A crucial issue in healthcare policy is: what should the underlying structure of our (in my case the U.S.) healthcare system be? Should it be a pure government run socialist-style single payer system with no private option; or should it be essentially a free market in which healthcare providers and patients enter into voluntary contracts to exchange healthcare services for money or other wealth; or should it be some combination of both? An example of the latter might be the UK, which, besides its beloved NHS, also has a system of private doctors and clinics (e.g. on London's "Harley Street") that provide services in exchange for "cash on the barrel head", and sometimes can do so better and/or faster than the NHS even for patients of modest means.
Note that any system that permits patients to purchase healthcare services (or insurance) with their own money could be classified by some people (particularly but not only DEI adherents) as "racist", since it would allow wealthy people to access better healthcare than poor people, and race, ethnicity, gender, etc. correlate with wealth. Of course those with more money don't always spend it wisely, but it's reasonable to guess that on average they will.
I'm new to this newsletter, so I don't know to what extent this issue has been addressed in previous articles and comments.
Appreciate the article. I think the best way to reduce healthcare disparities would be to expand the Community Health Center model (working in concert with programs like National Health Service Corp, to incentivize young doctors to work in high need areas while helping reduce medical school debt). Make healthcare available in high need areas & then do further research into groups that have access to it, but choose not to utilize it.
As a physician, I am thankful that there are still physicians, medical school professors even, who will echo the truth stated in this article. Say it out loud! Someday, future generations will ask what the %&*! we were thinking when we ignored longstanding moral precepts to chase morally suspect ideologies.
This is an excellent piece (absent the introduction). The mantra has reached absurd levels. I am a hematologist (full professor) in a medical school, but we are (literally) not allowed to note that sickle cell anemia is more prevalent (far, far more prevalent) in black patients. We cannot go through the permutations of beta-thalassemia disproportionately impacting southern Europeans/Italians. I am a rare voice that makes the "It's only about the patients" speech literally daily -- and patients are one by one, never group by group. As vonEye pointed out years ago, if you know everything about every individual you know everything about the group. If you know everything about the group, you know NOTHING about any individual.
THAT is what we need to be teaching our students. Thanks for publishing this. Wish it had broader exposure, but I am sending it around to other medical schools.
Very good article. That the AMA would issue a directive for physicians to "dismantle racism" is a good illustration of the reason only a very small percentage of physicians ever join up or contribute to that collection of pompous windbags. It irritates me no end when the popular press quotes the AMA on some issue and implies that what they say is representative of doctors in general. I have to question the first paragraph in the introduction to the article. I could be wrong, but I suspect that disparities in mortality rates and other medical statistics may be more due to socioeconomic status rather than racism.
Ah yes, but I think adherents of DEI ideology would claim that the lower socioeconomic status of "disadvantaged groups" is also due to racism, which is continuously practiced by a single big conspiracy of racists, be they physicians, police officers, employers, or whoever.
No doubt they would. Some of those racists might even say that the low percentage of two parent families might be a factor. Thomas Sowell, for example.
True, and I'm a fan of Thomas Sowell. On the other hand, DEI would say that the dearth of two parent families is another consequence of 400+ years of racist policies.
They would say that, but they would be wrong. Sowell has written about how the two parent family was common in the black community when he was young but has eroded considerably due to the promotion of the welfare state.
I tend to agree with you and Sowell that the modern welfare state provides incentives for women to bear and raise children out of wedlock. But the relatively recent advent of those welfare state policies falls within the "400+ years of racist policies" I referred to. DEI believes that historical and current racism is at fault for nearly everything that has gone wrong in the black community, and any suggestion to the contrary amounts to "blaming the victim".
Continuing my reply above: That's the crucial issue: to what extent are the "victims" responsible for fixing themselves and their communities, regardless of what society may have done to them in the past?
“As for closing health gaps, the American Medical Association’s directive that physicians “dismantle racism” is unworkable.”
As soon as race or culture are a primary factor for triage the ability for unbiased care goes out the window. Sure, we have our own biases, and THAT is what’s important to address. Not the BAD OLD SINFUL HORRIBLE USA. I used to actually spend more time with my non white patients because culturally, many were afraid to ask for acute pain meds. I made sure we addressed this as a team and people were able to be more free to be egalitarian in their own care. The craziest things I saw during my time were addicts who were stable on methadone who, after an acute injury, were deemed OVERMEDICATED on their methadone dose. I had to teach a lot of people that their use was baseline. What we need is an ability to check our own biases without the BS DEI agenda and provide care to every single patient who comes our way. For EACH INDIVIDUAL. Rant over.
