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Physician bias and cultural competence revisited
In a medicolegal symposium published in Clinical Orthopaedics and Related Research, Frank M. McClellan, JD, Ramon L. Jimenez, MD, and Augustus White, MD, examined the provocative question of whether poor people are more litigious toward physicians. The authors showed that contrary to popular opinion, poor people are less likely to sue physicians, in part because of less access to qualified lawyers and legal resources. Other research has supported these findings, i.e., financially disadvantaged patients have less access to both legal and medical care, and are less likely to file malpractice claims.
McClellan and colleagues postulated that physician subconscious bias can adversely affect both the access to and the quality of care rendered to the financially disadvantaged. This bias may be driven, in part, by the perception that poor people are more likely to sue their physicians. Training in cultural competence may help, at least by increasing self-awareness of bias. However, physician self-awareness of cultural bias may not be a panacea for the alleged differential treatment of patients. We present an illustrative case from clinical practice that shows that misguided notions of social equality may sometimes themselves contribute to suboptimal care.
B. Sonny Bal
Lawrence H. Brenner
Illustrative case
An elderly, independent woman underwent total knee replacement. Her income was modest and she was reliant on a number of public services. Inpatient rehabilitation seemed appropriate after the hospital stay, but she insisted on going home. A social worker found out that the patient was the primary caregiver for seven children, including an infant and two children with special needs. During the patient’s hospitalization, her neighbors and the older children in her care were taking care of the younger siblings. The children’s parents, who were related to the patient, were incarcerated. The patient had not divulged this information during the social work assessment before surgery.
Floor staff also discovered the air conditioning system in the patient’s home had malfunctioned, making convalescing from surgery during the summer more difficult. In response, the surgical unit had a small fundraiser and voluntarily bought and installed an air conditioner for the patient’s home. Social services were arranged, and the patient had uneventful recovery. She was pleased with her clinical outcome, and was grateful for the thoughtful assistance that made her recovery easier.
Hospital managers were concerned that the generosity of the hospital employees extended care to the patient outside of the patient-provider relationship, thereby potentially placing the institution at legal risk. Specifically, the managers were concerned that if the hospital’s employees or the patient’s family were injured by the air conditioning equipment, that the hospital might be exposed to unpredictable liability. Fortunately, none of these adverse scenarios manifested, and the patient was sent home with working air conditioning and a happy outcome.
Conrad B. Ivie
The social and economic circumstances of this patient were not fully explored during pre-surgery screening. Only after surgery did the social work staff discover that the patient was the sole caregiver of many children who shared her home.
We interviewed the personnel involved in the patient’s care to identify why certain information related to the patient’s social circumstances was missing from the patient’s history. It was found that if the social work staff and other practitioners had framed their questions differently during the patient intake process, then they would have uncovered her suboptimal social and personal circumstances. The social challenges of hospital discharge after knee replacement could have been addressed sooner or the operation could have been postponed.
We also found that inquiry related to the social and living conditions of an elderly woman of a particular ethnicity, as was the case here, was hampered because of preconceived notions based on gender, ethnicity and the patient’s economic worth. Those notions were driven, at least in part, by the prevailing value system of political correctness, a desire to be seen as treating all patients as equally situated, and attendant apprehension related to these considerations on the part of the social workers. Those factors are what McClellan and colleagues identified as provider bias in their article. If culturally competent care stands for the proposition that health care providers should be conscious of their own bias when treating patients, then a bias-neutral inquiry failed to identify this patient’s living situation, and complicated her postoperative care.
Discussion
This case illustrates valuable points. People are products of their socioeconomic and cultural settings that are, in turn, influenced by race, gender and ethnic background. These factors can affect the delivery of health care, and complicate recovery from elective surgery. Patient-specific factors should be investigated during the pre-surgical workup, and proper inquiry requires a conscious awareness that patients come from different ethnicities, value systems and backgrounds in terms of economic and educational status. Patient-specific care can ensure that all patients receive appropriate support within the context of their conditions, cultures and environment.
