred years. My medical school was founded by white philanthropists on the principle of ensuring that the Blacks had access to doctors, dentists and other healthcare. In many other scenarios, Blacks were simply not welcome (or allowed) in White hospitals or clinics. It is no surprise that the numbers you quoted respresent that.

To your theory on board certification, it is important to look at the issue of "BC" itself. Board certification has not always been necessary for medical practice. BC is now considered more of a neccessity to physicians in various fields due to the changing scope of medicine. Litigation, malpractice, and gaining and/or maintaining your privileges at hospitals. 25-30 years ago, the case was not such. This brings me back to the differences in %'s you quoted. The number of African- American medicine and surgical specialists is most likely less than that of whites (I do not have numbers to quote specifically). Therefore, more older Black PCP's (IM, Family Med or Peds) may not be BC. However, I will doubt if that trend continues in the next decade or so as more specialization in medicine occurs. I THINK ANYONE WILL BE HARDPRESSED TO FIND A RADIOLOGIST, ANESTHESIOLOGIST OR MED OR SURG SUBSPECIALISTS NOT BOARD CERTIFIED.

IF YOU THINK THAT THIS IS A REVOLUTIONARY PIECE OF LITERATURE, I THINK YOUVE BEEN SLEEPING DUDE
Later

 

[Neuron]

I dont know since I cant see the article you are referring to,

It?s the New England. You?d be able to access it in virtually any reasonably large library/ medical library/hospital library/hospital computer terminal.

but if you see a resident, is that not the same as seeing a non-BC doc

No. A resident is a physician in training who is supervised by an attending (who is almost always BC, since he is on staff at a teaching institution). Most non-BC docs (not including recently graduated residents who just haven?t taken their final exam yet) are non-BC because they couldn?t pass the boards, or for some reason didn?t attempt it.

Couldnt there be other factors for this lower number of BC doctors being seen by african americans?

I didn?t postulate any reason for this. I know that the docs who see most black patients have a higher % of non-BC practitioners. I don?t know why.

And I really dont think the 9% difference is very significant, honestly. It doesnt fully account for the large difference in healthcare minorities receive.

A ~10% difference is not only statistically significant, it is very substantial. But while it is so, no one, certainly not I, implied that this ?fully accounts for the large difference in healthcare minorities receive?. I specifically stated that it is likely part of the reason. And that I do believe.

 

[Neuron]

If you believe discrimination does not exist, you are naive. If you believe doctors are "above" discrimination because of their place in society, you are even more naive.

I believe neither. Strawman.

I do believe that it?s untrue that the health care disparities experienced by minorities are caused by systematic/calculated racism, an allegation you (seem) to have made in your first post on this thread.

 

[Neuron]

Studies have shown that all else being equal (socioeconomic status, insurance, ability to pay, symptoms, SAME DOCTORS, etc.), african americans get worse treatment (delayed treatment, outdated medication, etc.) than whites. And the majority of blacks see white doctors. Sounds like prejudice to me.

I disagree. Perhaps prejudice is not the word you intended to use. Was it?
Look it up.

As to your contention, I can do no better than to quote others more learned in this matter:

 

[Neuron]

Arnold Epstein ? long time chronicler of racial disparities in health care at Harvard?s Health Policy and Management Section ? writes in his accompanying editorial in the Journal

Much of the literature on mediators of racial disparities in the provision of health care has focused on characteristics of the patients, such as their ability to afford care, their knowledge and beliefs, and their preferences, as well as on aspects of the doctor?patient relationship that involve patients' education, trust, and the physician's sensitivity to a patient's culture. These factors may be important?The findings of Bach et al., however, suggest that there are structural features of the delivery system that also contribute to racial disparities in the quality of care?

Many have worried that racial differences in the use of health care services stem from conscious or unconscious bias on the part of physicians. The findings suggest an alternate pathway and point away from interpersonal discrimination.

 

[Neuron]

From the landmark IOM report Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (see Page 30).

