Skip Navigation
American College of Physicians Logo
  • Subscribe
  • Submit a Manuscript
  • Sign In
    Sign in below to access your subscription for full content
    INDIVIDUAL SIGN IN
    Sign In|Set Up Account
    You will be directed to acponline.org to register and create your Annals account
    INSTITUTIONAL SIGN IN
    Open Athens|Shibboleth|Log In
    Annals of Internal Medicine
    SUBSCRIBE
    Subscribe to Annals of Internal Medicine.
    You will be directed to acponline.org to complete your purchase.
Annals of Internal Medicine Logo Menu
  • Latest
  • Issues
  • Channels
  • CME/MOC
  • In the Clinic
  • Journal Club
  • Web Exclusives
  • Author Info
Advanced Search
  • ‹ PREV ARTICLE
  • This Issue
  • NEXT ARTICLE ›
Ideas and Opinions |3 August 2004

Will Racial and Ethnic Disparities in Health Be Resolved Primarily Outside of Standard Medical Care? Free

Theodore Pincus, MD

Theodore Pincus, MD
From Vanderbilt University Medical Center, Nashville, Tennessee.

Article, Author, and Disclosure Information
Author, Article, and Disclosure Information
  • From Vanderbilt University Medical Center, Nashville, Tennessee.

    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, t.pincus@vanderbilt.edu.

×
  • ‹ PREV ARTICLE
  • This Issue
  • NEXT ARTICLE ›
Jump To
  • Full Article
  • FULL ARTICLE
  • FULL ARTICLE
      1. References
  • Figures
  • Tables
  • Supplements
  • Audio/Video
  • Summary for Patients
  • Clinical Slide Sets
  • CME / MOC
  • Comments
  • Twitter Link
  • Facebook Link
  • Email Link
More
  • LinkedIn Link
  • CiteULike Link
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.

References

  1. Racial and ethnic disparities in health care. A position paper of the American College of Physicians.
    Ann Intern Med
    2004
    141
    226
    32
    CrossRef
    PubMed
  2. Engel
    GL
    .  
    The need for a new medical model: a challenge for biomedicine.
    Science
    1977
    196
    129
    36
    PubMed
    CrossRef
    PubMed
  3. Pincus
    T
    ,  
    Esther
    R
    ,  
    DeWalt
    DA
    ,  
    Callahan
    LF
    .  
    Social conditions and self-management are more powerful determinants of health than access to care.
    Ann Intern Med
    1998
    129
    406
    11
    CrossRef
    PubMed
  4. Marmot
    MG
    ,  
    Rose
    G
    ,  
    Shipley
    M
    ,  
    Hamilton
    PJ
    .  
    Employment grade and coronary heart disease in British civil servants.
    J Epidemiol Community Health
    1978
    32
    244
    9
    PubMed
    CrossRef
    PubMed
  5. Pincus
    T
    ,  
    Callahan
    LF
    ,  
    Burkhauser
    RV
    .  
    Most chronic diseases are reported more frequently by individuals with fewer than 12 years of formal education in the age 18-64 United States population.
    J Chronic Dis
    1987
    40
    865
    74
    PubMed
    CrossRef
    PubMed
  6. Guralnik
    JM
    ,  
    Land
    KC
    ,  
    Blazer
    D
    ,  
    Fillenbaum
    GG
    ,  
    Branch
    LG
    .  
    Educational status and active life expectancy among older blacks and whites.
    N Engl J Med
    1993
    329
    110
    6
    PubMed
    CrossRef
    PubMed
  7. Peterson
    ED
    ,  
    Shaw
    LK
    ,  
    DeLong
    ER
    ,  
    Pryor
    DB
    ,  
    Califf
    RM
    ,  
    Mark
    DB
    .  
    Racial variation in the use of coronary-revascularization procedures. Are the differences real? Do they matter?
    N Engl J Med
    1997
    336
    480
    6
    PubMed
    CrossRef
    PubMed
  8. Ibrahim
    SA
    ,  
    Siminoff
    LA
    ,  
    Burant
    CJ
    ,  
    Kwoh
    CK
    .  
    Understanding ethnic differences in the utilization of joint replacement for osteoarthritis: the role of patient-level factors.
    Med Care
    2002
    40
    I44
    51
    PubMed
    CrossRef
    PubMed
  9. Boulware
    LE
    ,  
    Ratner
    LE
    ,  
    Cooper
    LA
    ,  
    Sosa
    JA
    ,  
    LaVeist
    TA
    ,  
    Powe
    NR
    .  
    Understanding disparities in donor behavior: race and gender differences in willingness to donate blood and cadaveric organs.
    Med Care
    2002
    40
    85
    95
    PubMed
    CrossRef
    PubMed
  10. Ross
    CE
    ,  
    Mirowsky
    J
    .  
    Does medical insurance contribute to socioeconomic differentials in health?
    Milbank Q
    2000
    78
    291
    321, 151-2
    PubMed
    CrossRef
    PubMed
  11. Pappas
    G
    ,  
    Queen
    S
    ,  
    Hadden
    W
    ,  
    Fisher
    G
    .  
    The increasing disparity in mortality between socioeconomic groups in the United States, 1960 and 1986.
    N Engl J Med
    1993
    329
    103
    9
    PubMed
    CrossRef
    PubMed
  12. Rogers
    RG
    .  
    Living and dying in the U.S.A.: sociodemographic determinants of death among blacks and whites.
    Demography
    1992
    29
    287
    303
    PubMed
    CrossRef
    PubMed
  13. Keppel
    KG
    ,  
    Pearcy
    JN
    ,  
    Wagener
    DK
    .  
    Trends in racial and ethnic-specific rates for the health status indicators: United States, 1990-98.
    Healthy People 2000 Stat Notes
    2002
    23
    1
    16
    PubMed
  14. Ackerknecht
    EH
    .  
    Rudolph Virchow: Doctor, Statesman, Anthropologist.
    Madison
    Univ of Wisconsin Pr
    1953

