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A 2000 survey of residents in the Seattle area shows that one in five adult residents believe they have experienced discrimination in health care. One-sixth of African-Americans interviewed and nearly a tenth of all people of color reported discrimination in medical care settings in the previous year.
"I think if it’s happening here, it’s happening everywhere," says Michael Smyser, MPH, an epidemiologist with the Seattle and King County (WA) public health department and one of the study’s authors. "Other studies have shown that reports of differential treatment can’t be ascribed to education or income but [are] clearly about a person’s race. They are getting less rigorous treatment, treatment that isn’t of the same quality."
Smyser cites several investigations and literature reviews by Robert Mayberry, MD, MPH, PhD, director of Morehouse Medical Treatment Effectiveness Center at Morehouse School of Medicine in Atlanta, that show differential practices. Smyser adds that it seems natural his study found perceptions matched practice. "We are seeing it on both ends."
The King County study was a random survey of more than 1,500 King County residents that dealt with a variety of issues, including health care. Smyser says the percentages of people of color reporting discriminatory practices in health care settings were so disturbing that the public health department opted to look into it further. Fifty-one African-Americans were selected for in-depth interviews, and their reports have lessons for providers in clinics, private practices, and hospitals, he says.
The 51 people reported incidents at 30 facilities throughout King County, the 12th most populous county in the country with more than 1.5 million people. Among the findings (see table for breakdown of events):
• Many of the interviewees could cite more than one perceived incidence of discrimination.
• All felt the rude and/or differential treatment they received was racially motivated.
• The events were recent; about half of the 92 reports were less than 10 months old, and most were within the last two years.
• Most reported changing their health-seeking behaviors as a result of the events. Many avoid the health care institutions or even delay seeking health care.
And lest providers and health care facilities think they are immune because they don’t see a lot of indigent patients, Smyser says more than half of the interviewees had private medical insurance, and a similar number were college graduates or had some college education. "Interviewees who were college graduates and who had private insurance reported many of the more severe events," the study notes.
Table: Description of Discrimination Events
Number of Events
Percent of Total Events
|Event by Provider/Facility Type|
|Medical center outpatient||12||15.4|
|Urgent care center||3||3.8|
|Personnel involved in event|
|Front desk staff||18||23.1|
|Type of perceived discrimination|
|Perceived negative attitude||36||46.2|
|Treated as dumb||22||28.2|
|Made to wait||13||16.7|
|Inflicted unnecessary pain||5||6.4|
|Note: Multiple responses allowed in each category.|
|Source: Racial Discrimination in Health Care Interview Project, Public Health — Seattle & King County, WA.|
The findings are divided into several categories:
• Receiving differential treatment. Respondents said they were treated as if they didn’t matter or differently than Caucasian patients. One respondent who had differential treatment on two successive visits took a 15-mile detour to obtain care at a different location.
• Experiencing negative attitudes. People interviewed reported being treated rudely, being treated as if the patient smelled, not being looked at, and being disregarded. The behavior was not seen as hostile but as uncaring. Many respondents used the term "belittled" in describing their experiences, or reported that the physicians weren’t interested in what they were saying.
• Being made to feel stupid. Several patients reported that physicians described problems or treatments slowly, as if they were not intelligent or were unable to care for their children.
• Being ignored. Some respondents reported that in an emergency department setting, they were made to wait a long time or ignored when they asked for help.
• Being accused of drug abuse. Two patients said they were accused of using drugs. In neither case was the patient a drug user, and both were shocked by the accusations. In one instance, a nurse told a hospitalized respondent, "I know you shoot dope." The other reported a physician wanted to know if the patient always asked for specific drugs. "He treated me as if I were drug shopping."
• Experiencing perceived racist remarks. One respondent, a registered nurse, reported that she was told her daughter’s condition, asthma, was "an African-American thing." One patient who asked for a sedative during a breast biopsy was refused pain medication and told "you people accepted pain as part of slavery because you tolerate pain so well." A nurse told one woman who had come in for a scheduled appointment at a major medical center that "you people never make appointments. You want to come in whenever you want." Another respondent was told by an attending physician that, "being a typical black woman, I bet you haven’t dieted in over 20 years."
In the most serious incident reported, a hospital refused to treat an unconscious patient. Family members overheard some racial comments during the event. They sued and won their case. The hospital admitted the treatment was denied based on race and fired the physician, a physician’s assistant, and a nurse. The event, which occurred three years ago, still causes distress to the family.
The study authors admit that it is difficult to determine how many of the events were racially motivated, but all the interview subjects perceived the events that way. About 85% of them were shocked by the incident that occurred, indicating they weren’t predisposed to expect discriminatory behavior. Half the time, the patients made a complaint, although in only 9% of the cases was it a written complaint. In two-thirds of the cases, the perpetrators were providers.
"In a health care setting, people feel vulnerable and want good advice," says Smyser. "We like to take it for granted that we provide that. But we find a significant number of minority residents feel they are treated differently, discriminated against, or treated rudely. And it goes beyond all of our frustrations with managed care. We might want to blame it on limited time or say that everyone is ruder these days. But it is more than that. Patients see themselves treated one way and other people treated another. And the stories most frequently come from people of color." Smyser says the interviews spawned several community forums that led to specific recommendations to improve the situation.
Tom Lonner, PhD, the research manager at the Cross Cultural Health Care Program in Seattle — the organization conducting the interviews for the public health department — says one of the toughest things about dealing with discriminatory behavior is that changing person-to-person interactions is more difficult than doing something concrete, such as hiring interpreters to ease interactions between those with limited English skills and their providers.
At the U.S. Department of Health and Human Services, Office for Civil Rights, research analyst Lisa Evans, JD, sees the same problem. "We can go in and look for documents in multiple languages, or look for signs posted in other languages," she says. "That’s easy. But how do you find evidence that someone is culturally competent?"
Lonner says facilities need to make a commitment to address the problems throughout their organizations. For instance, Harborview Medical Center, a regional trauma center in Seattle, has several of its departments working on cultural competency, Lonner says. "And those parts are doing a great job, but the notion of cultural competency doesn’t pervade the whole institution."
It will take a social movement to solve the problem, says Lonner. "Right now, we are talking to one organization at a time. There just isn’t a critical mass."