?As noted above, the reasons for these health status disparities are complex. Individual risk factors for poor health are pronounced among many racial and ethnic minorities, yet these risks are confounded by the disproportionate representation of minorities in the lower socioeconomic tiers. Moreover, socioeconomic position in and of itself is correlated with health status, independently of individual risk factors, as people in each ascending step along the socioeconomic gradient tend to have better health, even when individual health risk factors are accounted for (Kaplan, Everson, and Lynch, 2000). Cultural factors also play an important role in health disparities... Further, environmental health risks, such as degradation, air, water, and soil pollution, and other physical health hazards are more prevalent in low-income racial and ethnic minority communities. These and other risk factors associated with health and poor health illustrate that racial and ethnic disparities in health status largely reflect differences in social, socioeconomic, and behavioral risk factors and environmental living conditions (House and Williams, 2000).

 

[Neuron]

Neuron, it seems as if you are pretty stirred by this "extraordinary study".

LOL. I would suggest that if anyone is stirred up it?s you.

You went to the trouble to register today (coincidence, I?m sure) just to make a single rant on this thread.

Curiously, you ?want Rads in 2005?, again coincidentally sharing the same aspirations as RLMD, who is ?Rads/IR bound? and will probably be in the 2005 match (MSII presently).


Most of your post has nothing of importance, but I will address this fallacy:

BC is now considered more of a neccessity to physicians in various fields due to the changing scope of medicine. Litigation, malpractice, and gaining and/or maintaining your privileges at hospitals. 25-30 years ago, the case was not such. This brings me back to the differences in %'s you quoted. The number of African- American medicine and surgical specialists is most likely less than that of whites (I do not have numbers to quote specifically). Therefore, more older Black PCP's (IM, Family Med or Peds) may not be BC. However, I will doubt if that trend continues in the next decade or so as more specialization in medicine occurs.

Rubbish. If the only blacks and whites who are not BC are older docs, you will expect the ratio to be about the same. In fact, if anything, you would expect a higher number of BC black physicians, simply because there were fewer black physicians back in the day than there are today.

This is the exact opposite of what we?re seeing. Whatever is the cause of the lower % of black physicians who are able to pass their boards, it has nothing to do with older docs from the ?pre-boards? era who?re still around.

Oh, and I have never propounded any ?theory of board certification?.

 

[beyond all hope]

I hate to point it out, but the whole 'blacks are less likely to be treated by a board certified physician' is just common sense if you ignore the politically correct attempt to even out a very uneven playing field.

Note that everything I'm about to say is a generalization and has no bearing on individual doctors.

1) Physicians who are not BC are less competative applicants than BC docs and will, in general, out of necessity have to take jobs in less-desirable areas

2) Less desirable areas for physicians include places where the patients are less likely to be insured or to pay their medical bills

3) A large percentage of AAs in the US are poorer than the average American. They are less likely to be insured and less likely to be able to pay medical bills out of pocket.

4) Therefore, AAs will more often have non-BC physicians.

It's not about race, it's about money.

On a somewhat related note, I also know AA physicians who return to their less-affluent communities in order to treat patients that they know will be less likely to pay them. These docs go where the hurting is, knowing they will sacrifice income in order to treat those truly in need. These men and women are heroes and should be treated as such.

Not BC does not necessarily mean stupid or incompetant.

 

[jwchop]

1

 

[Neuron]

I don?t know whose posts you?re referring to, but I?ll address the mistakes in yours.

Its the composition of those doctors, I would venture to guess that a lot of those doctors are the foriegn medical doctors who complete there residency on a J1 and in order to secure a job in the US to stay here, go to these "less" desirable places that a lot a US grads don't go to. As to the percentage of these foreign doctors who are board certifiied that would be an interesting question, if they are indeed treating more minority patients. I think that when you just try to break it down into whites go to white doctors and blacks go to black doctors (and white doctors) you miss a large part of the story.

The percentage of IMGs was looked into, among many other things. I noted them in the first post. There was no difference in the proportion of these doctors serving either population of patients (blacks and whites). In absolute terms, white patients saw more than 10 times the number of IMG doctors than black patients. The number of these individuals is too small to account for the higher % of non-BC doctors seen by black patients.

