The healthcare of blacks is just one more symptom of the underlying problem.
The underlying problem is poverty.
If we could fix poverty, get people education, move up the economic latter, most of the social problems would be reduced.
This is true for poor whites, too.
It's just that poverty is higher among blacks than whites.
34
"I was horrified. I strive to deliver the best care I can to each of my patients, regardless of the cost. I thought they trusted me to have the patient’s preferences in the front of my mind."
So in the end the doctor's concern was about himself instead of the patient. He was upset that they didn't totally trust him. That was the issue? After a lifetime of not receiving proper health care, and you write that this is what non-whites experience, why wouldn't they think that it was about the money. Your statement of shock reveals you still didn't get it.
11
Every conversation in the US seems to have a racial angle, I really think you need to stop blaming everything on racism. I don’t buy the writers racist innuendo directed at the health system. I suspect the difference between black and white treatment is more likely to result from who can afford health insurance. Universal health care in Australia works very well and I’d recommend to you. I can’t for the life of me understand the objections. I also hold private health insurance, which I pay directly for however, I rarely need to rely upon it as the public system works so well
37
Dr.Zitter-As long as we have white doctors in white coats telling the story,we end up with biased view of health disparities.First of all no one looks like the doctors white coat.And second,you failed to address the obvious mistrust of the system by experienced by minorities. You also ignored the biggest cause of health care disparity-money and insurance.
10
Some patients simply want more aggressive care at the end of their life, even when informed of its likely limited benefit. This author seems to forget this very real reason why certain minority groups are more likely to receive such care.
13
Is there a standard of care that requires medical care for pain that differs just by race? That would be institutional racism and needs to be considered whether there is any empirical evidence justifying it. Otherwise, the racism is a cultural or social issue that is independent of laws and institutions that is not being addressed.
If a doctor is serious about not participating in racism, focus on providing the best care for every patient, don’t try to read people’s minds based upon appearances related to race.
The culture of race is destructive of our free country and the health of people in disadvantageous conditions due to racial discrimination. These are concerns for epidemiologists rather that care givers.
Smoking and stupidly ineffective environmental policies make people who are poor and live in less safe places more vulnerable to devastating diseases. All a physician can to is offer treatment. The whole society is responsible for people getting sick on account of exposures to toxins like tobacco smoke and air pollution.
8
Some of these comments here are quite sad. I find myself skeptical of the NYT's woke agenda a lot of the time, but the disparity of care between African Americans and whites is a serious and ugly problem. This piece is poignant and demonstrates a need for greater compassion, both in medicine and in life. If the shoe were on the other foot, I wonder how some of us would feel.
61
Having worked for more than 50 years as a white clinical psychologist with mostly black folks, I learned the importance of joining a person's life space. When I saw first-hand the vast cultural divide between the white world professional and black folks, as a director of psychology I once attempted to recruit black psychologists and got no response. A psychiatric director once confessed he had never met a black person until working at the hospital. On each person I encountered, I first had to work through the legitimate mistrust of the white world from black people. I saw and supervised many psychologists who had no clue of their white privileged difference and their white middle class life and the suffering that black folks endure in the 'white world.' The majority of hospitalized patients are black, many of which deteriorated as a result of living in a 'white world.' Mental health courts are biased against black people. The institutionalized racism in society is amplified in the mental health system.
44
Depressing beyond belief. My understanding is that black patients are also more frequently poorly diagnosed and have to suffer from more extreme treatments as a result. Coming from a fair-skinned family where many of them are receiving excellent dermatological care due to the well-known threat of skin cancer in whites, I’ve read about the woeful lack of care for black men and women who are also at threat for skin cancer (remember Bob Marley). But black patients are rarely alerted to these potential dangers early on and they are often poorly diagnosed because their cancers are harder to detect due to lack of training and experience on darker skin tones. I wish there was far more focus on these very serious issues of racial injustice than whether some highly privileged Daughter of a Stanford Professor (Kamala Harris, btw) had their feelings allegedly “hurt” over politically toxic social experiments from the 60s and 70 such as bussing.
16
As an older Black man (near 70), I have to agree with this article. Fortunately, I spent 30 years in San Francisco, with all my friends developing AIDS and the rest of us caring for them, which included their medical care.
As a result, I am VERY hard on my doctors. I make them explain everything, what led to that medical conclusion, and what the usual treatments are for other patients. I'm sure they sigh when I leave, but I do not - after several significant missteps including drugs with significant side effects - feel confident about taking them at their word.
Such general terms as "within normal range" have me inquiring, is this for the general population or for the Black population? The PSA for White men is pretty dramatically different than for Black men. A "6" result for us is pretty bad. (4 is good.) For someone White, a 6??? Meh!!!
And the options to go have the more accurate PSA test (attached PSA vs. free-floating PSA) has rarely been offered to Black friends (and we're all seniors).
Until I tell them, anyway.
So, yes, the system is...neglectful to a portion of its population, many of whom still hold doctors in regard, when we should be questioning them more.
31
Dr. Zitter's account of her experiences is heartwarming. So why does she go and spoil it all with the obligatory claptrap about how differences in treatment are "manifestations of implicit bias and institutional racism"?
Has Zitter observed other doctors act out implicit bias? Then has she reported it? And if not why not? If that isn't professional misconduct, then what is?
The concept of implicit bias is a cop-out. It allows identity activists to demand special treatment based on supposed discrimination without offering a shred of evidence to substantiate their claims.
Zitter may reply that there are "disparities" between blacks and whites in healthy outcomes. Well, welcome to the real world, doctor. Disparities of all sorts are everywhere. That's what "diversity" means. The idea that all disparities are the result of bias flies is ridiculous -- and, without evidence to back it up, it is an unacceptable smear.
Take the estimate that, in the US, Latinos outlive white Americans by 2.5 years and black Americans by nearly 8 years. Infant mortality is probably somewhat lower among Latinos than whites, and a third of the number for blacks. Another study finds that knee arthroplasty rates are higher for black women than white men. (White women do far better than both). As for opioid use, if African-American children are one-fifth as likely to receive opioid medication is that a curse or a blessing?
Some disparities are perfectly innocent. Let's stop lying to ourselves.
20
I don’t see any connection between this article’s title and its content. As far as I can tell, Dr. Zitter has an intense case of White guilt about her inability to inspire confidence in her predominantly Black patients. Dr. Zitter would no doubt benefit from understanding the culture of her patients, but it’s hardly mistreatment to be awkward when delivering bad news to a patient.
It also seems that Dr. Zitter made her recommendation without regard to the cost of her suggestion, which again means no mistreatment of her Black patient.
As for the idea that Black patients receive fewer pain medications in emergency rooms, I find it extremely difficult to believe that this is a result of direct racism. That’s especially true in Atlanta, a majority Black community. And the referenced article’s summary seems very fuzzy.
The author seems to be stretching to make a point. I just don’t know what it is.
10
Again, universal healthcare evens the score -- though racial prejudice does rear its vile head from time to time here, I admit. I've seen it in petty ways, though, not life-threatening ones.
We do have issues with access to medical care in rural areas. Canada has remote villages through the north, and access can be a challenge. But care -- or lack of it -- based on race? I don't see it. If you come through the door, you get help. No need for expensive employer insurance.
4
It is just as well that black Americans received fewer "opioid medications for pain." Fewer opioids, the lower the chance of addiction.
4
Aggressive efforts across all levels of medical education need to be made to recruit and train more African American physicians. The mistrust is justifiable and deep, and cannot be remedied without representation of African American physicians.
12
This is as superficial as one can get in the discussion of race in medicine. Let's talk about the exclusion of Black students from medical school. What about the racial barriers in academic appointments and specialty/subspecialty training? The Institute of Medicine spoke of the importance of Blacks in medicine more than two decades ago. CML, the highly qualified black Chief of Medicine at the hospital of my residency was "acting" for more than ten years!
The black patient in this story had a literate and interested adult son. The chronically ill man also had enough time to think about his deteriorating condition. This white doctor had his ethical choices outlined and was under observation. This is not often the case in institutions where ethical principles are diluted and absent when black patients need them. The expensive roll of loaded dice at life's end of the typical American black patient is acceptable when compared with unacceptable and avoidable infant and maternal black morbidity and mortality at life's dawn. This patient lucked out.
7
African American people are overwhelmingly protestant evangelicals and the most 'Churched' demographic in the nation. An evangelical worldview insinuates itself into every corner of African American life and culture and it certainly shapes their views on death, dying and end-of-life decisions. White patients are far more religiously diverse; only a fraction are evangelical and many more than that are unaffiliated or non-religious. It's no accident that Oregon, with the nation's lowest rate of religiosity, has its highest rate of assisted suicide. Suspicion of white doctors may be a slight factor affecting decisions made by the families of your black patients, but I'd hazard a guess it's the religious one that's most important.
9
Good article.
I have had biased doctors and I have had good doctors. I am far from poor.
I think the assumption that black people receive inadequate care due to poverty is part of the problem. What does poverty have to do with pain relief? What does poverty have to do with listening to a patient's recitation of their symptoms?
Someone mentioned that people should consider cultivating good relationships with their primary care physicians. I think that is a good idea. I also think it's important to be proactive about your care. Do your own research. Ask good questions, and if your doctor seems impatient or dismissive, find another doctor.
I am glad so many people are talking about this issue, because that means that hospitals and doctors are paying attention to it. Hopefully, that means that one day soon, we will not see gaps in care for people no matter their race, gender, ethnicity, age, etc.
12
@POW it’s not an assumption that black patients receive inadequate care. It’s a well-known, well studied phenomenon in many aspects of health care. The truth hurts/is sad sometimes, denying it not the right approach
20
"Doctors must do a far better job of caring for African-American patients from birth all the way to death. There is so much we have to do, but a good first step would be to stay in the room and face our discomfort, instead of running away from it. "
Did you mean to say, "White doctors..."?
Clearly, with pervasive and subconscious societal racism, identity doctoring is a real need. As a white, Jewish man, I feel more comfortable with and trusting os a white, Jewish doctor. We need more Black doctors, especially where many African-Americans live, like in Oakland, CA.
5
It's tragic there remains a great disparity in healthcare that whites and blacks receive. When will our culture evolve? I'm afraid never.
5
Why do we need yet another white person’s commentary on the challenges of black people’s lived experience? I find it hard to believe that the NYT couldn’t find a black physician to speak to the same issues (and perhaps with greater tact and impact).
Also, did no one on the editorial staff consider the poor taste of a white woman suggesting that MDs use black support staff to gain black patients’ trust?
9
@Christine
I read this as directed toward an audience of white doctors who need to learn how to do a better job of connecting with their black patients. So that is why a white doctor was talking about a personal experience of learning to provide better care. A black doctor could also write about the subject, but the whole point of the essay is on improving white doctor relationships with black patients.
25
I read this guilt-ridden, race-obsessed wail and I have to wonder if the good doctor subconsciously tries to makes up for some perceived medical injustice towards blacks by treating her white patients with less attentive care.
You know, because of white privilege or some such nonsense.