Clinical Slide Sets

Terms of Use

The In the Clinic® slide sets are owned and copyrighted by the American College of Physicians (ACP). All text, graphics, trademarks, and other intellectual property incorporated into the slide sets remain the sole and exclusive property of the ACP. The slide sets may be used only by the person who downloads or purchases them and only for the purpose of presenting them during not-for-profit educational activities. Users may incorporate the entire slide set or selected individual slides into their own teaching presentations but may not alter the content of the slides in any way or remove the ACP copyright notice. Users may make print copies for use as hand-outs for the audience the user is personally addressing but may not otherwise reproduce or distribute the slides by any means or media, including but not limited to sending them as e-mail attachments, posting them on Internet or Intranet sites, publishing them in meeting proceedings, or making them available for sale or distribution in any unauthorized form, without the express written permission of the ACP. Unauthorized use of the In the Clinic slide sets will constitute copyright infringement.

This feature is available only to Registered Users

Subscribe/Learn More
Submit a Comment

0 Comments

PDF
Not Available
Citations
Citation

Pincus T. Will Racial and Ethnic Disparities in Health Be Resolved Primarily Outside of Standard Medical Care?. Ann Intern Med. ;141:224–225. doi: 10.7326/0003-4819-141-3-200408030-00014

Download citation file:

  • Ris (Zotero)
  • EndNote
  • BibTex
  • Medlars
  • ProCite
  • RefWorks
  • Reference Manager

© 2019

×
Permissions

Published: Ann Intern Med. 2004;141(3):224-225.

