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1. Bias in health care remains a significant problem

   • Victor S. Sloan, MD

   Robert Wood Johnson Medical School

   As the writer points out, our health care system is indeed broken. With more than 40 million Americans lacking health insurance, one could hardly argue that point. However, while all Americans are subject to the same broken system, there are numerous studies demonstrating that minorities have worse health outcomes. The Institute of Medicine notes that in most studies, differences in care are present even after controlling for other confounding factors (1). There is ample evidence of racial and/or ethnic differences in cardiac care (2), cancer care (3) and diabetes (4). Perhaps more importantly, like the writer, many physicians erroneously believe that race or ethnicity does not play a significant role in the quality of care patients receive (reviewed in 2).

   Certainly, we cannot know for certain the true feelings or biases (if any) of Amanda Gonzalez’s physicians. We can only know that she, like many patients of color, received substandard care. The literature provides ample evidence of prejudice in American health care. Ascribing poor outcomes to a “broken system” and dismissing racial/ethnic bias as a cause for poor health outcomes is not supported by the data.

   (1) Institute of Medicine. Unequal Treatment: What Healthcare Providers Need to Know About Racial and Ethnic Disparities in Healthcare. Washington, DC, National Academies Press, 2003. (

   2) Lillie-Blanton, M, Maddox TM, Rushing O, Mensah GA. Disparities in cardiac care: rising to the challenge of healthy people 2010. J Am Coll Cardiol. 2004; 44: 503-508.

   (3) Gross CP, Smith BD, Wolf E, Andersen M. Racial disparities in cancer therapy: did the gap narrow between 1992 and 2002?. Cancer; 2008; 112: 900-8.

   (4) Sequist TD, Fitzmaurice, GM, Marshall R et al. Physician performance and racial disparities in diabetes mellitus care. Arch Intern Med 2008; 168: 1145-51.

   Conflict of Interest:

   None declared

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   Published September 2, 2008
2. Broken Systems

   • Steven M Hegedus, MD

   Memphis Health Loop
   Dr. Sloan outlines his patient, Amanda. Gonzalez, and her struggle with a devastating illness, an unjust health care system, and medical error. Her story is tragic. Furthermore, the author speaks toward bias in the care she received. Instead of prejudice, this story demonstrates a failing system as a cause of the patient's delays in care. Like the orthopedist and emergency department physician in Dr. Sloan's story, many others are trying to serve those with the greatest need. We are the physicians working on the front lines of a broken system. Individual racism certainly exists, but systems issues contribute to an overburdened system, and these pose the greatest challenge to patients such as Amanda Gonzalez. As I consider the orthopedist in the story, I sympathize with a frustrated and busy surgeon. She would have rather not been scheduling underinsured patients 9 months out, I''m certain. Attributing the delay to personal prejudice is unfounded. I would rather attribute this delay to a fundamentally broken system which further marginalizes the poor. Conflict of Interest:

   None declared

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   Published July 23, 2008