In any event, find me another doctor...
7
@EGD "Such nonsense" such as black and brown people don't receive the same treatment in clinical settings as their white neighbors, family and friends. My white husband thought he knew what those words meant until he married a black female CEO and discovered that I never receive the same standard of care or treatment in the ER.
That I'm almost ALWAYS suspected of being there to access drugs or some other negative untrue stereotype.
So you want someone to "find you another doctor" because this doctor actually knows how blacks are frequently treated in clinical settings and is concerned about it.
It's a PRIVILEGE to be this dismissive of the lived experiences of black and brown people through no fault of our own. Imagine being frightened and in need of care and being treated as though you are a criminal.
I've been literally spurting blood and writhing in pain while trying to figure out if I need to get into the ambulance or rather I have time to go home and get dressed so that I have a better chance of receiving caring health care in the ER.
Once, in the ER I had a doctor freeze with the needle in my head because he realized I was a very respected friend of his wife. He stopped putting in 8 stitches in my forehead and instead put in 28. I'm a professional. Can you imagine the resulting scare from receiving only 8 stitches instead of 28 interlineated stitches?
And, of course, to tell my story is “perceived” as wanting to be a "victim" who "plays the race card."
48
I am sick and tired of doctors writing as if doing their job shines light on a darkness the rest of the country does not see. Health inequality for African Americans is already well-publicized in healthcare, as in every other factor of American life. This article is more self aggrandizing than eye opening.
How about a real story on racial injustice? I went to residency where almost the entirety of my colleagues were white. The city we treated, and the public hospital we trained in, is majority black. There was a private hospital we rotated that was mostly white. At the public hospital I remember seeing my colleagues, and supervisors, walk into rooms of critically ill black patients, with the goal of convincing the family to withdraw care or legally document they [the family] would not like their loved ones resuscitated.
If this was all "to get the care they wanted", why did I never see this at the private hospital with white patients?
The first time I had a difficult conversation with a white family was two years into training. I stuttered despite doing this so many times before. Much later I would realize this is because my training was racially biased, and this made the consequences of losing a black life easier to stomach than losing a white life.
When will the NYTimes publish stories where the doctor is wrong, instead of a reference to some kubaya Oreo the author was in?
11
I admit that the first few paragraphs of this story really drew me into it where it was I visualizing myself laying there in that hospital bed and having to be forced to make such a wrenching human choice and thinking what I would do if that were me, but then the next paragraph switched to being an exclusively African American disparities story so as a white I felt I no longer had any right to continue reading since now my feelings were no longer possibly capable of coinciding. Apparently due to our skin color difference alone, the die is permanently cast either/or.
1
@John Doe,
Sorry you felt that way. Then you missed the point of the whole piece by not reading it through. As a self acknowledged non ethnic minority, you don't have to deal with the added layer of making those difficult choices within the context of a system that is designed in theory to heal that has exploited minorities in its darker elements.
As a black person myself, I don't have the luxury of not being able to step away when it doesn't apply to me. As a hospital staff who worked with a black gentleman inpatient who was very guarded during his terminal cancer diagnosis, there was no sidestepping the issue of skepticism/distrust of the system. I had to nicely call out my SW colleague out on her lack of awareness of this in her interactions with the patient. But because she is white, she had access to the choices to take it in and modify her approach OR brush it off and label the patient as difficult (which she did initially). Again, nice to have the choice based on privilege where either option is "acceptable", when it reality only one is appropriate.
Just because the playing field isn't level for everyone doesn't mean we need to choose to focus only on either what is common - the basic humanity you identified with OR the differences - which you excerised your privilege of sidestepping.
24
I was struck by this statement:
“Given the condition of his lungs, he would probably spend the rest of his life in a facility, attached to a breathing machine, his arms tied down to prevent the tube from dislodging.”
What nonsense. Mentally competent adult patients with properly secured and fitted tracheostomies in place do not need to be tied down. If this is what you tell your patients at risk for prolonged ventilation, you provide a disservice.
I am an African-American physician who cares for newborn infants who require intensive care. I have the recent experience of an older sister who required prolonged mechanical ventilation and tracheostomy. She now no longer requires mechanical ventilation.
My sister’s recent experience has absolutely convinced me that “needing health care while black” is a serious problem, and education and high income status do not mitigate the risk. But this op-ed was disturbing for more than that reason. As physicians, we need to present an honest, comprehensive picture of the choices that are available to patients and their families, not presentations skewed to get the response we want. The long term financial implications of your patient’s care are a legitimate topic for discussion, and should not be avoided. The job is to allow the patient to determine the goals for his/her remaining time with everything on the table, including quality of life, as the patient perceives it.
24
@CMA
There are a host of recent research articles on the survival rate and quality of life for the patient needing prolonged mechanical ventilation.
All of the research that I have read [Multidisciplinary Respiratory Medicine 201813:6 among many others] support the narrative provided by Dr. Zitter but I would be delighted to see any contrary findings from respectable medical journals.
9
We need to hit this hard and head on as quickly as possible. The best ways to start is bringing back more wellness focused education in grade schools. Home economics with health focused classes. If healthcare is failing a demographic we need to give them the tools to hit back hard at home. We need to provide access to these communities to affordable non processed foods. Put more physical activity in the schools and HEALTHY natural non processed school lunches. Our broken healthcare system is not helping minority communities get well in any meaningful way they’re just treating them when it’s too late. This is a cycle of pain. More doctors more access to wellness. Lift these communities up.
6
According to the Kaiser Family Foundation, only 22% of African-Americans express a preference toward being medically treated by a same race physician, while 65% don't care what the race of their healthcare provider is. Obviously, despite this article, blacks aren't feeling mistreated by doctors of other races, or this survey data would have indicated otherwise.
My father was born into a poor, white, Jewish family in the Weequahic section of Newark (NJ), and was a family physician in neighboring Elizabeth from 1951-2006, serving every race, creed and color of American living in that cultural melting pot, including the black community. He was adored by his patients, and treated them all the same, no matter their background. I don't believe he was an outlier in his profession, as my sister practices internal medicine the same way, as does her daughter, a third year resident physician.
17
I laud Dr. Zitter's focus on the aggressive and often inappropriate end of life care that ethnic and racial minority patients receive at the end of life. However, I cringed at the patronizing depiction of her chaplain colleague, the Rev. Betty Clark, whose hugs and shared acquaintainces with the patient "built a bridge" that Dr. Zitter "cross[es] over." The lives and professional skills of African-Americans are not meant to empower white physicians as they persuade families to accept specific recommendations. We need to focus more intently on the voices of underrepresented minority providers, patients, and families and less on the benevolence of white clinicians who mean well, but often (as in this piece) miss the racialized overtones of their praise of African-American staff.
5
@Rachel Lewis I understood the reference to Rev. Betty Clark not in terms of her role in providing a "bridge" for the author as a white doctor, but rather, as a means of communicating better, as a doctor.
Helping to facilitate such communication is one of the roles of hospital chaplains. It may be that the information the author wanted to communicate had little to do with the spiritual/chaplaincy concerns chaplains deal with.
9
Thank you Dr.Zitter for this article. I am a brown immigrant ICU physician and see this on a daily basis. There are historical reasons for why the black community does not trust what is told to them medically-Tuskegee experiments etc. As a brown doctor I find this bridge easier to cross. I often see white doctors a bit intimidated by multiple family members of black patients during family meetings and end of life decisions in the ICU. As ICU doctors it is very easy for us to keep 'doing more stuff' to keep the patient going. Doing 'less' is more difficult. It takes time (we are always lacking in this), caring and concern. But sometimes doing less is correct. What is paramount is what the patient wants? But often one or another dominant and vocal family member tends to sway others in one direction or another. But this article is a good start. A very important albeit a bit uncomfortable (for some) issue has been highlighted. Please keep such articles coming.
22
The thesis of the article is that inequities of health care according to race results in the more extremely costly and least successful treatment of patients according to race. But the story that he tells is how difficult it is to treat patients when he feels that they mistrust his care due to his race and the race of his patients. Instead of focusing upon the patient he’s focusing upon how they perceive himself. He has to treat them inconsideration of their attitudes towards white people. He seeks assistance from professionals without health care skills to do it. He cannot see how he is amplifying not reducing the distraction from the best medical care.
2
A 2017 study found that in New York City, African-Americans were significantly underrepresented in the best hospitals,
The study (found through the link) was limited to, and based on AMC;s ("Academic Medical Centers"), which are what? Facilities only tied to medical schools? Is the same true for all medical facilities? Just asking. The disparity in the Atlanta study could be the result of different types of injuries? There are fractures and there are fractures. Also, as the government has been clamping down on the over use of many pain killers could this have anything to do with a disparity? I have no idea, but perhaps a bit more journalistic research may even show the disparity between whites and African Americans to be greater than reflected in the article. Or not.
@Mark Shyres —It was a shattering report, proving that minority and poor patients in NYC get lower quality healthcare. Its first paragraph explains AMC's:
"Academic medical centers (AMCs) ... which typically comprise a medical school and a closely a related teaching hospital, train health professionals, conduct research, and provide patient care. AMCs are often among the largest hospitals in their service areas: despite representing only 5% of the nation’s hospitals, combined, they account for one-fifth of the total hospital volume in the United States. AMCs typically serve a medically complex patient population and provide specialized expertise across a range of clinical areas. Many AMCs are ranked among the top hospitals in the country..." https://journals.sagepub.com/doi/full/10.1177/0020731416689549
The implicit conclusion: "some private hospitals with deep pockets leave care for the sickest and poorest patients to a struggling public hospital system" which are disproportionately staffed with medical students, not the experienced MDs at AMCs, which have fewer supplies and diagnostic equipment.
This study was rigorous, focused on data, and wasn't news to most NYC doctors, public health experts, and govt officials. But it did provide confirming data.
NYC is not alone. Underfunded public hospitals and rural hospitals struggle to give good care. But even in AMCs, there is health disparity, and injustice:
post #2 follows
11
I remember seeing Dr. Zitter featured in a Netflix documentary called Extremis about her work with patients and families in ICU. Highly recommend watching it!
8
What a simple and movingly written piece.
10
Right to Die laws need to be a federal so each of us can, individually, decide when the pain, suffering & cost is too much to bear. If religious people choose to ignore this right, that's their decision but their decision should NOT be forced upon me.
Second, US health care responds when we get sick rather than promote wellness. Whether Medicare, VA or private insurance, congress needs to set preventive care goals and a timeline so it gets done.
Of course, all of this requires a functional government which we simply do not have under The Grifter. If Trump can pander and pick up votes and campaign contributions, he's proven to completely disregard what's good for the 99%.
6
No matter what color of your skin, I think you probably will want to have some control and autonomy when the end is near. I can recommend the book by Barbara Coombs Lee "Finish Strong". She is the founder of Compassion and Choices which is the leading group in the U.S. urging options at the end of life.
6
The compelling subtext of Dr. Zitter’s poignant piece is the argument against poverty.
