Theodore Pincus, MD
Acknowledgment: The author thanks Darren DeWalt for helpful discussions.
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Theodore Pincus, MD, Division of Rheumatology/Immunology, Vanderbilt University Medical Center, 203 Oxford House, Box 5, Nashville, TN 37232-4500; e-mail, email@example.com.
Pincus T. Will Racial and Ethnic Disparities in Health Be Resolved Primarily Outside of Standard Medical Care?. Ann Intern Med. 2004;141:224-225. doi: 10.7326/0003-4819-141-3-200408030-00014
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Published: Ann Intern Med. 2004;141(3):224-225.
I agree with almost every point in the position paper (1), including the 6 fronts addressed: increased access to quality health care, patient care, provider issues, systems that deliver health care, societal concerns, and continued research. The first 2 fronts, however, present a “physician-centric” perspective, which implies that the major advances to eliminate racial and ethnic health disparities will emerge from one-on-one encounters in the examination room. This view reflects a “biomedical model” paradigm (2), in which physicians, rather than patients or the society, are responsible for good health. This model is spectacularly successful in high-intensity, acute medical care, the setting of most medical education and training, but has many limitations when applied to general health and chronic diseases.
Perhaps the most convincing evidence of limitations of the biomedical paradigm is seen in the strong associations of socioeconomic status and health (3). Job classification predicted cardiovascular mortality more effectively than cholesterol level, hypertension, or smoking in London civil servants, all of whom had access to the National Health Service (4). In the United States, people who do not complete high school have a substantially higher prevalence of cardiovascular, gastrointestinal, pulmonary, renal, and musculoskeletal disease (but not most types of cancer, allergies, thyroid disease, or multiple sclerosis) compared with high school graduates (5). Sociodemographic factors explain in large part, although not entirely, the higher mortality rates in black people compared with white people (6). The health status of educated minorities is far closer to that of the educated white population than to that of poor minorities. Conversely, poor white populations and poor minorities have similar but lower health status. These relationships are largely independent of access to medical services (6).
One important limitation of the biomedical model is an underlying assumption that patients with access to needed resources will implement any recommended evaluation and therapy on the basis of medical necessity. However, experienced physicians recognize that most patients often do not implement what might be best for their health. Lower rates in black patients than in white patients of adherence to recommendations for angioplasty and coronary bypass surgery (7), joint replacement surgery (8), and willingness to donate blood or cadaveric kidneys (9) are explained at least as much by belief systems, mistrust, and religion as by limited access to these interventions. These and many other observations suggest that patient self-management and social conditions appear to be as important as actions of health professionals in determining long-term health (3). Furthermore, according to strong evidence, medical insurance minimally contributes to eradicating socioeconomic differences in health (10). Indeed, health disparities have widened over the past 3 to 5 decades despite the National Health Service in the United Kingdom, Medicaid in the United States, and other measures (3, 11, 12), as acknowledged in the position paper (1), which cited a report by the Centers for Disease Control and Prevention (13).
The latter 4 fronts in the position paper present more promise. Provider issues are important. Surely, all physicians could improve their capacities to communicate with patients about beliefs that lead to poor choices about health behaviors and health care. Systems that deliver comprehensive health care by providing transportation to the site of care, patient education, and other services might improve the health outcomes that we currently achieve. Societal concerns that transcend the examination room may be crucial—for example, expenditures on new school textbooks may advance health more than a new magnetic resonance imaging scanner.
We need to think beyond a biomedical model toward a biopsychosocial model (2). Research should help us to understand the true causes of disparities in the health of patients of minority or low socioeconomic status so that we can move beyond our well-intentioned but often oversimplified thinking that improved access and higher-quality medical care are the primary arenas for important progress. As greater insights are gained into underlying causes of disparities, our definition of quality will incorporate more ideas from a biopsychosocial model (2, 3), which recognizes the importance of social conditions and community effects on health outcomes.
Rudolf Virchow, the founder of modern cellular pathology as a cornerstone of the biomedical model, said more than 150 years ago that “the improvement of medicine would eventually prolong human life, but improvement of social conditions could achieve this result now more rapidly and more successfully” (14). He also said that “the physicians are the natural attorneys of the poor, and the social problems should largely be solved by them.” These prescient ideas suggest that returning to our roots as “healers,” in the largest sense of the word, may lead to real progress toward reducing disparities in health due to minority or low socioeconomic status. I hope that the pages of this journal will become a forum for new ideas and approaches and that we will look back on this ACP position paper as opening a new chapter in medical care.
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