Talmadge E. King, MD; Margaret B. Wheeler, MD
Potential Financial Conflicts of Interest: None disclosed.
Requests for Single Reprints: Talmadge E. King Jr., MD, San Francisco General Hospital, Room 5H22, 1001 Potrero Avenue, San Francisco, CA 94110; e-mail, email@example.com.
Current Author Addresses: Dr. King: San Francisco General Hospital, Room 5H22, 1001 Potrero Avenue, San Francisco, CA 94110. Dr. Wheeler: University of California, San Francisco, 1001 Potrero Avenue, San Francisco, CA 94110.
King T., Wheeler M.; Inequality in Health Care: Unjust, Inhumane, and Unattended!. Ann Intern Med. 2004;141:815-817. doi: 10.7326/0003-4819-141-10-200411160-00015
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Published: Ann Intern Med. 2004;141(10):815-817.
The reputation and integrity of American medicine have been sullied. A striking 60% of Americans are unsatisfied with the health care system (1). Our system is unsafe—preventable deaths in hospitals exceed deaths attributable to such feared threats as motor vehicle accidents or AIDS (2). Physicians and medical institutions are mistrusted, with widespread concern that entanglements among physicians, health centers, and big businesses (managed care companies and the pharmaceutical industry) motivate physicians to act out of interests other than their patients' well-being (3, 4). Despite being the most expensive health care system in the world (1), the U.S. health care system fails to provide care to all our citizens and the care actually delivered is substandard (5).
University of Iowa
November 28, 2004
Quality and Equality in Health Care: The Role of Race.
The editorial by King and Wheeler (1) is a sweeping indictment of health care system and medical professionals in United States. The authors selectively site studies that point out the weaknesses of US health care system and, without any intellectual hesitation, brand our present system as substandard, dangerous, unjust, racially biased, and inhumane. According to the authors, in addition to the above mentioned ills, our health care delivery system has lost the trust of the public and is viewed by them as corrupt. The authors are entitled to their view but an editorial in a reputed journal like Annals of Internal Medicine should be more balanced.
The components of high quality care are adequate access to health care, adequate scientific knowledge, competent health care providers, separation of financial and clinical decisions, and organization of health care institutions to maximize quality (2). The authors should have examined these factors in a systematic manner to examine the issue of race, access to health care, and quality. Undoubtedly, race is an important factor while assessing access to health care. The Institute of Medicine Report "Unequal Treatment" (3) is an objective effort to evaluate potential sources of racial and ethnic disparities in health care and the report provides specific recommendations to remove the health care disparities. Instead of taking a similar constructive problem-solving attitude, the authors started with the idea that US health care professionals are racially biased, either consciously or at a subconscious level. For that reason, they argue that the physicians are primarily responsible for perpetuating this disparity. The authors make the mistake of considering physicians as a homogenous group in terms of race, region, practice setting, and political belief. The idea that we need a medical care team to second-guess every physician decision-making process and scrutinize all medical decisions for signs of racial bias is a direct challenge to patient-physician relationship and physician autonomy. There is no scientific proof that such an effort will lead to better outcome.
The issue of disparities in health and health care is more complex than what the authors will like us to believe. Nations with universal health insurance systems that have greatly reduced the disparity in access to care continue to have disparities in health status among socio-economic classes and racial groups (4). Clearly there is a need for more debate and scientific examination of this issue. However, I can not accept the fact that US health care system is inherently unjust, or the patients in US routinely receive substandard care. In fact, US remains world leader in medical education, medical research, and vast majority of patients here receive care that is envy of the rest of the world.
References 1. King TE Jr, Wheeler MB. Inequality in health care: unjust, inhumane, unattended!Ann Intern Med. 2004;141:815-17. 2. Bodenheimer T, Grumbach K. Access to Health Care. In: Bodenheimer T, Grumbach K, eds. Understanding Health Policy: A Clinical Approach. 3rd ed. New York: McGraw-Hill, 2002:15-32. 3. Institute of Medicine. Unequal treatment: confronting racial and ethnic disparities in health care. Washington (DC): The National Academies Press; 2003. 4. Susser M. Health as a human right: An epidemiologist's perspective on the public health. Am J Public Health. 1993; 83:418-26.
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