It is not always the case, but poor people tend to have fattier diets and evince higher rates of obesity, smoke more, consume more alcohol and drugs, and exercise less. These habits cause the body to break down much earlier and, with the advance of unchecked medical conditions, there is often very little that physicians such as Dr. Zitter can do.
Beans and rice, cabbage and ground beef with lowfat milk is not a bad diet, but the poor are more likely to chow down at McDonald’s and Popeye’s.
Dr. Zitter’s meditation would have been even more effective had she cited statistics cross-indexing race, income, and longevity.
Poverty kills.
5
@JD
Your intentions may have been good, but you need a lot more information before going after the lifestyle of all African Americans in general.
To take an actual example instead of stereotyping as you do, high blood pressure occurs much more frequently in African Americans than other American populations. For a long time the medical community sought genetic or life-style (your choice) causes for this discrepancy. It has now been strongly suggested by well-controlled, scientific studies - of African Americans vs Africans who have immigrated here as adults - that one of the most pernicious, if not the single most damaging, causes of high blood pressure is the daily stress of living in a racist society. Not only the justifiable anger caused by actual affronts (which must often be swallowed because it is impossible or just not worth the time to react) but also the constant wariness caused by likelihood of receiving such affronts in any public setting wears down the immune and other naturally supportive systems.
You could also look at the statistics for low-birthweight and/or premature babies and infant or maternal mortality among African American women. This problem occurs across socio-economic lines, even among middle and upper-class African American women (there are some of those, you know, and I think you can be pretty sure they are not eating regularly at McDonalds). Poverty does kill, but so does racism and its occurrence is not limited to any socio-economic setting.
15
@JD Yes, poverty kills, but well-documented studies
"even after taking into account income, neighborhood, comorbid illnesses, and health insurance type — factors typically invoked to explain racial disparities — health outcomes among blacks, in particular, were still worse than whites." Commonwealth Fund 2018 newsletter.
Access to care, a focus on preventive care, and better working conditions for doctors on the frontlines (primary care, ER, internists ...) and all those doing active clinical work, as this MD does — all of these are harmed by our current private-insurance system, where profits depend on denying care, particularly preventive care and time-taking clinical conversations.
It is also, as the author explains, enabling doubt about MD intentions. That is corrosive to any doctor-patient relationship.
All of this is part of why I support a single-payer system, a) where hospitals will get a "global" budget (plenty to take care of patients without charging for every bandaid) and
b) preventive care has priority and
c) patients can CHOOSE their doctors rather than being squeezed into narrow networks while they're healthy — then shoved off the policy into a public plan when they get sick (AKA too expensive to be profitable to private insurers).
It won't eliminate racial disparities but it will give patients more agency around doctors — and doctors to do more of what they trained to do.
2
This comment is rife with the subtexts of racism that are what cause such things as the disparities in medical care that this article discusses. What the original writer had spoken on is the fact that, across the board, regardless of economic status, black Americans get measurably, quantifiably worse or less treatment than their white counterparts. This is not an issue of poverty and blame should not be laid upon a misplaced stereotype of a poor diet. This is systemic racism at play. Furthermore, using this "poor person bad diet" reasoning as an excuse for taking the onus off doctors ("there is often very little that physicians can do") is the exact opposite of the point of this article, which is highlighting the fact that doctors (and others in the healthcare industry) can do more and should do more to change this inequity.
7
The young African American custodian at the hospital I was stuck in for awhile, told me she only had 1 child, 7 years old, because she had a C-section and was sent home without any pain meds. She was afraid to have another. An older African American lady who helped me with housecleaning for a while, while I was laid up, told me that her doctor told her he would not give her an MRI for her aching knee because he was only allowed to give so many per year (large managed care system) and he wasn't going to waste one on her. Only anecdotal stories. But stuff happens that shouldn't be happening, I can't prove anything about why.
19
I am an RN and white and had the privilege of teaching in a college of nursing in a large city, urban area with a student population of smart, ethnic minorities. If the non-medical public wants to learn about health care disparities, sit in a nursing school lecture and listen to minority students describe their experiences, and those they love, with medical care. One horrifying story included a student weeping as she told me about her father experiencing a stroke and being transferred from one hospital's ER to another (long distance) via ambulance in highway, rush hour traffic. A white patient would have had air transport as time was of essence for treatment to save and preserve neurological function. The student's father suffered global aphasia (complete loss of ability to speak or comprehend language) and permanent hemiplegia (one-side paralysis) due to the delay in care. Peruse any 20 pound Western medicine nursing or medical school textbook and note the "special boxes" of information that describe the increased incidence of hypertension, diabetes type 2, as only two examples, in adult, ethnic minorities, that have catastrophic outcomes if not controlled. Not all disorders are specifically genetically linked in minorities, but due to lack of early intervention, missed diagnoses or insufficient care. I empowered my students to speak up for themselves and those they love, be persistent and advocate for the appropriate, culturally sensitive and safe care that they deserve.
21
@NMV
Yes, the disparate treatment is systemic and immoral — and well-documented — and available to anyone who takes the time to listen to minority, particularly female and poor, patients.
Your work empowering future medical staff to recognize healthcare discrimination is terrific.
Consider Commonwealth Fund findings:
"It’s been 15 years since the publication of the Institute of Medicine’s Unequal Treatment report, which synthesized a wide body of research demonstrating that U.S. racial and ethnic minorities are less likely to receive preventive medical treatments than whites and often receive lower-quality care. Most startling, the analysis found that even after taking into account income, neighborhood, comorbid illnesses, and health insurance type — factors typically invoked to explain racial disparities — health outcomes among blacks, in particular, were still worse than whites."
"To reduce racial and ethnic health disparities, advocates say health care professionals must explicitly acknowledge that race and racism factor into health care. Less directed efforts to improve health outcomes, ones for instance that fail to consider the particular factors that may lead to worse outcomes for blacks, Hispanics, or other patients of color, may not lead to equal gains across groups — and in some cases may exacerbate racial health disparities."
https://www.commonwealthfund.org/publications/newsletter-article/2018/sep/focus-reducing-racial-disparities-health-care-confronting
7
The MD, Dr. Zitter, has raised some fundamentally important questions. What she did not acknowledge is that SHE IS NOT RESPONSIBLE for the lack of previous medical care made available to her patients, irrespective of whether they are black or white or any other hue.
The key focus is via the Hippocratic Oath, "Do No Harm." Whether HARM was done to these patients in previous encounters with the Health Care System (such as it is), her responsibility is dealing with the patient as she/he presents at this time.
Whether previously less than optimal health decisions were made in ignorance (patient simply not provided with the necessary information to make an informed decision) or for any of a multitude of other reasons, we can only control the situation that is in front of us.
When I do investigative work (some of it in Public Health), I neither look at "the checked demographic boxes of the Client" nor do I look at the ability to pay. Rather, I am looking at someone who (without our intervention) is likely to be taken advantage of by a system that is (for all practical purposes) impossible for the lay citizen to navigate.
We can do better and we must do better. The reality is that WE CANNOT REWRITE HISTORY, but per Santayana, If we don't learn from it, we are condemned to repeat it.
11
@dmanuta History is an incredible tool in the education of medical students, interns, and residencies. Do no harm is reinforced when young doctors are made aware of the burden of injustices upon minorities. History is a significant manner in which to build empathy and awareness, and should not be ignored because minorities still live with a dark history that manifests itself everyday. Doctors must be cognizant of this when they walk into the patient's room, otherwise harm may still be done, consciously or not.
9
Dr. Zitter sounds like a conscientious and extremely well-intentioned physician, and we should always be on the lookout for racism and racial bias. But racial disparity and inequality in healthcare (like racial disparity and inequality in housing, education, clean water, etc.) also result from class and economic inequality and an essentially market-driven healthcare system. (With regard to the last point,I would note that physicians are, sometimes involuntarily and subconsciously, gatekeepers, and that non-black patients and relatives sometimes ask, and should ask, the same question as the son of Dr. Zitter's patient).
14
The doctor is right. But, from the perspective of medical professional. The studies are quoted, the thoughts based in highly credentialed education, solid, scientific. So why does it continue? What creates a lack of trust or faith in modern medicine for millions? Maybe it is not a lack of faith, but an abundance of faith. Maybe religious beliefs are so strong, which is not a factor in studies, that it removes the fear of being sick, even death. Maybe the knowledge that when it is time to pass on, it is a blessing, not something to fear. Maybe the knowledge that each individual will share the same amount of shock, numbness, and sorrow, whether they go through the path of medical science, or die, pass on, to the next existence, are the same. So why chose to let doctors experiment on You? That's what they do. Yes , they heal, they save life, but how many examples of using masses of people, as human guinea pigs, do the public have to see, before, as individuals they chose not to allow it to happen to them and their loved ones, at a critical time in their lives. Yes , in the eyes of science, medical professionals, religion has no basis in fact. It is superstition. But, for millions, after the system, and the professionals that run the systems, have chronically failed them, and their loved ones, faith in God is far more comfortable. Quantifying this is impossible, but some Sunday, drive through the poorest neighborhoods in your city, and you will see the crowds at church.
5
This was a beautiful article, Dr. Zitter. These are issues I think of a lot. I am not religious, nor is spiritual counseling is part of my scope of practice, but I think the integration of chaplains into hospital care and not politely leaving the room while the chaplain sees the patient, makes a lot of sense in order to ease some of these barriers. It’s really heartbreaking that this lack of trust still exists, though not at all surprising.
18
The Sunday New York Times this morning has an A section that is all fluff about the debates. How the Times can spend page after page after page "deducing" information from a debate where the top speaker got 11 minutes total is a mystery of statistical science or more likely a fallacy. Why they do so is more important: Your Sunday Review is 9/10 race, your NYTimes Magazine has more race, and a couple of other articles before spending 2/3 of the magazine on in vitro fertilization offspring person by person.
If you spend any more of your ink extreming your wokeness there won't be any news in the paper whatsoever. It just isn't a paper of record or a paper for all readers anymore. We're wondering whether to cancel, the thousands of dollars per year for a print subscription to a paper that hates us because of our age is not probably worth it.
38
@ondelette Eh, we can never talk about race enough. It seems like saying you don't want to read about race, which sounds more like your problem than the paper's.
6
@ondelette How incredibly bitter do you have to be to take it personally when people want to talk about the things that are still not right in this country? Like race relations and the intersection with healthcare for example.
The world doesn't revolve around you.
6
@ondelette. I have been thinking the same thing!
5
Why do we privilege the voices of white physicians working with black patients instead of the few black physicians working in this space?
Notice not once did the author mention the very real need of training more black doctors.
We don’t need to learn how to tell white doctors to do better, we need more black doctors working with communities to inspire trust before it’s too late.
Also you can’t talk about Black Death without realizing that we are constantly being reminding how worthless our lives are.
Do better nyt. I expect much more nuance not this tired white savior narrative. It’s 2019.
41
@Amani Sampson
Dr. Zitter's sensitive and courageous article is not "tired", or without "nuance". Hardly, indeed quite the opposite. It is an open, brave admission of a lesson learned in a cross-cultural context and may well help other physicians and health professionals deal with future patients.
