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Racially and Ethnically SelectiveOligoanalgesia: Is This Racism?

See related articles, p. 11 and p. 77.

[Goldfrank LR, Knopp RK. Racially and ethnically selectiveoligoanalgesia: is this racism? Ann Emerg Med. January2000;35:79-82.]

The work of Todd et al1 with regard to African Americansin Atlanta and their work2,3 with regard to Hispanics inLos Angeles should act as a wake-up call for emergencyphysicians and emergency medicine. Their studies ofpatients with acute extremity fractures not only demon-strate that many emergency patients receive insufficientand inappropriate analgesia, but according to 2 of thesestudies, African American and Hispanic patients are evenless likely than white and non-Hispanic white patients toreceive appropriate analgesic care.

We believe that Todd et al have identified a crucialproblem not only for emergency medicine but also for thehouse of medicine. There is a growing body of evidence1-17

that minority patients are not receiving timely and appro-priate medical care when compared with nonminoritygroups. Although all the answers are not available regard-ing the various reasons for such disparities in care, wehave the moral responsibility to address this issue if weare to meet our obligations to our patients. It is not onlythe responsibility of our specialty but also that of the restof organized medicine to ensure that all our patientsreceive timely, equitable, and appropriate care. If we can-not assure each and every patient that he or she willreceive comparable high-quality care, we have abdicatedour moral authority. We also have the added responsibil-ity to those who have reason to question any perceived oractual instances of inequitable care.

In that light, it may not be reassuring to racial and ethnicminorities that these authors1-17 have been exceptionallyrigorous in describing the results of the studies citedabove as observations that cannot demonstrate an overtor conscious commitment to racism. Certainly, there arefactors that might affect the conclusions of the studies by

Racially and Ethnically Selective Oligoanalgesia:

Is This Racism?

Lewis R. Goldfrank, MD

Department of Emergency Medicine

Bellevue Hospital Center

New York, NY

Robert K. Knopp, MD

Regions Hospital

Emergency Medicine

St. Paul, MN

Address for reprints: Lewis R. Goldfrank, MD, Bellevue Hospital Center,

Department of Emergency Medicine, First Avenue and 27th Street, Room

OB345A, New York, NY 10016; 212-562-3346, fax 212-562-3001;

E-mail lgoldfr@bhc.org.

47/1/103485

and routes of delivery of analgesics in our emergencydepartments. Moreover, we should also take necessaryaction to ensure that all our patients receive timely andappropriate medical care for any complaint. That meansincluding such specific interventions as obtaining datafrom quality improvement studies to determine howmedical care is administered in our own departments. Ifresults of such studies indicate differential care to anyonein systems, we must correct any inequalities.

Regardless of the effectiveness of our long-term solu-tions, we need to attempt to understand what underliesthis differential application of analgesia to develop spe-cific educational measures for those physicians who arecurrently practicing. Do physicians simply discount thecomplaints of minorities? Do minority patients not voicecomplaints for fear of misinterpretation? Obtaining accu-rate information on this issue will be difficult; however,such information could be very useful in focusing educa-tional efforts.

The results obtained by Todd et al1-3 suggest that weare underexposed to and undereducated in the culturaland ethnic differences of our patients and therefore inap-propriately prepared to meet the needs of the more diver-sified patient population that awaits us in the 21st cen-tury. Most of our coworkers and students have grown upmedically and socially in isolated, racially and culturallyhomogenous environments.

Several approaches are suggested to affect long-termcare. One approach to improve care for the AfricanAmerican, Hispanic, and other nonwhite populations isto proceed with affirmative action in our society20 in gen-eral and in medicine and emergency medicine specifi-cally. We hope this approach will achieve an enrichingand broadening human exposure while improving ourpotential to be effective clinicians for all our patients.

The American Association of Medical Colleges(AAMC) President Jordan J. Cohen’s Presidential address,“Finishing the Bridge to Diversity,”21 offers a solution toeliminate perceived or actual personal, institutional, andorganizational racism: affirmative action. Cohen statedthat, “Given that our primary obligation to society is tofurnish it with a physician workforce appropriate to itsneeds, our mandate is to select and prepare students forthe profession who in the aggregate bear a reasonableresemblance to the racial, ethnic and of course, genderprofiles of the people they will serve.”