I wish I could give this article more than 1 “like”.
The entirety of “equity” (equality of outcomes) is patently stupid on its face. And anyone who advocates for equity, I now consider stupid until proven otherwise.
One of the many problems with “equity” folk is that they are unserious people when it comes to doing the hard work. Using your example about “more blacks being restrained in ER”, the actual solution is upstream of the “lipstick on pig” answer of simply restraining black patients less frequently; it requires discerning why black patients tend to be more frequently agitated, and hence in need of restraint; then offering a solution to those manifold causes of agitation among black patients such that, in time, their need for restraints matches overall population averages. It’s hard work. It won’t happen overnight. And the “equity” folk are simply too stupid and too lazy to do it.
The examples from this OP are a microcosm of the reasons why the entire DEI framework that has infected society in the last 10-15 years needs to go the way of the Dodo.
Something that no one wants to mention here is genetics. Some disparities in outcomes could simply be genetic. I feel like the only times people are willing to admit genetics has an effect is alcoholism in Native American populations and lower vitamin D in dark-skinned people. It's not racism to acknowledge that different races will have different outcomes for any disease or responses to a medication even if everything else (location, income, diet etc.) is the same.
it should be named un-critical theory. The all-too-common proceeding is to observe a disparity and infer racism as the cause without any empirical investigation that might elucidate actual causes whether of what brought the disparity about or of what perpetuates it. That the medical literature now commonly takes this approach is deplorable; as are the deeply immoral prescriptions that often follow the unwarranted diagnosis
Let me say out loud what was supposed to be unspoken. The disparities are due to corrosive cultural factors. Could this have some root in past oppression? Perhaps. But betterment can only come from the inside. Victimhood will not solve the problems. There.
Great piece that would never see daylight in msm. Free speech, verified facts, use of scientific method for deep analysis and turning off agendas is the answer to sound public policy.
“As a physician, my care for patients has nothing at all to do with the relative health of groups. The only gap that concerns me is the discrepancy between a patient’s current and optimal health. This should be our guiding philosophy more broadly: improved access to quality care for the sickest and underserved, across the board.”
This should have been your opening line. Physicians and our system have moved away from this idea, and our patients are the ones who lose.
Critical theory holds that a disparity among outcomes is due to systemic racism, sexism, ableism, etc. The author describes a couple of supposed examples in medicine.
This rationale is utterly wrong. For example, look at life expectancy in the USA. Women outlive men by six years. If believers in CT were consistent, then they'd be ranting about the grave injustice that 'men are victims of systemic sexism in all the factors that contribute to life expectancy'. (Note that black women outlive white men by about a year.)
Along these lines- what about the damage done to people that aren’t viewed as marginalized. I worked at a prominent hospital in a Peds ICU… a very smart ICU physician/ ICU diversity lead, who is also a friend and is brown.. has bought into the oppressor/ oppressed narrative so much so that it consumes every social media post she has. Many of these posts talk about how white people are oppressors and always oppressors and will never understand anything brown/ black people go through… if we are going by bias being a main predictor of how you take care of patients- I certainly wouldn’t want a physician saying things like this to take care of my white child…. But it has never been called into question…
Also- a different hospital. A friend who is a hospital administrator (he is a POC also) called me one day and was furious that one of the new POC Peds surgery attending was treated poorly and he thought it was due to racism (he wasn’t at the event and he has never done clinical work- and is not a clinician). I asked what happened. He said a code in the CVICU occurred ( the child was not doing well at all) and an icu attending yelled at this surgery attending and asked why this person was in the room. The icu attending had never met the new attending and didn’t apparently didn’t know why they were there. All icu people know you want a controlled room with the minimum amount of people there to do the job well. It’s not appropriate to yell at people,.. but tensions are high when a life is literally on the line. This administrator made up the racism part of the story with no details/ data . The surgery attending hadn’t even told him that they were worried about racism. This is the type of stuff that happens when we fill our heads with this stuff. This administrator told a group of other admins he thought this was the reason this person was treated badly with no evidence and wasn’t there. He wanted to provide disciplinary action - to me this is crazy.
A crucial issue in healthcare policy is: what should the underlying structure of our (in my case the U.S.) healthcare system be? Should it be a pure government run socialist-style single payer system with no private option; or should it be essentially a free market in which healthcare providers and patients enter into voluntary contracts to exchange healthcare services for money or other wealth; or should it be some combination of both? An example of the latter might be the UK, which, besides its beloved NHS, also has a system of private doctors and clinics (e.g. on London's "Harley Street") that provide services in exchange for "cash on the barrel head", and sometimes can do so better and/or faster than the NHS even for patients of modest means.