30
@Amani Sampson. This article is of value just as it is. Have you considered that perhaps black doctors will read it and think about how they interact with white patients? And how doctors of all races and ethnicities might read it and think about how they interact with patients different from themselves?
Or is your idea that each patient will be cared for by a doctor of their own race/ethnicity? Gender too?
10
We wouldn’t be subjected to white savior narratives if there wasn’t so much energy being directed toward imposing white guilt. Apparently we should now feel guilty about feeling guilty (lest we’re called a white savior).
7
The Tuskegee experiment, and Henrietta Lacks sampling are just some of the widely known examples where blacks were used to advance medical treatment.
If you research further, you would find that the whole field of gynecology was founded on experimenting on black women. Many of the statues of founding gynecologists are being taken down because of their racist experimentation on blacks.
Do we really need to question whether slavery was a laboratory for medical experimentation on blacks? You could ignore a black person’s pain and if they died, it was not considered a valuable loss. It is intellectual betrayal that doctors and scientists would not recognize the humanity of blacks while using their bodies to advance medicine. I guess blacks were considered the better mouse. We could use what we learned from experimenting on them because there are only slight differences between whites and blacks. Of course, the Nazis did the same experimentation on the Jews.
The distrust is historically justified and not personal.
22
I have several years experience working in direct patient care in New Orleans, in hospital emergency departments and as an EMT with an ambulance service. Black people do not get good medical care, especially if they do not have well paying insurance. Medicaid or Medicare is not well paying insurance. It provides only the bare minimum and doctors will make decisions based on what they will be paid. But this isn't all due to racist attitudes by doctors, it's monetary, and poor education. Most medical people in New Orleans know what a technical shot is. Black people are not doing themselves any favors by remaining ignorant and uneducated by dropping out of school because they see the school system as representative of white racist oppression. Of course physicians should recognize that people don't know everything and should easily understand that a 'technical' shot is actually a tetanus shot, but people don't recognize the word tetanus and they call it a technical shot.
As for pain medication, perhaps they are ultimately better off without the opioids anyway. 48 hours after surgery I was not allowed to take ibuprofen because it has an anticoagulant effect, but after that two tablets of ibuprofen provided a solid six hours of relief that was more effective than the Vicodin they prescribed.
If the man's eyes widened in panic when the respirator did not breath for him how could he die peacefully when it was finally turned off to let him die? The doctor is fooling herself.
8
@Aristotle Gluteus Maximus. In the first case the patient did not completely know what was happening and he experienced shortness of breath due to not getting enough oxygen. That lead to fear and the widened eyes. His comfort level during disconnection of the respirator was part of the information the doctor needed to judge how much he needed intubation. In the second, he had chosen the path and was, no doubt, treated with medication so that he did not experience any shortness of breath. Hence the peaceful death.
2
@Aristotle Gluteus Maximus;
It is possible to discontinue a futile repirator comfortably for the patient.
2
Dr. Zitter is quite persuasive in her description of the inequities in the healthcare system—as with so many other American institutions—for African Americans. For Democrats, her essay is a powerful argument on behalf of universal healthcare. Republicans, on the other hand, would adduce Dr. Zitter’s piece as an argument against universal healthcare.
Education and income are the keys to better healthcare. The impetus of Dr. Zitter’s essay, however, as with like-minded articles that cast women exclusively as victims, tends to deny blacks agency. Black Americans are intelligent, thinking human beings who enjoy sufficient exposure to culture and media via television—if not books and magazines—to understand habits that are deleterious to their health.
Hats off to Dr. Zitter for specializing in palliative care. It cannot be easy. Many physicians choose a specialization—ophthalmology, radiology, cardiology—based on the potential for earnings. Pediatric medicine—shepherding new life—has always seemed rewarding to me.
Female physicians do tend to have a more calming bedside manner and are less invested in maximizing income.
9
@Andrew Shin Edited
You are from Canada.Most of what you say bears no relation to medical care here.
As for education: have you never indulged in any substance or habit that is bad for your health?
Female physicians do obtain better outcomes (referenced in recent literature) but this has nothing to do with consideration of "maximizing income". We all know that one ICU patient will be too quickly replaced by another one--same income for a day's work in ICU.
@Andrew Shin
You are from Canada.Most of what you say bears no relation to medical care here.
As for education: have you never indulged in any substance or habit that is bad for your health?
Remale physicians do obtain better outcomes (referenced in recent literature) but this has nothing to do with consideration of "maximizing income". We all know that one ICU patient will be too quickly replaced by another one--same income for a day's work in ICU.
Like so many other embedded problems related to race relations in the USA, the politics and policies surrounding racial biases in health care have been too resistant to change: https://www.vox.com/polyarchy/2018/5/24/17389742/american-health-care-racism ("The politics and policy of racism in American health care," May 2018).
The NYTs has been writing focused columns about this for at least the past 15 years: https://www.nytimes.com/search?query=racial+discrimination+health+care . At times we appear better at finding subtle ways to discriminate than we are at cleaning up the problem.
7
You have to be very careful here between discrimination and playing the race card.
Either way blacks get hurt.
Pre 1970 your headline was definitely true but although one must always be vigilant re discrimination rearing its ugly head someplace by and large it is night and day re treatment of blacks re medicine pre and post 1970.
The real crime is our country is the tremendous gap between people who can afford medical insurance and not afford it.
People who can afford it black or white get good care, people who can't are shunted to the worst hospitals, have poor health and many times go bankrupt.
16
@Paul I wish for the sake of black Americans you were right. But even at higher incomes black people get worse care. Check it out. It's really brutal. Also, "race card"? Do better.
6
Just opened this story today after reading about a black patient attached to an IV outside his hospital (told to walk by his Dr), arrested for "trying to steal" the IV! Good lord.
https://newsmaven.io/pinacnews/cops-gone-rogue/man-following-doctor-s-orders-to-walk-around-hospital-arrested-for-stealing-iv-FYad0bj-fk-An-K4ob3SEQ/
12
Great piece
7
I was expecting the latest NYT article with black=long-suffering, noble, good and white= guilty(of something), entitled bad.
And here it is.
29
@Dennis You know, making it about you isn't how the problem gets solved. No one wants white people to feel guilty. They want white people to do better. Guilt is completely non-productive in the long term. Handwringing solves nothing. When people of color call out racial issues, don't you think it would be more productive and useful to actually work on addressing those issues than feeling sorry for yourself? I do.
5
It would seem the obvious answer is to train more African American Doctors.
14
@Bill Dan
If more African Americans (and other minorities) are able to grow-up healthy and safe in a neighborhood with quality education and teachers that prepare them for the rigor of college and medical school, there would be more African American doctors. Lack of intelligence is not the issue with minorities entering professions, it is lack of opportunity for a good start.
2
It starts much earlier than med school.
"“Please believe me when I say I just want to get your father the care that he wants.”
After hundreds of years of pointless racism, if I were black, I wouldn't believe it.
Vile racist politics has just about destroyed our country.
7
@David Henry
In light of your last statement, you should ask yourself why Democrats and so-called ‘progressives’ endlessly stoke racial division.
3
Well said, Dr. Zitter, and poignantly, too. What holds for our physicians also does for us hospital nurses. I am retired, but like Jessica I too was employed in Bay Area hospitals. And it is not only our African American community but also our diverse Brown skinned neighbors whom we need to empathize with. We are taught to heal from the "womb to the tomb." We take classes to guide us in connecting on a human level with all peoples no matter their race, ethnicity, religion, gender, or socio-economic group. Being in the medical profession, I have hope for all caregivers to be all that they are taught to be. Yet we are human, and we need to be reminded that it is imperative that we transcend our personal ideologies. We are no better than the bigot and the racist if we can not change a dark side which must be changed.
8
While in practice I noticed that African Americans were more likely to resist palliative care and request that every effort be done to prolong the inevitable death. They were less likely to enroll in clinical trials. Was this the result of distrust of medical community, a legacy of the Tuskegee experiments? ( black men deliberately infected with syphilis to study the natural history) .
Did the fear about being mistreated prevent them from seeking preventive care?
7
@FACP, you are repeating a commonly held misconception about the Tuskegee experiments - the actual facts were horrifically unethical enough without misstating them. No one was deliberately infected with syphilis, the participants already had it when recruited for a study to see what the effects of syphilis were when UN-treated. Even after penicillin was proven to be a cure, they went untreated. This would be enough to explain ongoing distrust of the medical community without distorting the facts.
17
@FACP My daughter is an ICU nurse, and I often hear stories of a beloved patient kept on "life support" far past any chance for recovery. With technology it is possible to keep a body functioning for many days. This does seem more common among African Americans and some other minorities and I think it is indeed born of historical mistrust, and also a good measure of faith in a God that heals.
13
People tend to have prejudices and there are misogynistic, venal, racist, bigoted doctors as well as similar attitudes from their patients. Yet as a professional (ER doctor) whatever evil might reside in my soul, I have sworn an oath not to let that corrupt my treatment of patients. I don't claim to like everyone I have to treat but I don't let that influence my behavior, and I have not seen any different behavior from the paramedics, nurses, or my colleagues over the years. Maybe I live in a bubble.
12
@Elwood What you wrote is what being a "professional" is about. Working effectively cross culturally requires this plus ability to see how your "outsides" (profession, race, gender, etc) might be perceived by people with negative experiences in these various arenas, and how people with different life experiences perceive "treatment" as well as illness and wellness.
6
This beautiful piece spotlights racial mistrusts, but mistrust is not just racial. It’s a national cancer eating us alive.
The profound aching mistrust so many of us carry around with us is a disease. It’s tribal. We need to trust others our back. Racial, religious and political rancor leaves all of us wary.
For profit insurers and Big Pharma don’t have our backs either. And with politicians unable to survive without their rivers of cash (thank you Citizens United), it is easy to not fully trust our health care “industry.”
12
The human connections we make today will save our world’s tomorrow.
We must see the humanity of a person that lies beyond skin color, in the eyes, in the voice, in the laughter and the smile. To see that, we must look with generosity to every person we meet. We must think about that person’s viewpoint and experience before we speak. We must be more interested in them than interesting to them.
This doctor has discovered this newest truth about inter-cultural relationships. However, this good doctor should think more deeply about the patient’s experience in arriving at the hospital. What environmental conditions, so different from the doctor’s own life, have imposed worse health outcomes on patients of color?
That is an important part of race relations in America today: the legacy of racist policies that place minority populations directly in the fallout zones of industrial pollution. Our two lowest economic quintiles suffer disproportionately from health impacts due to pollution.
That is a bigger reason minority citizens end up with an end-of-life dilemma, and the distrust he experienced, as this doctor describes.
7
After reading this article and the comments, it seems necessary to mention two underlying problems in the U.S. The first being Racism of African Americans on every level. And apparently this extends into death and dying.
Then in addition to racism, we have another underlying problem: Greed, which permeates our entire culture.
It seems to me that until these two issues are addressed, we will continue to neglect and abuse people who need kindness, care, and solutions.