Other doctor variables that were not significantly different between the two populations:

Sex (both black and white patients have ~85% male docs)
Practice type (both mostly see docs in solo or two partner practices)
Location (both see mostly Urban docs)
PCP Specialty (both see about the same proportion of specialty type, IM v FP)​

 

[Neuron]

A poster above acutally tried to link the non-board certified doctors to a large percent of black doctors, that makes me laugh, nowhere in the study nor from the synopsis of the article from post above did it mention the equation black doctors = taking care of more black patients; more non-board cerified doctors = taking care of black patients; therefore black doctors = non-board certified doctors.

No poster here has claimed that this NEJM study showed that the non-BC physicians serving blacks were black physicians. Again, whose post are you referring to?

In the post that opened this thread, I in fact specifically stated that this study did not address that issue. In a discussion with RLMD, in post #3, I again specifically stated the same thing. I also pointed out, since he made an incorrect assumption, that we know from other studies that a greater proportion of black doctors are not BC, compared to white doctors. (there is ~ 10% difference: 79% white docs BC, vs. 69% black docs BC).

This NEJM study showed that white patients see virtually no black physicians (0.7%). It showed that black patients see a hugely disproportionate number of black physicians (22.4% vs. 0.7%), ie. In the words of the authors, ?[this finding] supports the hypothesis that black patients preferentially seek care from primary care physicians of their own race.?

Whether or not most of the physicians who are non-BC who are seeing black patients are themselves black, we know from elsewhere that a higher proportion of black doctors are non-BC; it would be good health policy to identify the reasons for this and try to rectify it.

In fact, it would be good policy to try and improve the BC rate across the board.

 

[Neuron]

The same thing was mentioned with the post above mentioning the "unqualified" apllicants, what do you mean by "unqualified"? Do you mean at the medstudent level when a student is applying to residency and they are "unqualifed" to go where they want, and instead to the boondocks? Or at the resident level when someone is looking for a job? Who is this population of unqualified "applicants" is it grades, race, immigrantion stauts, where the person went to medschool?

Again, who is ?you?? Speaking for myself, when I wrote ?less qualified?, or ?inferior qualifications?, I placed them in quotation marks, because I was borrowing the terms used by the authors themselves. Did you even read the abstract, let alone the article? By ?doctors whose qualifications are inferior?, the authors mean attending level physicians who are not BC.

I do not understand what you?re asking in that last question.

 

[MD'05]

This research does not concern AA, but I would be na?ve to think it wont be brought up. My thoughts on that:

1. I think it would be disastrous for the percentage of minority physicians (not just blacks, but hispanics, asians and others) to fall. This is because these patients tend to see physicians of their own race, as is amply demonstrated here for blacks. (To be fair, that may be as true for whites, but it is impossible to demonstrate because the physician workforce is overwhelmingly white). With the documented poorer healthcare minorities receive as it is, it would be awful if a proportion of them simply stopped seeing doctors at all because of physician imbalances.

2. Whether or not the best way of doing this is through AA is debatable, but it is the most practical way at present, since the system is already in place.

3. An equally serious problem is to bridge the ?performance gap? between black and white/asian doctors. Why is it so many more blacks are unable to be BC?

4. Why do I get the feeling that Neuron is purposely race-baiting?

 

[whispers]

But you can not assume that the low bc rate was due to black non bc physicians. In fact most of the black patients in this study had physicians who were white males.

 

[Neuron]

Why do I get the feeling that Neuron is purposely race-baiting?

Because you?re not thinking.



And so you imagine every attempt at dispassionate discussion about important social issues - that involve sensitive topics, such as race ? must be insincere.

It is all the more ironic that you referenced that post ? where I specifically state my support for AA, despite my belief that it is a morally inferior option.

 

[Neuron]

But you can not assume that the low bc rate was due to black non bc physicians. In fact most of the black patients in this study had physicians who were white males.

I?m starting to wonder if some of you read anything before you post.
Either that, or you find this genuinely difficult to understand.

Please see this, and this.