Note that any system that permits patients to purchase healthcare services (or insurance) with their own money could be classified by some people (particularly but not only DEI adherents) as "racist", since it would allow wealthy people to access better healthcare than poor people, and race, ethnicity, gender, etc. correlate with wealth. Of course those with more money don't always spend it wisely, but it's reasonable to guess that on average they will.
I'm new to this newsletter, so I don't know to what extent this issue has been addressed in previous articles and comments.
Appreciate the article. I think the best way to reduce healthcare disparities would be to expand the Community Health Center model (working in concert with programs like National Health Service Corp, to incentivize young doctors to work in high need areas while helping reduce medical school debt). Make healthcare available in high need areas & then do further research into groups that have access to it, but choose not to utilize it.
As a physician, I am thankful that there are still physicians, medical school professors even, who will echo the truth stated in this article. Say it out loud! Someday, future generations will ask what the %&*! we were thinking when we ignored longstanding moral precepts to chase morally suspect ideologies.
This is an excellent piece (absent the introduction). The mantra has reached absurd levels. I am a hematologist (full professor) in a medical school, but we are (literally) not allowed to note that sickle cell anemia is more prevalent (far, far more prevalent) in black patients. We cannot go through the permutations of beta-thalassemia disproportionately impacting southern Europeans/Italians. I am a rare voice that makes the "It's only about the patients" speech literally daily -- and patients are one by one, never group by group. As vonEye pointed out years ago, if you know everything about every individual you know everything about the group. If you know everything about the group, you know NOTHING about any individual.
THAT is what we need to be teaching our students. Thanks for publishing this. Wish it had broader exposure, but I am sending it around to other medical schools.
Thanks so much Dr K for your words and for your sending it around.
best
Sally
Very good article. That the AMA would issue a directive for physicians to "dismantle racism" is a good illustration of the reason only a very small percentage of physicians ever join up or contribute to that collection of pompous windbags. It irritates me no end when the popular press quotes the AMA on some issue and implies that what they say is representative of doctors in general. I have to question the first paragraph in the introduction to the article. I could be wrong, but I suspect that disparities in mortality rates and other medical statistics may be more due to socioeconomic status rather than racism.
Ah yes, but I think adherents of DEI ideology would claim that the lower socioeconomic status of "disadvantaged groups" is also due to racism, which is continuously practiced by a single big conspiracy of racists, be they physicians, police officers, employers, or whoever.
No doubt they would. Some of those racists might even say that the low percentage of two parent families might be a factor. Thomas Sowell, for example.
True, and I'm a fan of Thomas Sowell. On the other hand, DEI would say that the dearth of two parent families is another consequence of 400+ years of racist policies.
They would say that, but they would be wrong. Sowell has written about how the two parent family was common in the black community when he was young but has eroded considerably due to the promotion of the welfare state.
I tend to agree with you and Sowell that the modern welfare state provides incentives for women to bear and raise children out of wedlock. But the relatively recent advent of those welfare state policies falls within the "400+ years of racist policies" I referred to. DEI believes that historical and current racism is at fault for nearly everything that has gone wrong in the black community, and any suggestion to the contrary amounts to "blaming the victim".
Continuing my reply above: That's the crucial issue: to what extent are the "victims" responsible for fixing themselves and their communities, regardless of what society may have done to them in the past?
Such a great article.
“As for closing health gaps, the American Medical Association’s directive that physicians “dismantle racism” is unworkable.”
As soon as race or culture are a primary factor for triage the ability for unbiased care goes out the window. Sure, we have our own biases, and THAT is what’s important to address. Not the BAD OLD SINFUL HORRIBLE USA. I used to actually spend more time with my non white patients because culturally, many were afraid to ask for acute pain meds. I made sure we addressed this as a team and people were able to be more free to be egalitarian in their own care. The craziest things I saw during my time were addicts who were stable on methadone who, after an acute injury, were deemed OVERMEDICATED on their methadone dose. I had to teach a lot of people that their use was baseline. What we need is an ability to check our own biases without the BS DEI agenda and provide care to every single patient who comes our way. For EACH INDIVIDUAL. Rant over.
I wish I could give this article more than 1 “like”.