7
The waiting rooms of the physicians I see these days are always full of black people, so -- one way or another -- they are getting to see good, experienced doctors, which is not a situation that I ever encountered when I was growing up in the Fifties, when blacks were largely attended to in emergency rooms.
Democracy is making advances in American medicine in other ways too. Large numbers of the people I see in waiting rooms these days -- whatever their color -- are grossly overweight.
14
We need to help poor people live more health lives.
Eat more healthy. Reduce obesity and cigarettes.
This is true for both poor blacks and poor whites.
I understand it is easy to say but much harder to do.
And there are people working on it.
It doesn't help when there are food deserts and Coca Cola and McDonald's, and cigarette companies care more about profits and about people.
8
It sounds like you've made a good start. I imagine it would be easy when that son asked his question to become defensive or to be offended. Apparently your response was what he needed at the time.
4
This country has legitimized systemic racism since the birth of this nation. It has got to stop. We must all do the work of making room for all people to thrive.
8
I hope I'm not the only one who doesn't see much value in these pieces that are emblematic of woke self-flagellation. Although, it's a great way to establish one's virtue, it does nothing or very little for those in need.
23
I remember Hurricane Katina and how doctors volunteered to tread hurricane victims and that they discovered so many chronically sick people. It would seem a lot of poor health care neglect starts in the South where the politicians don't want to pass health care bills. A statical map of the age of death for the current year will show similar statistical troughs.
11
I wonder how much of the apparent racial differences are actually class differences. Wealthier, more educated individuals are more likely to take an active role in their healthcare, probably including demanding pain medication rather than just deferring to what the doctor proposes.
As for the excess of treatment at the end of life, that's not surprising. I think many white people go out of their way to not appear racist in their interactions with blacks. (Again, more likely with more educated whites.)
8
Serena Williams nearly died from a post-partum complication. Hardly an economic factor.
17
@J. Waddell That class difference cuts both ways. The open resentment that is displayed when a person of color dares to "take an active role in their healthcare" can be insightful. Demand. You are now classified as both angry and belligerent. Question. You cannot possibly understand what I am saying. Additional pain medication. You are clearly a part opioid crisis. Even if you the patient cannot prescribe anything for yourself.
2
"The Neverending Mistreatment of Black Patients" is an inflammatory title purposely worsening racial animosity and divisiveness.
Magnifying racial differences is destructive not constructive since it reinforces racial stereotypes.
Depicting black Americans as a group separate and different from all other Americans is damaging to all Americans.
The goal should be to view black Americans as Americans like all others.
14
Ignoring discrimination will not make it go away, but it may allow those who are not affected by the discrimination to live more comfortably. Pretending everyone is treated equally will not magically cause it to be so.
19
@jck This vision of peace and harmony will be closer to reality when bigotry, prejudice and the behaviors that arise from them are not experienced daily by Black Americans of all ages.
8
Ah Louise-
It is the poor that are discriminated against systematically.
I do not think Beyoncé or the Obamas would have any difficulties along these lines.
Why is the NYT so invested in promoting racial division and so disinterested in correctly framing these issues as socioeconomic?
Easier to cry racism than to foster some poor children or let them play with your kids- send your precious darlings to school with my precious darlings, public schools, funded by the citizenry, and we can have some unity.
Hire someone who was a waitress or construction worker and Train them!
I know these things are harder than assiduously recycling and carrying a tote bag with a woke message to Whole Foods, while chewing out someone poor on the Internet- but Golly, you might actually, hashtag makeadifference.
4
Wow! I guess we all have subconscious biases we must be able to recognize, and fight against, by introspection. Overcoming any prejudice, religious, ethnic, gender (you name it) is a decision we physicians take early on as we know our goal is doing whatever is in the patient's best interest; this is entirely possible and, in the medical profession, essential. And you made your mission to care deeply for this patient, and yet, try to guide him/her and the family to keep reality alive and not present wishful thinking in a desperate situation whose end is near...or it's prolongation, painful to no measure. Insofar death is concerned, of course physicians must be 'comfortable' facing their own...before conveying the brevity of life, hence, the need to live in the 'here and now' to fully enjoy it. And having an able assistant to build a bridge so you can convey the message sounds just right. Though never easy, as our time is always in demand in a busy place, a moment of pause does wonders, as your bedside manners and holding of hands attest. Well done. Of note, the perception still present out there, that a black individual may not be treated as well because of the color of his/her skin is deplorable, and to be condemned. I suppose that a well rounded education may take care of that feeling of unfairness, at least show how stupid it is, besides it's violence in society, particularly when institutionalized. Let humility and prudence dictate our steps (so, doing what's right).
1
I can second the conclusions of the author from my medical practice.
bI believe that radical action must be taken.
Remove the Blacks and Hispanics from the inner city,
Hire thousands of people like Reverend Betty as family mentors
Put the kids in charter schools with high expectations and standards
Stop the horrible wasting of minds and bodies.
Or maybe fund our public schools lavishly for All American children.
5
God bless you, Dr Zitter. You're a true physician.
The Tuskegee experiments, and the testing on Henrietta Lacks for medical benefits are common knowledge.
What is not common knowledge is that the field of gynecology was founded based on experimenting on black women. Some founders of gynecology are having their studies removed due to their racist experiments.
It can only be imagined what medical advancements were made due to testing on slaves.
The distrust by blacks is well earned and should not be taken personally.
15
For heavens sake, the world was a brutal place 150 years ago. You don’t have to look far in any society to see mistreatment of indigenous peoples or minorities. The rest of the world seems to have been able to forgive past injustices to their ancestors, maybe it’s time to try this in the US
2
I am shocked to know that even in the U.S.A. of the 21st century such things are happening . Shame on all of us, the Non- African Americans.
3
Given our history of slavery, Jim Crow and current hostilities between law enforcement and many African American communities, black candor with whites has varied from very dangerous to troublesome. This reluctance to be open and candid has often made blacks appear inscrutable to some whites.
On the other hand, blacks have cooked the food of whites, raised their children, and served in their households in many capacities—intimate and otherwise.
Unfortunately, this imbalance of “knowledge” has given rise to the somewhat cynical:
“Whites don’t trust blacks because they DON’T know them, and blacks don’t trust whites because the DO know them.”
25
The Tuskegee experiment is where plenty of blacks learned of the use of blacks for experimentation in our health care system.
The field of gynecology was started by doctors practicing their craft on slaves. At the time, slave women were considered perfect for medical testing due to their supposedly high tolerance for pain.
Who really knows whatever other experimentation has happened to blacks for medical advancement. If you consider someone inferior, you can mistreat them for your benefit.
Science and medicine has earned the distrust by blacks. It is probably not personal towards an individual doctor.
7
I don't get this because people live with trachs every day. A trach is a common way to get patients off the breathing machine....
1
The trach was not to remove the breathing machine, it was to enable a more secure, long term attachment to the breathing machine.
6
@Patricia shulman The gentleman in the article declined to live "...the rest of his in a facility, attached to a breathing machine, his arms tied down to prevent the tube from dislodging." Two things - one, this would be as good as it would get, and two, the person decided he did not want to live this way.
2
We all must work hard to be mindful of trust issues that happen in the present that are based on past experiences be it racism, homophobia, anti semitism, anti Muslim or any other bias toward people that are different than yourself.
1
There is nothing more despicably inhumane evil cruel separate and unequal than condescending paternalistic white liberal European American Judeo-Christian pity presumption and familiarity.
Particularly from an alleged medical science professional who' cares' about black folks. Playing Tarzan and Superman is not humble humane empathetic.
There is only one biological DNA genetic evolutionary fit human race species that began in Africa 300, 000 years ago.
What we call race aka color is an evolutionary fit human pigmented response to varying levels of solar radiation at different altitudes and latitudes primarily related to producing Vitamin D and protecting genes from damaging mutations.
What we call race aka color is a malign socioeconomic political educational demographic historical white supremacist nationalist American right-wing myth. Meant to legally and morally justify humanity denying black African American enslavement and separate and unequal black African American Jim Crow.
When I was born black and poor on the South Side of Chicago you were either born at home, Cook County or Provident Hospital. Those were also your hospital choices until the late 1960's. I never had a white doctor nor visisted a white hospital until the 1970's
See ' The Race Myth: Why We Prrtend That Race Exists in America" Joseph L Graves; ',Watson Defined'
4
Yes.
Race is not based upon biology, it’s a cultural artifact of people trying to justify their terrible treatment of other people.
1
“. . . I often sense that my African-American patients and their families see me more as a gatekeeper than a caregiver . . .’
That sounds pretty racist, you know pre judging people by the color of their skin.
4
@kaydayjay The doctor was talking about her patients and their families, people she knew and worked with, not some random African Americans she had no contact with. Racist thinking draws conclusions from the color of the skin alone with no other information about the individual inside that skin.
1
Although race is a factor in healthcare access and delivery, the conversion of healthcare from a personal service to a business, controlled by financial intermediaries, such as insurance companies, pharmacy benefit managers, for-profit hospital chains, for-profit pharmaceutical and durable medical equipment suppliers, and corporate physician groups is likely a more important factor in undertreatment of relatively well patients, especially in terms of preventative or functional maintenance therapy, as well overtreatment of terminally ill and functionally compromised patients.
When there is no identifiable covered diagnosis, care is parceled in industrial units of time, and episode, leading to physicians rushing out of the room.
When there is an identified covered diagnosis, care is often delivered whether there is utility.
The fiction that the insurance companies increase efficiency of care based on utilization scrutiny is due to the frquent denial of services and medication on initial authorization request. But this delay is purely an accounting intervention to increase present quarter profit. In the long run, insurance simply pocket a share of total costs, and gradually increasing their premiums allows more coverage of expensive care whether it is beneficial to the patient or not.
5
@TVCriticA self-declared "caravan" of Americans bused across the Canada-U.S. border on Saturday, seeking affordable prices for insulin and raising awareness of "the insulin price crisis" in the United States.
The group called Caravan to Canada started the journey from Minneapolis, Minn., on Friday, and stopped in London, Ont., on Saturday to purchase life-saving type 1 diabetes medication at a pharmacy.Quinn Nystrom, a leader of T1International's Minnesota chapter, said in May that the price in the U.S. of insulin per vial was $320 US, while in Canada the same medication under a different name was $30. Insulin was discovered by 2 Canadians in 1921 who sold the patent to the University of Toronto for $1.00 to keep costs low for they felt their discovery belonged to the world at large.
1
I am seriously concerned by the tone of many comments that blame Black patients for their health problems, ignoring the long history of poor treatment at the hands of medical professionals (such as the Black men intentionally left untreated for syphilis as part of a ‘study,’) the lack of access to healthy food in poor Black neighborhoods, the effects of long term poverty, the deep impact of inherited trauma over many generations, implicit bias, etc. The fact that so many respondents feel such a strong need to immediately refute the thoughtfully described effects of ingrained racism on the medical care afforded many Black people speaks volumes about our defensiveness and inability to attempt an honest reckoning with that very racism.
