An Examination of Healthcare Quality—

With a focus on physician-rendered care

Teri Abel
1999

Copyright  1999. All rights reserved. No other uses without express author permission.
 Note: Following is the original contents page. Subsequent pages represent
selected excerpts written exclusively by Teri Abel from the original co-authored
forty-two paged document, assembled and edited to present adequate context for
purposes of public viewing.

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 Contents

1 The definition of quality in the health care sector: the need for clarification
1.1 Perspectives on quality in the health care sector
1.2 Benefits and limits of each approach and the need for integration
2 The introduction of quality measures to improve health care performance
3 Physician autonomy and physician-delivered care: problems with the medical perspective
3.1 Physicians’ education
3.2 The impact of group distrust for healthcare systems on physician-rendered care
3.2.1 The biology of sociology—American-style: race as a demarcation line for
differentials in health status
3.2.2 The sociology of the biology: The Under-representation of Groups in
Clinical Trials and Clinical Training
3.3 Bias in the medical perspective: Variances in treatment across patient groups

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…
3.2.2 The Under-representation of Groups in Clinical Trials and Clinical Training
…
General medical recommendations and treatment standards are generated in great part

from clinical training and clinical trials. If a given set of standards is biologically and

statistically less relevant to African American disease progression vs. Caucasian American

disease progression, for example, then either African Americans are not adequately represented

in clinical training and trials, or if they are adequately represented, their health status is not

charted in a way that is attentive to systematic variations across race.

For different reasons, patient populations can be alienated from the healthcare system.

For example, to the degree that there is distrust by a group for the healthcare system, that group

stands to be less available to and represented in clinical training and trials. Consequently, the

clinical training and trials can be expected to return conclusions and recommendations that may

not be maximally applicable to the underrepresented group. Even if an underrepresented group

abides by the scientific conclusions of certain clinical training and trials, health benefits may not

be perceptible in them. Whatever the reason for under-representation by groups in clinical

training and trials, potential differences in the physician’s perception of beneficial treatment

outcomes during the physician-patient encounter can effect an impression upon the physician of

a disconnect from or disregard for medical advice by the underrepresented group. Such can

potentially alter the advocacy which physicians do for these patients’ improved health status, and

can undermine their energetic care-rendering, thereby promoting a differential in the quality of

care rendered across patient groups. After all, the scientific method that encourages and rewards

the physician’s confident care-rendering to the represented group, is the same scientific method

by which she perceives the underrepresented group’s systematic failure to reap the benefits of

clinical training and trials. In this event, the working assumption on the physician’s part is that

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variances in beneficial outcomes for the underrepresented group are due to perhaps sociological

rather than biological factors.

This issue is illuminated by a long-standing puzzle and set of assumptions confronted by

researchers at the George Washington University Hospital, who were investigating differences in

breast cancer survival rates between African American and Caucasian American women.

According to Dr. Robert Siegel, director of the university’s cancer center, statistics show black

women are less likely than whites to get breast cancer; but five-year survival rates are 63 percent

for black women compared with 76 percent for whites. Researchers had long believed that the

discrepancy was due to socioeconomic factors and the quality of delivered care, or to black

women’s “delay” to go to the doctor. In his study of six years of breast cancer data, Siegel found

that even when black women's breast cancer is discovered at the same stage as whites -- and even

when the treatment is the same -- the cancer in African-American women shows "more

aggressive behavior."1

"The bottom line is black women are getting more aggressive cancers at an earlier
age."2

According to Siegel, there were "clear biological differences" between the cancers found

in whites and blacks. Regardless of the tumor size or whether the cancer had spread, black

women were more likely to have breast cancers that grew faster, contained more malignant cells

and did not respond to hormone treatments:

"For some reason -- and I have no idea what the explanation is -- black women
have cancers that look worse under the microscope."3

1
Detroit News, Washington Bureau, “Investigating a medical mystery: Why do African-American women with
breast cancer have much lower survival rates than whites?”,1995.
2
Ibid., Siegel, R.
3
Ibid.