DOI: 10.7326/0003-4819-141-3-200408030-00014

©
2004 American College of Physicians
4 Citations

See Also

From Unequal Treatment to Quality Care
The Patient's Role in Reducing Disparities
Diversifying the Racial and Ethnic Composition of the Physician Workforce
Racial and Ethnic Disparities in Health Care: A Position Paper of the American College of Physicians
View MoreView Less

Related Articles

Racial Disparities in Colon Cancer Survival: A Matched Cohort Study
Annals of Internal Medicine; 161 (12): 845-854
Prevalence of Advanced Colorectal Neoplasia in White and Black Patients Undergoing Screening Colonoscopy in a Safety-Net Hospital
Annals of Internal Medicine; 159 (1): 13-20
Recommendations for Teaching about Racial and Ethnic Disparities in Health and Health Care
Annals of Internal Medicine; 147 (9): 654-665
Inequality in Health Care: Unjust, Inhumane, and Unattended!
Annals of Internal Medicine; 141 (10): 815-817
View MoreView Less

Journal Club

Guideline: USPSTF recommends against menopausal estrogen for primary prevention of chronic conditions
Annals of Internal Medicine; 168 (6): JC26
Review: In older patients with chronic disease, transitional care reduces mortality and readmissions
Annals of Internal Medicine; 167 (6): JC32
Review: Exercise interventions reduce anxiety in patients with chronic illness
Annals of Internal Medicine; 152 (12): JC6-4
Care coordination for patients with chronic conditions did not reduce hospitalizations or Medicare costs
Annals of Internal Medicine; 150 (12): JC6-14
View MoreView Less

Related Topics

Healthcare Delivery and Policy

Healthcare Delivery and Policy.

PubMed Articles

[Long-term results of chest wall arteriovenous graft for establishing hemodialysis access].
Zhongguo Xiu Fu Chong Jian Wai Ke Za Zhi 2019;33(2):227-231.
Physiologically-Based Pharmacokinetic Modelling to Predict Exposure Differences in Healthy Volunteers and Subjects with Renal Impairment: Ceftazidime Case Study.
Basic Clin Pharmacol Toxicol 2019.
View More

Results provided by: PubMed

CME/MOC Activity Requires Users to be Registered and Logged In.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
The Comments Feature Requires Users to be Registered and Logged In.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
link to top

Content

  • Home
  • Latest
  • Issues
  • Channels
  • CME/MOC
  • In the Clinic
  • Journal Club
  • Web Exclusives

Information For

  • Author Info
  • Reviewers
  • Press
  • Readers
  • Institutions / Libraries / Agencies
  • Advertisers

Services

  • Subscribe
  • Renew
  • Alerts
  • Current Issue RSS
  • Latest RSS
  • In the Clinic RSS
  • Reprints & Permissions
  • Contact Us
  • Help
  • About Annals
  • About Mobile
  • Patient Information
  • Teaching Tools
  • Annals in the News
  • Share Your Feedback

Awards and Cover

  • Personae (Cover Photo)
  • Junior Investigator Awards
  • Poetry Prize

Other Resources

  • ACP Online
  • Career Connection
  • ACP Advocate Blog
  • ACP Journal Wise

Follow Annals On

  • Twitter Link
  • Facebook Link
acp link acp
silverchair link silverchair

Copyright © 2019 American College of Physicians. All Rights Reserved.

Print ISSN: 0003-4819 | Online ISSN: 1539-3704

Privacy Policy

|

Conditions of Use

This site uses cookies. By continuing to use our website, you are agreeing to our privacy policy. | Accept
×

You need a subscription to this content to use this feature.

×
PDF Downloads Require Access to the Full Article.
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
INSTITUTIONAL SIGN IN
Open Athens|Shibboleth|Log In
Annals of Internal Medicine
PURCHASE OPTIONS
Buy This Article|Subscribe
You will be redirected to acponline.org to sign-in to Annals to complete your purchase.
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×
Access to this Free Content Requires Users to be Registered and Logged In. Please Choose One of the Following Options
Sign in below to access your subscription for full content
INDIVIDUAL SIGN IN
Sign In|Set Up Account
You will be directed to acponline.org to register and create your Annals account
Annals of Internal Medicine
CREATE YOUR FREE ACCOUNT
Create Your Free Account|Why?
To receive access to the full text of freely available articles, alerts, and more. You will be directed to acponline.org to complete your registration.
×