26
This is quite distressing given the work we did as part of the Robert Wood Johnson Foundation initiative to improve access to health care in the South. In the face of dire needs, what was amazing in Tennessee, Mississippi and Louisiana were the structural obstacles, including turf fights between cities v. Counties authorities. I'm just hoping that it is easier to open a community clinic with a bus route in inner city Memphis today than it was in 1995.
8
This underscores the argument for a universal government healthcare system, for allowing the private ones to monopolize it allows for legal racism to continue. Private schools, like private insurances or medical facilities, are within their rights to treat those who pay for them as they wish to. When a person pays they sign up for what that private organization is offering. However, a government run medical industry is not free to violate the 14th Amendment and must provide the same quality care to people of all races, genders, religions, sex, and ethnic origins (did I leave something out? -- them too.) When the federal government creates a policy that gives the power to the private company, it gives that company the right to offer unequal services and those who choose to go to those private schools or medical facilities, know, in advance that the private sector has more right to give one kind of service to one customer and a different kind of another. That's what the private medical insurance and medical service industry is allowed to do. That we are at the mercy of it, is a government decision and one that they have to own up to.
10
@Maxine and Max
This is only true to a certain extent. The desire to save money is just as prevalent in Canada's national health care system. While the patient may not be paying directly for the services, we are constantly reminded in the press and by the government that health care costs are a major issue. The feeling that your doctor is recommending or not recommending treatment based on how expensive it might be applies here as well.
I have personally experienced my physician rushing me through a visit and not answering my questions in order to "improve efficiencies in the system" and "manage costs". Regardless of who runs it, that will always be the case.
8
@Vince
I'm not familiar with the Canadian Constitution, however, I would assert that under the American one, a government that had had the reputation of using laws to further the aims of racial discrimination and which adopts a policy that does not provide a public alternative to the rights of the private sector to ill treat the members of that same race it had legally discriminated against, for so long, smacks of a policy that uses the private sector to evade equal treatment of Blacks, legally. If the Federal government here had a public alternative to the legal discrimination the private sector enjoys, then it would be hard to suggest that the Federal government is in cahoots with a policymakers whose aim is clearly discrimination. However, the absence of a public health plan makes it clear that the Federal government is unrepentant and is simply making policy to accomplish racial disparity. Healthcare is a right because our bodies have the inalienable right to get sick, age, and become injured. Since the body has that right, we have a corresponding duty to it, for all rights are paired with duty or the rights are unenforceable. That is the legal definition of right: something that is described in terms of it's inalienable existence and the corresponding duty one has to it.
1
@Maxine and Max What you are describing is medical malpractice. I very much doubt that even racist healthcare professionals want to subject themselves to lawsuits that could interfere with their ability to practice their profession. Furthermore, when the government is both the watchdog and the group providing care, how much of a watchdog will it really be?
Consider our military for a moment. We spend more on defense than any other country, but is that money used efficiently and cost effectively? As a government organization has it created a safe space for minorities? How about women? Yeah... that's what I thought.
2
The story of this man is a painful one but not uncommon across ethnicity. As a physician I believe data that shows a disparity in care among people of color, but it is a complicated issue that the author oversimplifies. One glaring example is the study she quotes has some significant flaws and should not be regarded as our litmus of the problem. The impact of socio-economic status, for one, is a powerful and major factor effecting health and remains constant across racial backgrounds. This is probably true even when one controls for diet and exercise—well known health modifiers effecting all racial backgrounds outside the doctors office. Another is education— again across racial backgrounds and likely related to socio-economic status.
While health care among people of color should be carefully evaluated, it should be realized that health outcomes realized at the hospital/physician level is due to a multitude of factors independent of race.
11
@No One Thanks for the white supremacist apology.
2
Dr. Zitter sounds like a caring doctor. But I have a lot of mistrust of doctors in general. My mother held a lot of trauma from giving birth to her children while knocked out by doctor administered "twilight sleep." She held that trauma until her dying day.
6
The article references an article about African-American children receiving less opioid pain medication for appendicitis. In multi variable analysis, there was no difference in the administration of pain medication by race. However, black patients did receive less opioids. The point I would like to make is that there is an over emphasis on opioids as the ideal analgesic. There may or may not have been racial bias. It can’t be determined if pain medication was selected to also relieve fever which both acetaminophen and non-steroidal anti-inflammatory drugs are both ideal.
As a retired pediatrician who practiced in the South for the majority of her career I would agree the is a racial bias that occurs but it is more systemic and is one of access. The patients I treated were for the most part minorities and on Medicaid. They were constantly battling as was I the ability to obtain the proper medication or see the needed specialist. Not to mention the need to update their eligibility status 3-4 times per year that they were indeed the working poor. My office staff as well as myself spent numerous hours ensuring that their access was fulfilled. I had a number of colleagues who were working tirelessly as well. The barrier was the Medicaid program or a few select providers who didn’t want to deal with the low reimbursement rate.
12
well written and important article. but I’d like to point out that the mistrust of physicians is not restricted to people of color. Last week, a white middle class father told me he assumed my therapeutic recommendations were motivated by “kickbacks”
although some of the approbation against health care providers has been earned, much of it is distortion rooted in the anti-science sentiment in large part fueled by the internet.
16
@Honeybluestar
It's fueled by the fact that medical error is the third leading cause of death in the USA and the American medical care system is the most expensive in the civilized world. These are not imagined anti-science myths.
27
I am a Critical Care Physician that has trained/practiced in Massachusetts, New York, and Western Pennsylvania. While I certainly wholeheartedly agree with your observations about the African-American experience at the end of life, I take serious issue with your characterizations of the "undertreatment" of African-Americans in the earlier phases of life. When you are citing the 2017 study, you are assuming that private academic medical centers are the end all/be all of good medicine practice. Boston Medical Center, Jacobi Medical Center [Bronx], and Bellevue Hospital [Manhattan] are staffed with some of the brightest physicians. These hospitals serve a large population of African-Americans, and they are staffed by a very dedicated and elite group of physicians. The care that is delivered in these public hospitals [at the physician level] far surpasses the care that is delivered in some of the wealthy suburbs of Massachusetts, and certainly surpasses the care that delivered in the under-served Caucasian populations of the Midwest and rural America. The information you have gathered to reach your conclusion is flawed.
25
Just because a hospital has some of the brightest and dedicated and elite physicians, that doesn't mean that they are dedicated in the care they provide for African American patients with out race bias. Your response is so defensive.
1
@Zaffar K Haque
Dr Haque: I, too, had the honor of working at Boston Medical Center. I miss it every day.
7
@Julie; It was always rumored that resident physicians there were selected on the basis of whether they could find their way to the interview!
3
It is frightening to realize a doctor does not have your family members best medical interest at heart, based on race. Faced with an immediate surgical intervention for a family member, I pushed back . I used the internet to research immunotherapy, clinical trails, and evidence based interventions as options. I did this after overhearing patients with similar conditions ( yes, I know/understand every condition is different) offered these alternatives never mentioned to us by medical staff in discussions on treatments. I emailed my research to the head of the depart. My research included two clinical trials for the same condition one less than 5 minutes from the hospital. This was in addition to research on immunotherapy drugs. The result, the tumor board reconvened not a part of their original plan. Currently my family member is doing well and received the immunotherapy drug. I am not saying my family member will never have surgery. I am saying the surgeon "told us" categorically they would have surgery immediately giving us the surgical date. I am well aware of the racial bias within healthcare. In this case surgery would have been a "fait accompli". It still frightens me that they were a few clicks away from immediate surgery.
16
@marielle I am glad you had the wisdom to put a hold on the surgery for your family member. Surgeons and Internal Medicine doctors often have different mind sets. I am over-simplifying here, but too often for surgeons "a chance to cut, is a chance to cure" Who was ostensibly in charge - a surgeon or internal medicine ? Were you in a community hospital or one that is part of a medical school? Was an oncologist part of the initial decision making process? And to be fair, could you have misinterpreted the surgeon? Often, due to scheduling issues, they will schedule surgery before so as not to lose a time slot. Could they have said something to the effect of "if you choose surgery, we have you scheduled for..."?
Having asked these questions, I still have to agree that it seems someone was limiting your options. I just dont know why.
7
@marielle
One of my doctors discovered I had gall stones by ultrasound. He sent me to a surgeon who suggested surgery. I declined and found an approved, recognized, OTC medication in Germany for my condition. A subsequent ultrasound about a year later showed no gall stones.
8
@LesISmore Please note this is a hospital with a well deserved (teaching) national and international reputation. Oncology works as a team. Oncology/radiation, surgeon, internal medicine, social worker, a full contingent and of course nurse navigator. I was told about the surgical date in an open public room by the surgeon (HIPPA). A part of another surgical team overhearing the conversation came over later to ask if the surgery was scheduled that same day. I take no offense but I was told the date of the surgery by the surgeon. He also went on to tell me if he found cancer in the bones "well" with a shoulder shrug. He did all of this without further consultation with the "team" nor they with him. I think this would have been appropriate in any case. This is what precipitated my research and thus my email to the department head. I do not as a rule believe in subjective pronouncements but based on my observations of interactions by him and others on the team with fellow patients versus my family member there is no comparison. The exception to that was nursing and social work.
2
This is a very thoughtful and sensitive piece on an important subject. Thank you, Dr. Zitter.
9
The purpose of applied medical science is to alleviate suffering as best we can to all, regardless of race, creed or nationality. Sometimes performing a tracheostomy is appropriate, sometimes not performing a tracheostomy, as discussed in this case, is appropriate as well. As an ear, nose, and throat doctor, I have had many end stage head and neck cancer patients sign do not resuscitate orders as there is no chance of curing their disease. However, at the end of life, if they develop slow airway obstruction and are fighting for air and their eyes tell you to do something, or if they are actively bleeding to death and the family and patient are obviously uncomfortable with this terrible situation, we still perform surgery even though they previously signed legal forms stating that they were DNR. We all agree to tear up the DNR legal forms and proceed to surgery to alleviate suffering. These are difficult situations and the doctor needs to have "good bedside manner" and deal with the ever changing needs of the patient and their loved ones.
As far as color entering into the decision making process, I agree that race (more likely their insurance or ability to purchase health care or health care insurance) does play a huge role in lack of care during life, but less so than inappropriate care once they are in the hospital or ICU.
Doctor's behavior is more monitored in the hospital setting than in the office. His/her receptionist can turn away patients based on insurance.
8
Healthcare in America is truly an oxymoron. Yes, the color of your skin does impact access to healthcare but in reality poor whites and middle class also struggle with access and affordability. The conclusion always remains the same, we spend more on healthcare, than any other Nation, but our outcomes are worse.
The pot of money is there, but first is Health Insurance Companies, Hospitals, Physicians, Pharmaceuticals and Medical Devices are all feeding at the pot. What remains is divided up according to a patient’s class in society. Access is definitely not the same for American citizens. Even Employee based healthcare is not utopia. Companies pay more yearly for less coverage. Employees are sharing more and more of the costs as well as larger deductibles.
