Friday, June 18, 2010
Black & white
This post by John H. Schumann, FACP, appeared at GlassHospital.
Imagine if I told you that because of the color of your skin, you wouldn't be allowed access to certain health care services. Pretty outrageous, right? After all, discrimination based on skin color or ethnicity is beyond the pale in 21st century America.
What if the color of your skin made you four times more likely to suffer a life-threatening illness? You might think it unfair, but you'd recall that certain disease states affect different groups of people at varying rates.
When we control for access to care, these differences in health outcomes are known to researchers and advocates as health care disparities. One of the places I encounter disparate health outcomes most starkly is in the dialysis unit. Dialysis is blood filtration for people whose kidneys have stopped working. It's been around since the early 1960s, but became mainstream therapy in 1973 when Congress expanded Medicare to include all persons with end stage renal disease. With that generous entitlement, no one with chronic kidney failure dies from it in the United States.
As you might imagine, since the government pretty much automatically covers everyone in this category, a massive economy has sprung up to cater to this market. From the Wall Street Journal's marketwatch.com (6/11/09): Dialysis treatment costs Medicare almost $72,000 per patient per year; total outlays for patients in kidney failure were $23 billion in 2006, 6.4% of Medicare's total budget. Overall chronic kidney disease and its complications account for over $49 billion, or about 25%, of all annual Medicare expenditures.
Dialysis also is big business. The vast majority of dialysis centers are for-profit, and DaVita Inc., the nation's largest provider with 1,400 centers, ranks No. 433 on the 2009 Fortune 500 list with reported 2008 revenues of $5.7 billion and profits of $374.2 million.
I live and work on the South Side of Chicago. In nearly a decade working at GlassHospital, I can count the number of white people I've met in the dialysis unit on one hand. In fact, I can count him on one finger. Pick a day and come visit our unit (you'll first have to get permission, of course): weekday, weekend, first shift or second; it doesn't matter. Every face you'll see in that unit is black.
After all this time, and in spite of the fact that our government pays for all of this care, I can understand why African-Americans might be mistrustful and even somewhat paranoid about forces conspiring against them in their quests for life, liberty, happiness, and implicitly, health. I've long thought that the unit would make extraordinary fodder for a documentary film by the likes of Fred Wiseman or D.A. Pennebaker. In that cinema verite style, I could easily imagine viewers having difficulty grasping why it is that outcomes for blacks are so much poorer, even as we've improved access to care and desegregated our facilities. I would line up to see such a film.
We're collectively so used to the fact that the vast preponderance of dialysis patients are African-American that we don't even question it. We rationalize away the stark contrast. Blacks have higher rates of diabetes, high blood pressure and chronic kidney disease. We live in an area of lower socioeconomic status, urban poverty, low educational attainment and higher crime.
One last item: Because of "national trends," GlassHospital has recently reached an agreement to sell its own outpatient dialysis units. The buyer: DaVita.
John Henning Schumann is a general internist in Chicago's south side, and an educator at the University of Chicago, where he trains residents and medical students in both internal medicine and medical ethics. He is also faculty co-chair of the university’s human rights program. His blog, GlassHospital, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people that inhabit them.
Contact ACP Internist
Send comments to ACP Internist staff at email@example.com.
- Why you should still see your doctor when you're n...
- Too much testing and treatment? Try superb primary...
- QD: News Every Day--The final day for fixing Medic...
- QD: News Every Day--Doctors worn down, quitting fr...
- QD: News Every Day--Doc fix is running out of time...
- Managing pain in primary care: moving beyond the r...
- QD: News Every Day--Medicare further delays paymen...
- QD: News Every Day--No closer to a doc fix than be...
- Defensive medicine drives overtesting, despite dir...
- QD: News Every Day--Doc fix fray heats up
Members of the American College of Physicians contribute posts from their own sites to ACP Internistand ACP Hospitalist. Contributors include:
Albert Fuchs, MD, FACP, graduated from the University of California, Los Angeles School of Medicine, where he also did his internal medicine training. Certified by the American Board of Internal Medicine, Dr. Fuchs spent three years as a full-time faculty member at UCLA School of Medicine before opening his private practice in Beverly Hills in 2000.
And Thus, It Begins
Amanda Xi, ACP Medical Student Member, is a first-year medical student at the OUWB School of Medicine, charter class of 2015, in Rochester, Mich., from which she which chronicles her journey through medical training from day 1 of medical school.
Zackary Berger, MD, ACP Member, is a primary care doctor and general internist in the Division of General Internal Medicine at Johns Hopkins. His research interests include doctor-patient communication, bioethics, and systematic reviews.
Controversies in Hospital
Run by three ACP Fellows, this blog ponders vexing issues in infection prevention and control, inside and outside the hospital. Daniel J Diekema, MD, FACP, practices infectious diseases, clinical microbiology, and hospital epidemiology in Iowa City, Iowa, splitting time between seeing patients with infectious diseases, diagnosing infections in the microbiology laboratory, and trying to prevent infections in the hospital. Michael B. Edmond, MD, FACP, is a hospital epidemiologist in Richmond, Va., with a focus on understanding why infections occur in the hospital and ways to prevent these infections, and sees patients in the inpatient and outpatient settings. Eli N. Perencevich, MD, ACP Member, is an infectious disease physician and epidemiologist in Iowa City, Iowa, who studies methods to halt the spread of resistant bacteria in our hospitals (including novel ways to get everyone to wash their hands).
db's Medical Rants
Robert M. Centor, MD, FACP, contributes short essays contemplating medicine and the health care system.