The entirety of “equity” (equality of outcomes) is patently stupid on its face. And anyone who advocates for equity, I now consider stupid until proven otherwise.
One of the many problems with “equity” folk is that they are unserious people when it comes to doing the hard work. Using your example about “more blacks being restrained in ER”, the actual solution is upstream of the “lipstick on pig” answer of simply restraining black patients less frequently; it requires discerning why black patients tend to be more frequently agitated, and hence in need of restraint; then offering a solution to those manifold causes of agitation among black patients such that, in time, their need for restraints matches overall population averages. It’s hard work. It won’t happen overnight. And the “equity” folk are simply too stupid and too lazy to do it.
The examples from this OP are a microcosm of the reasons why the entire DEI framework that has infected society in the last 10-15 years needs to go the way of the Dodo.
Something that no one wants to mention here is genetics. Some disparities in outcomes could simply be genetic. I feel like the only times people are willing to admit genetics has an effect is alcoholism in Native American populations and lower vitamin D in dark-skinned people. It's not racism to acknowledge that different races will have different outcomes for any disease or responses to a medication even if everything else (location, income, diet etc.) is the same.
it should be named un-critical theory. The all-too-common proceeding is to observe a disparity and infer racism as the cause without any empirical investigation that might elucidate actual causes whether of what brought the disparity about or of what perpetuates it. That the medical literature now commonly takes this approach is deplorable; as are the deeply immoral prescriptions that often follow the unwarranted diagnosis
Let me say out loud what was supposed to be unspoken. The disparities are due to corrosive cultural factors. Could this have some root in past oppression? Perhaps. But betterment can only come from the inside. Victimhood will not solve the problems. There.
Access to take home methadone is contingent on several safety factors that are not at all race based . Great piece
Great piece that would never see daylight in msm. Free speech, verified facts, use of scientific method for deep analysis and turning off agendas is the answer to sound public policy.
MSM is agonal breathing right now.
“As a physician, my care for patients has nothing at all to do with the relative health of groups. The only gap that concerns me is the discrepancy between a patient’s current and optimal health. This should be our guiding philosophy more broadly: improved access to quality care for the sickest and underserved, across the board.”
This should have been your opening line. Physicians and our system have moved away from this idea, and our patients are the ones who lose.
That could have been the entire article! Beautiful paragraph!
Ditto.
Thomas Sowell has useful insights into this issue
https://www.amazon.com/gp/product/154164560X/ref=as_li_qf_asin_il_tl?ie=UTF8&tag=thefede01-20&creative=9325&linkCode=as2&creativeASIN=154164560X&linkId=461f58e4b8cf32668b6a1d023b203ed7
Critical theory holds that a disparity among outcomes is due to systemic racism, sexism, ableism, etc. The author describes a couple of supposed examples in medicine.
This rationale is utterly wrong. For example, look at life expectancy in the USA. Women outlive men by six years. If believers in CT were consistent, then they'd be ranting about the grave injustice that 'men are victims of systemic sexism in all the factors that contribute to life expectancy'. (Note that black women outlive white men by about a year.)
Along these lines- what about the damage done to people that aren’t viewed as marginalized. I worked at a prominent hospital in a Peds ICU… a very smart ICU physician/ ICU diversity lead, who is also a friend and is brown.. has bought into the oppressor/ oppressed narrative so much so that it consumes every social media post she has. Many of these posts talk about how white people are oppressors and always oppressors and will never understand anything brown/ black people go through… if we are going by bias being a main predictor of how you take care of patients- I certainly wouldn’t want a physician saying things like this to take care of my white child…. But it has never been called into question…
Also- a different hospital. A friend who is a hospital administrator (he is a POC also) called me one day and was furious that one of the new POC Peds surgery attending was treated poorly and he thought it was due to racism (he wasn’t at the event and he has never done clinical work- and is not a clinician). I asked what happened. He said a code in the CVICU occurred ( the child was not doing well at all) and an icu attending yelled at this surgery attending and asked why this person was in the room. The icu attending had never met the new attending and didn’t apparently didn’t know why they were there. All icu people know you want a controlled room with the minimum amount of people there to do the job well. It’s not appropriate to yell at people,.. but tensions are high when a life is literally on the line. This administrator made up the racism part of the story with no details/ data . The surgery attending hadn’t even told him that they were worried about racism. This is the type of stuff that happens when we fill our heads with this stuff. This administrator told a group of other admins he thought this was the reason this person was treated badly with no evidence and wasn’t there. He wanted to provide disciplinary action - to me this is crazy.