Finally, the sad reality, is that we pay more for end of life care which does not change the outcome for patients.
This is a dialogue that America resists, our legislatures have access to the best healthcare our money can buy and they benefit from the largess of health lobbyists. So nothing changes, the ACA was possibly a good start while keeping our sad model.
22
Thank you Dr. Zitter for sharing this case with us. It highlights the shared decision making process, one where any decision is fraught. It seems you were well composed when confronted and thereby deserve the recognition of being a Physician.
In my practice, I try to remember that it is better to teach than to preach. Most patients appreciate the autonomy of making their choices, and it strengthens the doctor-patient relationship. This is especially important in tough cases like this one.
7
Critical care doctors like Dr. Zitter would be less likely to face life and death decisions with African American patients, if more primary care doctors and nurses were more conscientious in educating patients to stop smoking, eat healthy diets, and get adequate exercise. The real inequity is in primary care services, not care in ICUs or ERs. Imagine if there was a code call for primary care services for every patient who is smoking, instead of one that occurs -regardless of race, color or creed - when someone goes into respiratory arrest.
4
@MR1946 If a patient is at a higher risk for a disease appropriate screening ( clearly bench marked) would be one answer. However, this does not happen. Its one thing to be told the importance of eating well and exercise it is quite another to be at high-risk and not receive routine screening(s). Another bit of information not every encounter needs to be screened through the filter of obesity. I understand the medical impact of obesity. Yet, patients do not seek medical attention for early symptoms that need medical intervention because they will or have been told it is related to weight/obesity. A patient presents with back pain...told by doctor it is related to weight...reality tumor. This is the reality for many patients of color whether they are obese or not or they have "gold plated" health insurance. A dentist who has a son who is an MD, son traveled from California to his hometown to intervene so his father could have by pass (CAB) surgery. It was indicated. Age, overall health was not a factor but it took a trip to the east coast and a conversation that ended with my son the doctor and may we review. What changed in less than 72 hours?
2
It's not just non white patients who don't get proper care. If you have limited means, and no insurance, my family also believes doctors "pulled the plug/giving up" because you had no money for a out of hospital nursing care. This could include transportation to appointments after discharge. Affording chemo and other treatments.
I don't believe that anymore, but I still have many family members that do, and it totally determines how end of life care plays out.
14
The system needs more African American doctors and nurses who in spite of profitable health care system, understand the culture, distrust and sometimes emotional needs of the patient.
Medical school and internship cost is extremely high and years to complete. Income inequality extended into another walk of life for those historically disenfranchised.
15
Dr. Zitter raises some valid points. However, speaking from personal experience as a caregiver and as an African American woman with a clinical background, her primary premise is deeply flawed. Her assertion that black people receive "too much" end-of-life care is based upon a thinly-veiled utilitarian strain of bioethics that often withholds medical interventions based upon the socioeconomic status of patients. Too many people that I loved have died as a consequence of malpractice combined with a tendency on the part of non-black medical providers to withhold care based upon their own prejudices. In order to contain institutional costs, administrators and hospital ethics committees routinely override patient directives and push African American patients and their families into hospice or other instances where appropriate care is withheld on the basis of often dubious futility. Perhaps Dr. Zitter can expound on the disparities that African Americans receive at all levels of healthcare, including end-of-life care, in a future editorial.
14
Our country needs more caring loving Drs like you(actually if everyone would become more caring loving our quality of life would dramatically improve and probably decrease our need for medical care).
19
Until 2016, I must admit I had no idea how deeply racism was still ingrained into the fabric of this nation. With authoritative permission, it came out of the woodwork. Despite it seeming unconscionable that it exists in the medical field, I guess it's not surprising, even if heartbreaking on all levels. I remember when becoming a doctor was a calling and our family doctor, when I was five years old, nursed me back to life from whooping cough while sitting on the edge of my bed soothing and comforting me. There was no health insurance at that time.
But how do you apply good, quality healthcare to all when doctors must answer first to a bottom line? Medical care should not be a for profit enterprise. Perhaps, if we remove the profit incentive and doctors are free to treat equally, those that do not will become obvious and good doctors become free to call out the implicit bias. It's a very good reason, among many others, for all of us to insists on medicare for all.
50
@thoressa
Don't forget the profoundly ingrained sexism either.
Now, with this hysteria about "opiods" being trained on our doctors and us, the profitable low-hanging fruit, and the police state in our medicine, Women in pain are disregarded to the point of callousness as well.
If a man is in pain, he will always be taken MUCH more seriously than a mere woman.
We all have to fight for each other's rights and dignity
43
@Southvalley Fox
How right you are! When I recently went to the emergency with back pain so severe I hadn't been able to get out of bed for 24 hours except to stagger in pain to the toilet, I was treated with dismissal as if I was exaggerating the pain, although when after 3 hours of lying in a room with no treatment whatever, a DO came in, had me sit up, felt my back and commented that it was hard as a rock from muscle spasm. An hour or so later I finally got an X-ray. Still no pain meds of any kind and not even a glass of water or a cracker although it was now mid-afternoon and I hadn't had any thing to eat or drink since the day before. Another house or so passed before the nurse came in, and gave me discharge papers saying I didn't have a stress fracture and to call my doctor the next day (this was a Sunday). They did give me a prescription for ten pills, each the equivalent of half a valium and, of course, there was no way to get a prescription filled until the next day. I had to walk out of the ER to the waiting room (no wheelchair), borrow a cord to charge my phone which had gone dead, and call for a ride home. I took an Aleve when I got home and the next morning called a chiropractor. They got me in immediately and a back adjustment helped a lot. By Tuesday morning the chiropractor had gotten my X-rays from the hospital and told me I had a displaced vertebra. There had been no mention of this at the ER. Adjustments and exercise have helped a lot.
1
@thoressa — let's be very clear that the HUGEST profits are in pharma companies and health insurance companies. Doctors and nurses work really hard ... with far too little time allocated to patients because SO MUCH TIME is spent filling out paperwork and arguing with for-profit insurance companies who have denied care.
Really? You ask? Yes, single-payer works because it removes the profits from insurers so that costs can be controlled (and, yes, it's insurers that encourage the spiking costs since every dollar more gives them greater profit).
In other countries that have universal care and private insurance, those insurers are ruthlessly REGULATED as to what they can charge, the benefits they MUST provide, and what they cannot deny.
Ditto pharma: there's something called market-based valuation which means that a pill or shot that costs a few dollars to manufacture can be priced at HUNDREDS of THOUSANDS of dollars ... parents who don't want their children to die will pay anything ... so why shouldn't Pharma extort them? We believe in capitalism and greed is good, right?
For those who worry about innovation and paying for R&D to create new drugs, it may be news to you that of the most recent 200 brand new miracle drugs ALL of them were paid for by US TAXPAYERS. Jayapal's Medicare for All bill has a clause that would allow us to "march in" to those drugs and price them so that a) there would still be "profit" to the company but b) patients could afford them.
I think we missed the main point here. I lived in a small North Carolina city, half white and half black. And everything changed for the blacks when a recent graduate of Howard Medical School came to town. Dr. Hayes could have practiced in some fancy pants hospital. But he decided to go where he was needed. He never got to leave his office when his visiting hours were over. And he was often paid in kind.And it seems pretty obvious to me that the best way to improve black care, at least in some places is to have black doctors.
159
@michjas
Exactly my thoughts. The numbers are pretty stark, low income Americans of color are much more likely to receive care from a person born and raised in a country thousands of miles away, than from someone of their own background. Disparities continue as we do not nurture enough of our young people hungry for quality education and a chance to serve.
59
@michjas a great point and where are many of these doctors of color educated? Historically Black Colleges and Universities (HBCUs) of which Howard is one. These HBCUs are constantly under financial stress. If we support these schools we would see a real change in the number of healthcare professionals of color. They are needed in not only communities in need but in top tier teaching and research University Hospitals and Healthcare Systems.
24
It should be clear that doctors born in other countries are far less racist than American born doctors. Racism is taught in America from a young age, in families.
7
In a study that I conducted about 20 years ago, when subjects were given a case report of a youngster having academic and social difficulties in school that varied by gender and race, psychologists were no more or less likely to recommend services, i.e. psychotherapy, if the student in the scenario was african-american or white or female or male. I wonder what other uncontrolled variables are in play that are not being accounted for in the article here. By the way, the more classical Freudian guys were more likely to recommend intervention overall than the cognitive behavioral subjects.
7
@perltarry,
Perhaps the psychologists in your study were more conscious of bias as compared to physicians. Also, "african-american" should be capitalized.
1
I’m a retired lawyer. I worked for Legal Aid in Dallas. Many of my clients were African American. Before a hearing or trial, many of the families would pray together. I always joined them. The connection it established was immediate and genuine. Plus, I needed all the help I could get. Praying calmed me and made me feel as if I had a silent Partner on my side.
115
I am a white male. I have no doubt that the medical profession does not treat blacks the same as whites. The discrimination in the treatment of pregnant blacks, in particular, is unconscionable.
But I have to raise some issues that Dr. Zitter ignores. Who was going to pay for giving a dying patient surgery and hooking him up to a machine, to buy a few more weeks or months for him to live enslaved to that machine? Which immediately raises an related issue: how much money is going to be spent on patients suffering from ailments they brought on themselves?
We need answers, because these issues are going to be increasingly relevant as we cope with an increasing population of aging citizens. My position is clear: we need to practice severe triage in using insurance and Medicare to pay for treatment for patients who are sick because of their own acts, or just to buy a little more time for a dying patient.
And to those who might criticize my position, please be ready to discuss the fact that there is no mechanism for providing families coping with Alzheimer’s relatives the funds to pay for the round-the-clock care that dementia sufferers require. What a travesty that priority is given to smokers and drug addicts to pay to treat their self-inflicted wounds, while Alzheimer’s sufferers are given nothing for the care they need.
24
It may be difficult to determine who is responsible for their condition or not.
If people were eating the proper diet, exercising properly, and seeing their doctor regularly following through on recommended treatment, maybe their condition could have been avoided. If people avoided contact sports or dangerous activities, maybe their condition could have been avoided. It seems that most Americans are over the recommended weight guidelines, should their care be denied by the insurance companies or government because of obesity?
My mom did not follow through on treatment recommended by her doctor for a decades long condition because the insurance company would not pay. It was a few thousand dollars that she saved. We as a family had spent thousands on other unnecessary things.The condition left her bedridden for the last couple of years of her life with the need for 24 hour care. We only found out about the viability of the treatment after she became bedridden and start to improve from undergoing the recommended treatment.
We were penny wise but pound foolish when it came to her treatment. Proper Medical treatment doesn’t begin or end with who is going to pay for it.Don’t let the insurance companies dictate your or your parent’s treatment. And if you question your doctor, get a second opinion.
68
@SouthernView The mechanism for Alzheimer's care for individual patients is there: its called Medicaid. That care is not there for people with genetic issues. Sickle cell anemia for example has an effective treatment...but its not accessible to many young adults as they don't have jobs that pay enough for them to afford their meds. Elders like you won't give the hand up, preferring genetic culling and profiteering. That's just deplorable.