Juliet K. Mavromatis, MD, FACP, provides a conversation about health topics for patients and health professionals.
Dr. Mintz' Blog
Matthew Mintz, MD, FACP, has practiced internal medicine for more than a decade and is an Associate Professor of Medicine at an academic medical center on the East Coast. His time is split between teaching medical students and residents, and caring for patients.
Toni Brayer, MD, FACP, blogs about the rapid changes in science, medicine, health and healing in the 21st century.
Vineet Arora, MD, FACP, is Associate Program Director for the Internal Medicine Residency and Assistant Dean of Scholarship & Discovery at the Pritzker School of Medicine for the University of Chicago. Her education and research focus is on resident duty hours, patient handoffs, medical professionalism, and quality of hospital care. She is also an academic hospitalist.
John H. Schumann, MD, FACP, provides transparency on the workings of medical practice and the complexities of hospital care, illuminates the emotional and cognitive aspects of caregiving and decision-making from the perspective of an active primary care physician, and offers behind-the-scenes portraits of hospital sanctums and the people who inhabit them.
Ryan Madanick, MD, ACP Member, is a gastroenterologist at the University of North Carolina School of Medicine, and the Program Director for the GI & Hepatology Fellowship Program. He specializes in diseases of the esophagus, with a strong interest in the diagnosis and treatment of patients who have difficult-to-manage esophageal problems such as refractory GERD, heartburn, and chest pain.
Mike Aref, MD, PhD, FACP, is an academic hospitalist with an interest in basic and clinical science and education, with interests in noninvasive monitoring and diagnostic testing using novel bedside imaging modalities, diagnostic reasoning, medical informatics, new medical education modalities, pre-code/code management, palliative care, patient-physician communication, quality improvement, and quantitative biomedical imaging.
William Hersh, MD, FACP, Professor and Chair, Department of Medical Informatics & Clinical Epidemiology, Oregon Health & Science University, posts his thoughts on various topics related to biomedical and health informatics.
David Katz, MD
David L. Katz, MD, MPH, FACP, is an internationally renowned authority on nutrition, weight management, and the prevention of chronic disease, and an internationally recognized leader in integrative medicine and patient-centered care.
Richard Just, MD, ACP Member, has 36 years in clinical practice of hematology and medical oncology. His blog is a joint publication with Gregg Masters, MPH.
Kevin Pho, MD, ACP Member, offers one of the Web's definitive sites for influential health commentary.
Michael Kirsch, MD, FACP, addresses the joys and challenges of medical practice, including controversies in the doctor-patient relationship, medical ethics and measuring medical quality. When he's not writing, he's performing colonoscopies.
Elaine Schattner, MD, FACP, shares her ideas on education, ethics in medicine, health care news and culture. Her views on medicine are informed by her past experiences in caring for patients, as a researcher in cancer immunology, and as a patient who's had breast cancer.
Mired in MedEd
Alexander M. Djuricich, MD, FACP, is the Associate Dean for Continuing Medical Education (CME), and a Program Director in Medicine-Pediatrics at the Indiana University School of Medicine in Indianapolis, where he blogs about medical education.
Rob Lamberts, MD, ACP Member, a med-peds and general practice internist, returns with "volume 2" of his personal musings about medicine, life, armadillos and Sasquatch at More Musings (of a Distractible Kind).
David M. Sack, MD, FACP, practices general gastroenterology at a small community hospital in Connecticut. His blog is a series of musings on medicine, medical care, the health care system and medical ethics, in no particular order.
Reflections of a Grady
Kimberly Manning, MD, FACP, reflects on the personal side of being a doctor in a community hospital in Atlanta.
The Blog of Paul Sufka
Paul Sufka, MD, ACP Member, is a board certified rheumatologist in St. Paul, Minn. He was a chief resident in internal medicine with the University of Minnesota and then completed his fellowship training in rheumatology in June 2011 at the University of Minnesota Department of Rheumatology. His interests include the use of technology in medicine.
Technology in (Medical)
Neil Mehta, MBBS, MS, FACP, is interested in use of technology in education, social media and networking, practice management and evidence-based medicine tools, personal information and knowledge management.
Peter A. Lipson,
Peter A. Lipson, MD, ACP Member, is a practicing internist and teaching physician in Southeast Michigan. The blog, which has been around in various forms since 2007, offers musings on the intersection of science, medicine, and culture.
Why is American Health Care So Expensive?
Janice Boughton, MD, FACP, practiced internal medicine for 20 years before adopting a career in hospital and primary care medicine as a locum tenens physician. She lives in Idaho when not traveling.
World's Best Site
Daniel Ginsberg, MD, FACP, is an internal medicine physician who has avidly applied computers to medicine since 1986, when he first wrote medically oriented computer programs. He is in practice in Tacoma, Washington.
Other blogs of note:
American Journal of
Also known as the Green Journal, the American Journal of Medicine publishes original clinical articles of interest to physicians in internal medicine and its subspecialities, both in academia and community-based practice.
A collaborative medical blog started by Neil Shapiro, MD, ACP Member, associate program director at New York University Medical Center's internal medicine residency program. Faculty, residents and students contribute case studies, mystery quizzes, news, commentary and more.
Michael Benjamin, MD, ACP member, doesn't accept industry money so he can create an independent, clinician-reviewed space on the Internet for physicians to report and comment on the medical news of the day.
The Public Library of Science's open access materials include a blog.
One of the most popular anonymous blogs written by an emergency room physician.