Cohen presented 5 arguments for affirmative action:(1) achieving justice and equity, (2) ensuring access tohealth care for the underserved, (3) providing culturallycompetent care, (4) setting an appropriately comprehen-

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Todd et al.1-3 Their patient groups have many other dif-ferences beyond race: that the trauma incurred may bedissimilar, that ice may not have been applied in a randomfashion to the fracture sites, that substance and alcoholuse may have been different for these groups, and that theauthors have not differentiated the fact that an opioid ornonsteroidal anti-inflammatory agent was prescribedfrom the actual administration of an appropriate quantityof the chosen agent.

We recognize these and other noncontrolled variablesexist. Still, numerous recent studies4-14 investigating theuse of cardiac catheterization, coronary angiography,angioplasty, and coronary artery bypass graft surgeryhave demonstrated that members of the African Americancommunity and other underrepresented minorities, evenwhen possessing health insurance, will not be guaranteedequal access to care or even equitable care. Similar racialdisparities have been demonstrated in the evaluation andcare of patients with breast cancer,15,16 prostate cancer,12

and amputation rates as opposed to peripheral revascu-larization.17

In addition, American medicine lives in the shadow ofthe Tuskegee syphilis study, which was managed for 40years by the United States Public Health Service.18 Thepoor, uneducated African American men involved in theTuskegee study were led to believe that the care theyreceived for their advanced stages of syphilis was the besttreatment available. The US Public Health Department,along with certain individual physicians, supported thedenial of penicillin to these men, which was certainly aviolation of the then recently approved Nuremberg Code.

The Tuskegee study and the pervasive segregation ofAmerican health care through the 1960s were representa-tive of a malicious form of institutional racism.19 Theseepisodes in 20th-century medicine have created legiti-mate fears in minority populations that they will notreceive appropriate medical care.18,19 This suspicion ofour medical integrity places an added burden of profes-sional responsibility on physicians to demonstrate thatthese fears are unfounded. Unfortunately, a growing bodyof evidence strongly suggests that minority group suspi-cions of inappropriate and unequal care may indeed bewell founded.

If indeed racial minorities, ethnic minorities, or bothreceive differential care, the real question is what can bedone to remedy this now and in the longer term. Our suc-cess as emergency physicians requires that we treat allpatients with long-bone fractures (and patients withother conditions that require analgesia) so that they havea comparable probability of receiving appropriate doses

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balance. We must admit that with the increasing num-ber of studies reporting differential care to minoritygroups, it appears we are failing at a crucial criticalaction: timely and appropriate care for all our patients.We must refocus while modifying our attitudes, ourbehavior, and our beliefs if we are to create a raciallyand culturally competent environment for our patientsin the 21st century.1. Todd KH, Deaton C, D’Adamo AP, et al. Ethnicity and analgesic practice. Ann EmergMed. 2000;35:11-16.

2. Todd KH, Samaroo N, Hoffman JR. Ethnicity as a risk factor for inadequate emergencydepartment analgesia. JAMA. 1993:269:1537-1539.

3. Todd KH, Lee T, Hoffman JR. The effect of ethnicity on physician estimates of painseverity in patients with isolated extremity trauma. JAMA. 1994;271:925-928.

4. Wenneker MB, Epstein AM. Racial inequalities in the use of procedures for patientswith ischemic heart disease in Massachusetts. JAMA. 1989;261:253-257.

5. Maynard C, Litwin PE, Martin JS, et al. Characteristics of black patients admitted tocoronary care units in metropolitan Seattle: results from the Myocardial Infarction Triageand Intervention Registry (MITI). Am J Cardiol. 1991;67:18-23.

6. Johnson PA, Lee TH, Cook EF, et al. Effect of race on the presentation and managementof patients with acute chest pain. Ann Intern Med. 1993;118:593-601.

7. Peterson ED, Wright SM, Daley J, et al. Racial variation in cardiac procedure use andsurvival following acute myocardial infarction in the Department of Veterans Affairs.JAMA. 1994;271:1175-1180.

8. Peterson ED, Shaw LK, DeLong ER, et al. Racial variation in the use of coronary-revascu-larization procedures: are the differences real? Do they matter? N Engl J Med.1997;336:480-486.

9. Giles WH, Anda RF, Casper ML, et al. Race and sex differences in rates of invasive car-diac procedures in US hospitals: data from the National Hospital Discharge Survey. ArchIntern Med. 1995;155:318-324.

10. Whittle J, Conigliaro J, Good CB, et al. Racial differences in the use on invasive car-diovascular procedures in the Department of Veterans Affairs medical system. N Engl JMed. 1993;329:621-627.

11. Carlisle DM, Leake BD, Shapiro MF. Racial and ethnic disparities in the use of cardio-vascular procedures: associations with types of health insurance. Am J Public Health.1997;87:263-267.