24
@SouthernView People who take care of themselves
( no drugs, no smoking ,etc.) may actually cost more ( medically) than people who don't. They live longer, and eventually will die of a non self-self inflicted disease. Is Alzheimer more ( or less) expensive than lung cancer?
I don't know. Bu I do know that people who smoke have shorter lives and therefore need medical care for a shorter period , and that the cost of medical care increases in time much more than inflation.
27
Palliative.
That is the key to the heights of moral intervention. When are hospitals, all, going to afford and get reimbursement for palliative services?
Please, healthcare providers, advocate for palliative services - and that goes for rural areas, too. Every human being deserves the choices palliative can offer. As a nation, let us strive to make that happen.
75
Thank you Dr. Zitter for your honesty and bravery written in the article. The operative word here between the African-American and medical community is TRUST. As a women of age 50 who is always health conscious and maintain a healthy relationship with my doctors, I seek trusted advisors. Trust is build, as stated in the article, through connecting with patients or clients with other areas of what is important, like family or praying. The medical community certainly can do much better to bring the human connection back to health care.
31
This mistrust is not just restricted to African Americans, but some of the most egregious cases have come to light in recent times. Harriett Washington wrote a book entitled "Medical Apartheid." It chronicles decades of mistreatment by the medical profession against African Americans.
The mistrust is based in historic fact. With this in mind, the thought that a fragile, often elderly, person is not receiving proper care and being "dispatched" is not a fiction. One must address the difficulty for family members in making end of life decisions. Hospice and palliative care institutions must do better in outreach to these communities BEFORE their services are needed.
Better healthcare (mental and physical) over the span of a lifetime, means better health at the end of life, with less chronic disease, and less prolonged suffering and shorter end-stage decline. If only our society could recognize the important of good, affordable healthcare over the longterm contributes to a positive quality of life and health for all our communities.
48
Great analysis from a wonderfully new perspective--the perspective of individual patients, doctors and caregivers--not the perspective of Big Pharma or Big Insurance or Big Government medicine. All those could be improved if a few executives and managers spent a few days in hospitals visiting with human beings who are also patients.
16
Every statement in this short opinion piece is correct. The patient's wishes were met. The physician's treatment goals were met. The son's proper hesitancy was verbalized and placated.
Concerning opioids there are no "good" studies. There is no definitive or correct course of action.
Concerning ICU care, there is a white elephant in the room called profit that motivates therapy, rehab, treatment modalities, pharmacy policy, nursing assignments, shift changes.
54
I heard a paramedic say that some of those of his field serving poor communities of color would use a bigger IV needle than necessary on patients they didn't like. In 2017, two Delaware paramedics were investigated and put on administrative leave for exactly that practice.
I have no words for someone who would inflict greater pain than necessary in a job devoted to healing.
203
You sound like a caring physician. My mom was overtreated, despite having a signed DNR and repeatedly refusing procedures. A hospice agreement finally stopped the badgering but provided little to nothing in the way of actual care. I witnessed this with my sister and a close friend as well. Hospice agencies seem to function more as a liability shield for nursing homes, doctors and hospitals than as carer givers for dying patients.
35
the quality of hospice agencies varies, unfortunately. it seems that they only made a difficult time even more so. I'm so sorry you had those experiences.
10
I have never had even close to a bad experience with hospice.
Dr. Zitter mentions studies indicating that blacks are under treated for pain. It's worth noting that a recently published study indicated that blacks are more likely to be prescribed opioids by primary care physicians than are whites or Asian-Americans.
She is within her rights to believe her studies over the new one but she should at least note that all the research doesn't support what she says.
And something that she many not want to mention but is important is that African-Amerian medical students are no more likely to become primary care physicians, for which there is a dire need in inner cities, instead of choosing much higher paid specialties than are white students.
33
@Steve, care to mention the source? "a recently published study" doesn't exactly inspire confidence.
Why do you have to point out that black doctors choose the best opportunities, just like white doctors? It's as if you expect black professionals to stay 'down home' and take chickens for payment just to be a good example for you. If your point is that black physicians are no different than white doctors, I'm a bit confused. Why is that important?
Yours is the type of comment that uses vague questions and non-existent studies to keep the subject of racism muddled up.
Show us your evidence. And no, FOX/Breitbart don't count.
8
@Steve
Please provide your resources for the studies you quote.
6
@Steve there is an old song "How Ya Gonna Keep 'em Down on the Farm (After They've Seen Paree?)" African-American, Latino and Foreign Born Medical Graduates are just as likely to get subspecialty training and stay in the big city as are the White privileged doctors. FYI, not all White doctors are privileged either.
2
Black women are among the most mistreated of all. There seems to be a mistaken assumption about them when it comes to pain, having children, and illness in general.
As a white woman I don't trust doctors at all. They don't spend enough time with patients. They are too quick to give us prescriptions even when we don't ask for them. They cut us off when we're trying to describe our symptoms. They minimize our pain. And I know that the insurance companies do not have our best interests in mind at all when it comes to health care. Once a norm or standard is set, woe to those who cannot meet it. They will be denied, saddled with the extra costs, etc.
Perhaps if certain medical experiments hadn't utilized unknowing people African American patients wouldn't distrust doctors as much as they do. Perhaps if they were able to receive decent medical care regardless of their skin color (and minus the slurs and condescension that is so common) they'd trust more.
However, for me the bottom line is that every medical interaction is governed by people who are not in any way qualified to judge what is needed: those at health insurance companies where the main interest is their bottom line, not our health. Until that changes no one is going to trust the doctors, the nurses, or any other medical personnel when it comes to critical decisions.
6/29/2019 7:48pm
160
@hen3ry — yours is an argument for why private health insurance, as a system, harms us. It's not the only harm but by ruthlessly limiting the time doctors can spend with with patients and by setting up narrow networks so that we cannot choose better doctors (and, when we find a good doctor and then our insurance drops him/her, we cannot afford him/her) ... insurance co's keep us from getting needed care from doctors of our choosing.
It's not the only reason for healthcare disparities, but I've had good and bad doctors and know the difference.
I love original Medicare, NOT Medicare Advantage, because I want CHOICE of doctors, not choice of insurance. Med Advantage makes it really expensive to be sick — and, if you try to shift after you've gotten sick, you may find that NO supplemental plan (by private insurance) will take you ... although they won't say the phrase "pre-existing condition," that will be why.
Single-payer guarantees healthcare payments and give everyone access to any MD or hospital without extra (unaffordable) surcharges .... Your medical care will be determined by the trained medical professionals YOU CHOOSE, not as currently by untrained bureaucrats who are paid to say, "no."
9
What a horrible indignity to question a medical provider’s motives.
Every person deserves to be treated as having an inherent worth, no different from the next person’s, cradle to grave.
And during critical health situations, when painful decisions have to be made, no one should lack confidence that a Doctor is advising based on anything other than professionalism, care, respect and honesty.
8
@NM
You are correct about how every person deserves to be treated, but in the real world every person doesn't receive the treatment they deserve. Some medical providers do not put the best interests of the patient first.
36
As a physician who cares for premature infants, I have been asked questions that you might think are indignant. Each of us brings different life experiences to the plate. Don’t look at it as an affront. It is a question with much more behind it than you may think. Did the family have an issue with a different health care provider? Did the family feel care was withheld? Is the perception out there that physicians do make decisions based on money?
I answer truthfully and then try to find the root of the concern. I have been humbled many times as to the origins of the query. Just as in the case of this ICU attending, I do not have the luxury knowing and caring for a family for years before making life and death decisions. Trust can be hard to earn in such a short timespan.
16
NM, that's kind of funny. Hmmm, why don't African Americans trust the white-based medical system?
It's an insult to a white doctor if a black patient, in America in 2019, dares question motives? I'm sure you haven't been under a rock for the last 10 years, so you MUST be aware of the concept of institutional racism and the national discussion going on.
Many people don't get to choose the doctor they get at an ER, and many people don't even have a trusted primary care doc they see. The days of Marcus Welby making house calls are over, NM, if they ever existed.
You are blaming the wrong people: the confused and terrified patients/families.
7
What's with the headline of this article? Strikes me as sensational and deliberately provocative; not at all descriptive of the content. I have no doubt that there are disparities in medical treatment, but I rather expect that most of them are a function of economic resources, not race. The medical professionals I know exhibit the same commitment to the welfare of their patients that the author professes to embody.
79
sorry, but 'I rather expect' and 'the medical professionals I know' are relevant only to your experience. You ignore the actual data and reported experience of the physician. try listening to some folks outside the bubble of your experience, as we all should, and see how other people live (and die).
39
@JMM This is extremely naive, there are numerous studies showing poorer outcomes for black patients due to distinct differences in the care they receive. Studies show black women die from complications of pregnancy up to 6 times higher than white women. That is especially grim now that their access to birth control and abortion has been especially targeted.
20
@JMM
But this, even if I want to believe you, has nothing to do with the valid suspicions and historical experience of blacks in America.
5
Like it or not, doctors are now seen as the front line in winnowing out the old and terminally ill in order to reduce their unjustifiable and insupportable demands on medical services and funds.
Now that billing codes have been assigned by Medicare/Medicaid, physicians can be paid by the government for counseling patients or their surrogates to choose assisted suicide (in some states) or removal of life support systems/efforts (why isn’t that considered suicide or murder). You know, ending one’s life with dignity and without pain.
Are any doctors truly comfortable suggesting that the best care is suicide or removal of life support? And isn’t there a conflict of interest when these terminal recommendations reduce medical costs for the government and the insurance companies?
By the way, the concerns the author mentions are hardly limited to black patients; I would say a large majority of all patients of whatever race have similar concerns and have felt this way since “death panels” were first mentioned many years ago.
10
I was recently hospitalized and underwent major surgery after experiencing an emergency medical condition. I quickly became aware of, what was to me, a new type of doctor, the Hospitalist. They are employees of the hospital, and their clientele are the constantly changing patients coming into the hospital. Seems to me they have a major a major conflict in their responsibilities to the bottom line of the hospital vs. their responsibilities to the patients.
47
@s mohr
I hear you loud and clear. I am sure that these days Drs feel torn between their responsibilities to their patients and those to their employers which happen to be billion dollar corporations.
Witnessing this firsthand, as a staff RN, I have started wondering how they can protect themselves from this. Just as I was thinking about this I learned that the PAs (physician assistants) at the hospital had joined a union. Maybe it's time for Drs to start thinking about the job protection they need to do their best work.
50
@Mon Ray
This is what misinformation does to people. When you hear “death panels” it’s easy to confuse removal of life support with murder.
I am very comfortable suggesting removal of life support when care is futile and patient has no chance of meaningful recovery to a quality of life that is acceptable to patient.
There is no incentive for doctor to save any money for government or insurance. Most docs get paid fee for service, more services they provide, more they can bill. The author in this case could have recommended tracheostomy, billed for it if he performed, then bill for many more days that pt would have lived in ICU.
If you really want to know what doctors believe, you should look at how doctors die.
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