The phrase “physician bias” has a negative connotation. But conscious bias may sometimes reflect the exercise of medical judgment that is in the patient’s best interest. For example, patients of a disadvantaged economic background may have limited insurance, with no physical therapy benefits. If so, an orthopedic surgeon would be correct in postponing knee replacement surgery until such benefits could be obtained, or the surgeon may help the patient with making alternative plans to substitute for supervised therapy. A recommendation against elective surgery in this situation does not constitute cultural unawareness or bias. Rather, it demonstrates a thoughtful, patient-centric approach that takes into account all the factors that might affect a patient’s outcome. Yet, collective data would show that patients from impoverished backgrounds have less access to elective total knee replacement surgery. They do indeed, but not from a lack of cultural competence; rather, as a function of sound clinical decision-making, and awareness of differential cultural variables.
Conclusions
While poverty may be associated with less access to care (both legal and medical), attributing this phenomenon to physician bias oversimplifies a complex problem. Conversely, the misguided concept of “equal treatment” based on a rationale of cultural competence, may result in inadequate treatment. This is not to deny that in some cases, physician bias may result in the poor getting less medical care, just as public bias against poverty and misapprehension of crime statistics has contributed to less access to legal services for the poor. Cultural competence has value, but it is not the sole – or even the primary – answer to social inequities that reflect a complex interplay of societal, cultural, ethnic, environmental and patient-specific variables.
We suggest that patient care must be customized to include all factors, whether social, medical, environmental, personal, or family-based, in arriving at a treatment plan for a particular patient. The outcome will mean that not all patients get the same care. Poor patients may lack critical resources that are essential for a successful outcome from elective surgery, and, therefore, deferral of surgery until such resources are in place may reflect a prudent and thoughtful approach to care. Such limitations are in the best interest of the patient, rather than a culturally insensitive, biased approach to a socioeconomically disadvantaged patient.
In a culturally diverse nation, where poverty is a fact of life, the complexities of medical decision-making, as well as access to courts and the legal system must be considered in judging physician conduct. Legal scholars are equally aware of the difficulties and peculiarities of defending indigent clients, whose social, personal, cultural, and environmental backgrounds are entirely different from wealthier clients. Just as litigators must devise trial strategies to best serve the indigent client that take into account their clients’ particular limitations and circumstances, so must medical professionals devise the best treatment plans for economically disadvantaged patients. Far from cultural insensitivity and bias, these strategies reflect empathetic responses designed to best serve individuals seeking medical care or legal counsel.
Jimenez responds
I applaud the authors for their thorough and deep analysis of this important issue. They are correct when they say that it is not enough to treat a patient only with cultural competence and without bias. The case scenario they present is poignant, and it illustrates the issues well. A surgeon (and his or her team) must treat the whole patient, and must take into account the patient’s environment, not just the degenerative knee.
Ramon L. Jimenez
In the article I co-authored with Frank M. McClellan, JD, and Augustus White, MD, we emphasized that some of the key ingredients of cultural competence are awareness, compassion, sensitivity and communication. It follows, then, that a patient who is of a different culture or socioeconomic status needs to be understood more fully. One must ask questions. “Equal treatment” indeed results in asking different questions of each patient, depending on his or her circumstances. The truth – and thus the best treatment for that particular patient – lies in the answers to those questions.
Indeed, as Dr. Ivie notes, one must not presume or assume that a patient who presents with a particular pathology is a good candidate for elective surgery until that patient is ready to take on the demands of the surgical procedure, and until or unless adequate aftercare arrangements can be put in place. I believe these approaches are, in fact, at the center of thoughtful, culturally competent care. I also believe that sensitivity to these issues is stronger than any bias, conscious or unconscious.
References:
McClellan FM. Clin Orthop Relat Res. 2012;doi:10.1007/s11999-012-2254-2.
Komaromy M. West J Med. 1995;162(2):127–132.
U.S. Congress, Office of Technology Assessment. “Do Medicaid and Medicare Patients Sue Physicians More Often than Other Patients?” PB 93-176972.1992.
For more information:
Conrad B. Ivie, MD, is a fifth year orthopedic resident at the University of Missouri School of Medicine, 1 Hospital Dr., Columbia, MO 65212; email: iviec@health.missouri.edu.
Ramon L. Jimenez, MD, can be reached at Monterey Orthopaedic & Sports Medicine Institute, 10 Harris Ct., Monterey, CA 93940; email: ramon@jimenez.net.
Disclosures: Bal, Brenner, Ivie and Jimenez have no relevant financial disclosures.