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 If there are biological reasons explaining why certain diseases are more common or

aggressive in blacks, the medical system may be unfairly suspecting African Americans for

delaying prevention and treatment. Moreover, because certain diseases appear to behave

differently in blacks and whites, the medical system may actually be doing African Americans a

disservice by recommending prevention strategies, screening schedules and treatment options

developed from studies of ‘white’ disease progression.4

Siegel further thinks the medical community should consider revising its age

recommendations for screening mammographies -- based on a patient's race. The American

Cancer Society currently recommends women 40-49 years old have a mammogram every one to

two years, and women age 50 and over should have yearly mammograms:

"One potentially reasonable idea is that the guidelines for screening

mammographies should be earlier for black women."5

In a 1995 study published in the Journal of the American Medical Association it was

found that prostate cancer may follow a different biological course in blacks and whites, too. The

study of 1,606 military men found that even when they all got the same screening, prostate

cancer was diagnosed in blacks at a younger age and at a more advanced stage. Moreover,

researchers found the disease grew faster in blacks, even when they underwent the same

treatments as whites. This study confirms the suspicions of Dr. Isaac Powell, a urologist at

Harper Hospital in Detroit, who was one of the early advocates of screening African-American

men for prostate cancer at an earlier age than white men:

"We think the biology of progression may be different in blacks.” 6

4
Ibid.
5
Ibid.
6
Ibid.

5
 Until recently, the American Cancer Society recommended annual prostate-specific

antigen blood tests, or PSAs, to screen for prostate cancer in men beginning at age 50. But based

on research showing that blacks tend to get prostate cancer earlier than whites, the American

Cancer Society now suggests annual PSA testing for African-American men beginning at age 40.

According to the Detroit News story, Powell applied for a federal grant to study whether

doctors should use different standards to evaluate the PSAs of African Americans. Whereas most

doctors recommend further treatment for men whose PSAs measure four points and higher on a

10-point scale, Powell would like to see the treatment threshold lowered to two points for black

men.

Henry Ford Hospital cardiologist Fareed Khaja is one of eight researchers nationally

working on five-year grants awarded by the National Heart, Lung and Blood Institute to

investigate possible biological causes for higher heart disease rates in blacks. Working with 23

Ford cardiologists, Khaja is investigating why African Americans are more likely to suffer from

a thickening of the heart muscle than whites, and whether the condition explains why blacks are

less likely to survive heart attacks.

Asthma is another disease that appears to more severely impact African Americans than

whites. In early 1995, researchers at the Henry Ford Health System began investigating why

African Americans had more emergency visits for asthma than whites. In previous studies,

researchers speculated that African Americans were forced to use emergency rooms because they

did not have the money or health care coverage to obtain regular medical care, or because of a

fundamental alienation from the health care system. But by comparing asthma patients enrolled

in health maintenance organizations, who had the same health coverage and access to medical

care, Henry Ford researchers found that African Americans may actually suffer from a more

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severe form of the disease. Researchers at Henry Ford have received a grant from the National

Institutes of Health to study whether biological differences explain the increased severity of

asthma in African-American children. If biology is found to be the culprit, researchers may

recommend more aggressive treatment for African-American children with asthma.

Based on its research, Henry Ford's medical effectiveness center is one of four programs

nationally that has been awarded a grant to study the effectiveness of medical treatments in

minority populations. While all of these findings have obvious implications for the way doctors

treat breast and prostate cancer, and asthma in blacks, they also incline us to question long-held

assumptions about the reasons African Americans have higher death rates for a host of other

diseases.

A review of source integrity for the “original” medical recommendations in the above

cases seems warranted; for example we can inquire about the process and science that produced

a recommendation of PSA screening commencement at 50 years in age for all men before the

corrective of 40 years for black men specifically---a difference in age of 20%, which would be

well discernible in ideal studies or data sets that included African American men. It seems

debatable whether there has been a greater evolution of this process or of disease progression

across groups in the patient population.

3 Physician autonomy and physician-rendered care: problems with the medical

perspective

For all the variations in definitions of quality among American patients, physicians,

health management organizations, health policy experts, and public health agents, there is a

unifying concession worth recalling before engaging in a perspective-specific focus on quality.