 

[whispers]

Yes I did read your post.
"Whether or not most of the physicians who are non-BC who are seeing black patients are themselves black, we know from elsewhere that a higher proportion of black doctors are non-BC; it would be good health policy to identify the reasons for this and try to rectify it. "

Here some make the leap that the low board certification rate may be due to the higher percentage of black physcians because in previous studies ( I did not see a reference listed) black physicans have a lower board certification rate. I wonder if cause of the low bc of md visted by black patients was multifactorial. If we use the rate listed in the previous post for board certification rate of white physcians 79% and black physicans being 69 % we would expect the number of non bc mds of black and white physicans seeing white patients in this study to be 7637.74 and black patients to be 610.37. (excluding asian and other) But this is not the case. The board certification rate of physicians visited by white patients was higher than the the 79% why is this so? And to what extent will this influence patient outcomes in this population versus access to care.

Also the sample size of the physicians visted by black patients is lower. The study mentioned that predominantly black communities tend to have fewer primary care physcians. Black patients tend to recieve care in inpatient and emergency care setting. How does this impact on the disparity between these communities?

I do agree with you understanding and rectifying these differences would be good health policy. I think that this, identifying and understanding the disparities, is in part what health disparity research is about.

And I like this thread.

 

[CambieMD]

The authors of the article in the NEJM seemed surprised to learn that poor blacks in urban areas have worse outcomes and receive a worse care than others. Theses guys could have given me a fraction of the money and I would have come to the same conclusions in less time.

The urban poor live in more dangerous neighborhoods,the schools are inferior,housing is often substandard,abandoned buildings often dot these neighborhoods. Why would anyone spend good money to discover the obvious. I suppose they got a grant so it wasn't their money.

These patients have worse outcomes for a number of reasons. Certain types of physicians gravitate to these areas for a number of reasons. I wil not get into the debate rearding BC.

The issue of providing healthcare to the urban poor are very complex. The role that the patient plays in all of this cannot be overlooked.

The main reason for the difference in healthcare quality that urban blacks receive is related to economics and a poorly informed patient population.
How can a woman think that the orange size fungating mass in her breast is a "boil."

Healthcare in this country will never be the same for everyone. Economics and patients ability to read and digest health information play a larger role than policy makers want to admit.

This is just my .02.

CambieMD

 

[edinOH]

Regarding the whole BC thing...

How many residents do you know who are BC?

Exactly.

Poor people are more likely to receive their care through the county/university/charity teaching services than the private sector of medicine obviously.

I don't know if this point has been discussed but it seemed to me to be a pretty obvious source of bias in this study/thread.

 

[Seaglass]

The authors of the article in the NEJM seemed surprised to learn that poor blacks in urban areas have worse outcomes and receive a worse care than others.

Actually this has been shown in many other studies (which the authors refer to). This was the first to look at the doctors that patients see, and it showed that the doctors that the two groups see aren't the same. That was the surprise.

 

[iwantrad05]

LOL. I would suggest that if anyone is stirred up it?s you.

You went to the trouble to register today (coincidence, I?m sure) just to make a single rant on this thread.

Curiously, you ?want Rads in 2005?, again coincidentally sharing the same aspirations as RLMD, who is ?Rads/IR bound? and will probably be in the 2005 match (MSII presently).


Most of your post has nothing of importance, but I will address this fallacy:



Rubbish. If the only blacks and whites who are not BC are older docs, you will expect the ratio to be about the same. In fact, if anything, you would expect a higher number of BC black physicians, simply because there were fewer black physicians back in the day than there are today.

This is the exact opposite of what we?re seeing. Whatever is the cause of the lower % of black physicians who are able to pass their boards, it has nothing to do with older docs from the ?pre-boards? era who?re still around.

Oh, and I have never propounded any ?theory of board certification?.