12. Gornick ME, Eggers PW, Reilly TW, et al. Effects of race and income on mortality anduse of services among Medicare beneficiaries. N Engl J Med. 1996;335:791-799.

13. Schulman KA, Berlin JA, Harless W, et al. The effect or race and sex on physicians rec-ommendations for cardiac catheterization. N Engl J Med. 1999;340:618-626.

14. Blustein J, Weitzman BC. Access to hospitals with high-technology cardiac services:how is race important? Am J Public Health. 1995;85:345-351.

15. Satariano ER, Swanson GM, Moll PP. Nonclinical factors associated with surgeryreceived for treatment of early stage breast cancer. Am J Public Health. 1992;82:195-198.

16. Diehr P, Yergan J, Chu J, Feigl P, et al. Treatment modality and quality differences forblack and white breast cancer patients treated in community hospitals. Med Care.1989;27:942-958.

17. Guadagnoli E, Ayanian JZ, Gibbons G, et al. The influence of race on the use of surgi-cal procedures for treatment of peripheral vascular disease of the lower extremities. ArchSurg. 1995;130:381-386.

18. Jones JH. Bad Blood: The Tuskegee Syphilis Experiment. New York, NY: Free Press; 1981.

19. Reynolds PP. Hospitals and civil rights, 1945-1963: the case of Simkins V Moses HCone Memorial Hospital. Ann Intern Med. 1997;125:898-906.

20. Bowen WG, Bok D. The Shape of the River: Long Term Consequences of ConsideringRace in College and University Admissions. Princeton, NJ: Princeton University Press; 1998.

21. Cohen JJ. Finishing the bridge to diversity. President’s address. Presented at the AnnualMeeting of the Association of American Medical Colleges; Nov 8, 1996; Washington, DC.

sive research agenda, and (5) securing a diversified talentto lead the health care enterprise into the 21st century.

We, along with many others in organized medicine,believe that appropriately implemented affirmativeaction is an important solution, as well as enlightenedself-interest. In 1990, the AAMC began Project 3000 by2000, the goal of which was to enroll 3,000 underrepre-sented minority students annually in medical schools bythe year 2000.22 The failure to achieve the goals of theAAMC’s Project 3000 by 2000 emphasizes the lack ofcommitment to solving discriminatory academic prac-tices and subsequently limits our potential to remove raceand ethnicity as primary determinants of health.

Another related approach that we believe has greatpromise is the core strategy of Petersdorf,23 Nickens etal,22,24 and Cohen21 contributing to the growth of the“pipeline model” while creating sustainable partnershipsfor the future. These past and present leaders of the AAMCemphasized the need to effect small-scale educationalreform through durable, minority-focused partnershipsof academic medical centers and those K-12 school sys-tems and colleges that are responsible for the academicpreparation of potential applicants from underrepre-sented minorities.21 The recent announcement that theGates Foundation has agreed to donate $1 billion to pro-vide scholarships for minority students will guaranteerecipients full financing for college and advanced degreesprimarily in the sciences and education. It is unclear fromthe initial announcement how many of these will involvemedical careers.25

With the legacy of racism as outlined above, as well asthe growing body of medical evidence indicating differ-ential care in emergency medicine and other medical spe-cialties,1-17 we believe that the burden of responsibilityhas now shifted so that the medical profession mustdemonstrate that physicians are providing appropriateand timely care for all. The work of Todd et al raises theugly spector that we have not invested the social andintellectual energy necessary to reassure minority groupsthat they will receive appropriate care. We have the dutyto ensure that our specialty is guided by the principle ofdistributive justice and that means the elimination of per-ceived or actual medical racism. The goal of distributivejustice in emergency care is one that we all can and shouldbe able to support; however, reasonable people may dis-agree on the best means of attaining this goal.

The rigor with which we solve this overriding publichealth issue will define emergency medicine’s future, aswell as that of organized medicine in our society. Ourintegrity as a profession and as a nation hangs in the

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22. Nickens HW, Ready TP, Petersdorf RG. Project 3000 by 2000: Racial and ethnic diversity inU.S. medical schools. N Engl J Med. 1994;331:472-476.

23. Petersdorf RG. Not a choice, an obligation. Acad Med. 1992;67:73-79.

24. Nickens H, Ready T. Project 3000 by 2000: expanding our network. Closing The Gap: theNewsletter of the Office of Minority Health. Washington (DC): US Department of Health andHuman Services; 1999 May/June.

25. Verhovek S. Gates, ‘spreading the wealth,’ makes scholarship gift official. New York Times.Sep 17, 1999:A:19.