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In particular, quality is regarded as something fundamentally discernible, which lends itself to

not only outright description, but to calculable and systematic reproduction.

...

3.1 Physicians’ training

Toward the end of understanding certain disruptions in quality at the level of physician

autonomy, it is informative to consider a generic American model of physician training. Such

begins as a rigorous academic process culminating in clinical experience and training. Arguably,

few other disciplines have a breadth of intellectual uniformity and consensus comparable to that

found in the hard sciences which ground all medical training: students of hard science not only

establish allegiance with a singular modern cell theory, a singular fossil record and Darwinian

evolution, Mendelian genetics, or a singular atomic theory, as examples, but their references to

such lack the subjective inflection regularly harbored outside of science.

This is different from economics, for example, where theories and antagonistic counter

theories indefinitely reside quite credibly and seriously together: Keynesian economics vs.

Friedman economics. It is different from jurisprudence, where legal code interpretations can be

affirmed in one court only to be reversed within the same justice system in the appellate court. It

is different from fine arts, where two artistic movements may be contemporaneously celebrated

as each the superior aesthetic contribution.

The body of science hinges on a perpetual process of evidence-based consensus-making,

representing a culmination of repeatable and peer-reviewed experimental outcomes, explanations

that lack counterexamples, and a growing residual of intelligence from iterations of the scientific

method. Over the course of the physician’s professional development, a substantial piece of their

knowledge base and default mode of critical analysis, is indelibly imprinted by the scientific

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method. While medical practice is assuredly part art, there remains significant similarity in

medical recommendations, given physician consensus about a particular obstruction to a

patient’s better health status, which permits medicine to yield a discernible quality.

For example, if it is accepted that a presenting patient is infected with the influenza virus

and is suffering from its symptoms, physicians will not prescribe antibiotics as a pharmaceutical

address or expectation to specifically eradicate the influenza virus from the body. This is a direct

consequence of an intellectual consensus attendant with the physicians’ academic and clinical

training: antibiotics do not eradicate viral diseases. While simplistic, this example can be

extended to a multitude of other health problems.

It is precisely because there exist streams of intellectual consensus in medicine, that

nonrandom departures from such are not only discernible and represent risks to the consistency

and quality with which medicine is practiced, but are departures worthy of analysis.

3.3 Bias in the medical perspective: Variances in treatment across patient groups

In the February 25, 1999 issue of The New England Journal of Medicine, the conclusions

of a study titled “The Effect of Race and Sex on Physicians’ Recommendations for Cardiac

Catheterization” [Schulman, et al.] read:

“Our findings suggest that the race and sex of a patient independently
influence how physicians manage chest pain.”7

This controlled experiment, using multivariable logistic-regression analyses, aimed to

assess physicians’ treatment recommendations to patients who presented with different types of

chest pain. Scientists who conducted the study hypothesized that patient race and sex

7
Schulman, K.A, The Effect of Race and Sex on Physicians’ Recommendations for Cardiac Catheterization, The
New England Journal of Medicine, Vol. 340, p. 618.

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independently influenced physicians’ recommendations regarding cardiac catheterization. The

degree to which physicians were responsible for variations in recommendations according to race

and sex had not been captured by previous studies. In the discussion of the study, researchers

reported:

“We found that the race and sex of the patient affected the physicians’ decisions
about whether to refer patients with chest pain for cardiac catheterization, even
after we adjusted for symptoms, the physicians’ estimates of the probability of
coronary disease, and clinical characteristics. Our findings are most striking for
black women…Our finding…may suggest bias on the part of the
physicians…Bias may represent overt prejudice on the part of physicians or, more
likely, …subconscious perceptions rather than deliberate actions or thoughts.
Subconscious bias occurs when a patient’s membership in a target group
automatically activates a cultural stereotype in the physician’s memory regardless
of the level of prejudice the physician has…[Our findings] suggest that decision
making by physicians may be an important factor in explaining differences in the
treatment of cardiovascular disease with respect to race and sex.”8

This study promotes contemplation on at least three critical issues in the care-rendering

process: it implies some complexities attendant with the arguably unique American challenge of

rendering quality care to a particularly heterogeneous American patient population by a

relatively homogeneous American physician population; it identifies one way that current

medical education, medical ethics, existing regulatory regimes, physician autonomy, and

personal aims for professional integrity leave care-rendering qualitatively different across

groups; and it introduces clear questions around the very nature of physician professionalism.