Just a few points:
1) I did join the forum on that day, but certainly not to rant on a single thread (especially not one as irrelevant as this one)
2) Being that I dont know you from Adam, its commendable that you're reading and quoting the literature and sharing the knowledge but I just don't think the information is as surprising as others may
3) I speak for myself, I dont know the other poster and interest in Radiology has nothing to do with my post
4) Academia needs more physicians like you, quoting studies like this. Leave the high-paying private practice gigs to those of us who could care less (PS- I know that four is more than a "few" in case you felt the need to define it for me)

 

[Neuron]

And I like this thread.

Great.

Here some make the leap

Thanks

 

[Neuron]

I wonder if cause of the low bc of md visted by black patients was multifactorial.
If we use the rate listed in the previous post for board certification rate of white physcians 79% and black physicans being 69 % we would expect the number of non bc mds of black and white physicans seeing white patients in this study to be 7637.74 and black patients to be 610.37. (excluding asian and other) But this is not the case. The board certification rate of physicians visited by white patients was higher than the the 79% why is this so? And to what extent will this influence patient outcomes in this population versus access to care.

I'm not sure how you're getting this. The total number of black patient-MD pairs studied was 3211. The NEJM paper did not breakdown the non-BC docs by race. It broke down the race of docs seeing whites vs. blacks.

To reiterate from my 3 or 4 posts on this, this is what we know:

1. The NEJM study shows that blacks and whites largely see different doctors.
2. 80% blacks see 22% of doctors who see very few whites.
3. Whites see white and asian doctors. Only a fraction of 1% of white patient visits were to black doctors. I think this is mainly due to 2 reasons: firstly, there are very few black doctors to begin with, as someone pointed earlier ? I think the figure quoted was 6% though I can?t verify this. Secondly, geography.
4. Blacks see black, white and asian doctors. 22% of black patient visits were to black docs, 59% to whites.
5. So the majority of docs seeing both blacks and whites are whites, which is simply a function of most docs being white. From the above you can deduce that most black doctors are seeing black patients.
6. It turns out that the group of docs who see blacks are less likely to be BC. These docs include whites (60%), blacks (22%) asian +others (rest). As I repeatedly said, the NEJM study did not break this group of doctors down by race, so we can't reliably say anything about that issue.
7. We know from elsewhere that black doctors are not as likely to be BC than white doctors.

Now, the issue of black MD vs white MD board certification is important to me for one and only one thing: if there is a racial basis for poorer medical achievement/accomplishment, then it is important to identify - so that we can do something about it.

It is not the most important thing about this study. In fact it wasn't even addressed. I now regret merging these questions in the opening post, because I didn?t think everyone would concentrate on the doctor issue to the exclusion of all else. They deserve separate threads.

The important thing about this study is what it shows about the patients, not the doctors. As Epstein says, there are structural features of the delivery system that are at play in creating this disparity in health care. Right now, many people believe that the reason blacks get poorer care is that their doctors are racist. This study shows that there are subtler problems. The doctors who treat blacks are not the same as those who treat whites. They are more likely to be unable to access high-quality subspecialists, high-quality diagnostic imaging, and nonemergency admission to hospitals. They are more likely to have 'inferior qualifications'.

That's why this study is important.

 

[Neuron]

Regarding the whole BC thing...

How many residents do you know who are BC?

Exactly.

Poor people are more likely to receive their care through the county/university/charity teaching services than the private sector of medicine obviously.

I don't know if this point has been discussed but it seemed to me to be a pretty obvious source of bias in this study/thread.

Does it also seem to you that this "pretty obvious source of bias" may have occured to the study authors from two different institutions, the reviewers at NIH, the American Cancer Society, the American Lung Association, the peer reviewers at New England J, editors at New England J, and their consultant statisticians?

Because it did.

"The survey included only physicians who reported providing at least 20 hours per week of direct patient care in an office-based or hospital-based practice, including at sites of the Bureau of Primary Health Care of the Department of Health and Human Services. Residents and fellows were excluded."

 

[MD'05]

Neuron,

What exactly is your point? You are right, I don't read posts especially when the post is too wordy.

 

[ortho-mdmba]

Disclaimer- These are my opinions drawn from experiences...