For American professionalism, the Schulman study renders some profound implications:

for it suggests that even in perhaps the oldest and most esteemed of our traditional professions

where the most critical goal of sustaining life and health resides; even given a training

methodology that incentivizes intellectual weddedness to the evidence-based, consensus-building

8
Ibid., p. 623-24.

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process of the scientific method; even after the lengthiest apprenticeship program for any of our

professions; even given the regulatory apparatus of licensing requirements and board

certifications; even including the deterrent of an ever increasing personal tax in the

professional’s compensation profile in the form of a malpractice insurance premium; even amidst

the threat of lost reputation---expensively and doggedly won---from a failure to practice

evidence-based medicine; and even as the physician population itself credibly purports to

represent a subset of the population intrinsically interested in the welfare of others; the Schulman

study says that somehow, at the end of this dense array of preparedness and quality control and

professional surveillance----somehow, at the ultimate event of physician care-rendering, the

cloak of professionalism that distinguishes the medical profession can be systematically set

aside. Biology succumbs to sociology.

On the matter of health status for American populations, we can wonder what systematic

variances in health status are maintained over time for disparate patient populations who seek

physician-rendered care. On the matter of professionalism generally and other contracted

relationships residing outside of the traditional professions, an expanded concern is this: the

likelihood of similar disparities in other arenas of professional conduct for which the academic

and apprenticeship training is far less a function of intellectual consensus, less regulated, less

rigorous, and shorter. We can speculate about comparable professional lapses between attorney

and client; judge and defendant; teacher and pupil; police officer and citizen; and corporate

boards and consumers and workforces.

While a unique study, the results from the New England Journal study which suggests the

existence of independent racial and gender influences upon physician-rendered care are not in

isolation. In a 1993 study of the influence of ethnicity upon patient-controlled analgesia (PCA),

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researchers concluded that narcotic prescriptions for post-operative pain were correlated with

patient ethnicity.9

According to a study reported in the 1994 Journal of the American Medical

Association, poor and black patients do appear to receive systematically different (inferior)

treatment. In the Journal of the American Medical Association the study reported that gravely ill

Medicare patients who are black and poor receive worse care than other equally sick Medicare

patients in every type of hospital in America. The finding suggests that the quality of medical

care may vary tremendously with a patient's race and not, as other studies have suggested, with

whether a person has insurance.10

On the one hand physician autonomy is a central component of high quality

physician-rendered care. It is also the arena in which data suggests that physicians face a curious

challenge. They must not abandon the scientific critical analysis that has enabled their role as an

informed professional for pressures from sociology, and must nonetheless, be attentive to the

sociology that is relevant to their act of rendering care.

9
“Using a retrospective record review, we examined data from all patients treated with PCA for post-operative pain
from January to June 1993. We excluded patients who did not have surgery prior to the prescription of PCA or were
not prescribed PCA in the immediate post-operative period….While there were no differences in the amount of
narcotic self-administered, there were significant differences in the amount of narcotic prescribed among Asians,
Blacks, Hispanics, and Whites…The ethnic differences in prescribed analgesic persisted after controlling for age,
gender, pre-operative use of narcotics, pain site, and insurance status. Patient's ethnicity has a greater impact on the
amount of narcotic prescribed by the physician than on the amount of narcotic self-administered by the patient.”--
Ng B., Dimsdale J.E., Rollnik J.D., Shapiro H, Department of Psychiatry, University of California at San Diego, La
Jolla. 92093-0804, USA. Pain. 66(1):9-12, 1996 Jul.
10
Blakeslee, S. reported in New York Times (Late New York Edition).Apr. 20 '94 p. B9

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