I don't think its a matter of the medical education of these physicians per se. I believe a reason is the lack of accountability/responsibility that occurs when a physician works in a lower socio-economic community. In these communities, it is a physician's market as opposed to a patient's market as you would see in higher economic communities. Let me explain further, physician's working in these communities are not motivated and/or required to become BC because it is not needed to compete in these communities. These patients don't demand such things partly because they are less educated and are simply happy that they can even see a physician close to them. This is quite different from the better informed patients higher economic communities who are savvy enough to choose physicians based on board certification. Also, insurance companies give some slack to physicians practicing in these communities as far as participating in their networks. That is, there are physicians who are in networks of insurance companies and/or CMS (Medicare/Medicaid) purely to alleviate access issues sometimes at the expense of quality (including BC). Some of these physicians would not be network eligible if they set up practice in other higher economic communities because there are already so many qualified (or BC) physicians there to choose from thus BC becomes a proxy for quality and an economic requirement for practice. Simply, "A physician is better than no physician" logic plus it brings in revenues to the companies as well.

A nice parallel that illustrates this lack of accountability/responsibility because patients don't demand it is what occurs in some academic centers. My medschool has a couple of hospitals (the main medical center in a better part of town, the other, a county hospital in a rough part of town). Patients at the county are content (or have no choice but) to have residents and even medical students see them and do procedures on them that would certainly not happen in our main medical center (mostly because the patients are more educated and affluent). This fact has made our sugery rotation at the county the most popular one not because these students have altruistic goals of helping these people but these people serve as practicing templates for them (an attending walked me through an appy on a real patient there!). Our residents get most of their required procedures there and even alot of the junior faculty start out there.

Unfortunately, until the situation changes such that these areas become a patient's market as opposed to a physician's, I believe nothing will change.

 

[ortho-mdmba]

One criticism I have about the study is that it assumes all FMGs are created equal. This is, however, not the case...

In popular jargon, FMG unfortunately now passes judgement on quality of education. At my institution (a well-regarded academic center), there are many "FMGs" around. Matter of fact, during one of my third year rotations, our sub-I was from Germany and she matched directly from there to Harvard for Neuro/Peds or something. But the funny thing is we don't think of these people from Canada, UK, Germany, Ireland, Australia as necessarily "FMGs". Some of our faculty members are FMGs!

My brother went to medical school at Oxford and trained in Ortho there as well. Practices here in the U.S. (was in academia for a while). He is BC. He and many others like him would be considered FMGs as well.

There might not be a difference in percentages of FMGs but I imagine there would be a difference in geographic region of education, quality of education and training, and maybe even, race.

 

[ortho-mdmba]

Asians are also treated by "lousier" physicians (my hunch and I am not Asian).

Many Asian communities are hugely underserved but this is mainly because Asian medical graduates have put a premium on serving primarily the white population or going into sub-specialties. I am still not sure why. (Economic, Prestige, ??????).

I did my six weeks of family medicine rotation in an Asian (Chinese, Korean, Japanese, Vietnamese) community about 20 mins away from my medical school. My school has graduated about 15-40 Asian students every year since the 1960s and still this area suffers from lack of physicians.

My attending lamented daily about having to turn away patients because his practice was too full. He is a graduate of my medical school and has been in the community for 20y and is very active in many Asian national groups. He stated that in that particular community which is one of the largest ones in the U.S. most of the physicians are FMGs and worse, many don't even have a license to practice in the U.S. They would not be captured in a study like this.

It is unfortunate that the medical school admissions and graduation numbers do not tell the real story about many Asian communities. I believe the healthier lifestyle in general of Asian communities is insulating them from the kind of public health issues plaguing other minority communities. Lets hope this lasts. I guess closing this gap will require a change in mindset which is harder to accomplish.

 

[bundts]

Neuron,
you sure are "fired up" about this "breakthrough" study
GET INTO IT

 

[mountebank]

bump

 

[VentdependenT]

Way to bump this crappy thread buddy.

 

[Jaded Soul]

Way to bump this crappy thread buddy.

Definitely not bump-worthy. It was an indiscriminate bump too--didn't even add anything to the thread.