The question of racial bias in thoracic surgery: appearances and realities.

A decade ago the American Medical Association Council on Ethical and Judicial Affairs examined available data and concluded “that even when blacks gain access to the health care system, they are less likely than whites to receive certain surgical or other therapies.” Their study focused particularly on expensive therapies, including coronary bypass procedures [1]. In ensuing years, the data suggesting racial bias in availability of cardiac surgical care has grown. A retrospective review of 33,641 male ischemic heart disease patients at 158 acute-care VA hospitals found that black patients received invasive procedures significantly less often than whites with equivalent diagnoses [2]. Gornick and colleagues [3] had similar findings in reviewing 1993 Medicare administrative data for 26.3 million beneficiaries 65 years of age or older (24.2 million whites and 2.1 million blacks), and concluded that black people with the same medical characteristics received coronary bypass treatment for ischemic heart disease only 40% as often as whites. Hispanics also received percutaneous transluminal coronary angioplasty and coronary artery bypass graft operations proportionately less often than whites [4]. In other studies, even when adjustments for severity of disease were made, coronary revascularization was still underutilized in black patients [5]. Black people received surgical therapy for ischemic heart disease 22% [6] to 68% [5] as often as symptomatically similar white people, with the difference remaining significant in every published study on the subject. Blacks received a disproportionately low share of many other expensive therapies as well. Nonetheless, because coronary bypass operation was the most commonly cited disparity, our assessment will explore conclusions implying widespread unwarranted racial bias in patient selection within the specialty of thoracic surgery. Bias is morally neutral; it depends on context for ethical status [7]. In its medical or scientific context, it is commonly defined as “a systematic error introduced into sampling or testing by selecting or encouraging one outcome or answer over others” [8]. Studies have shown a clear distinction between use of surgical revascularization in white and nonwhite patients independent of socioeconomic status [9–12]. Because nonwhite ethnicity is no longer synonymous with poverty in America, it has been concluded that the lower rate of surgical revascularization provided to minorities unmasks a specifically racial bias among cardiac surgeons [1]. The process that results in a cardiac patient being brought to the operating room or treated in another manner may or may not reflect racial prejudice by nonsurgeons, internists, and surgeons. The answer reflects upon the integrity of the medical profession and the care we provide the patients who trust us. Components of this process should be closely scrutinized before we accept or deny a conclusion of systematic racially motivated exclusion, particularly by thoracic surgeons. Several procedural steps must always precede surgical therapy for ischemic heart disease. First, the patient develops manifestations of disease and seeks care from a primary physician or cardiologist. Next, the signs and symptoms warrant the physician’s order for a coronary angiogram. The results of that study show that the angiographic anatomy is satisfactory for surgical therapy rather than angioplasty, whereupon the patient is referred to a cardiothoracic surgeon. After reviewing the patient history and angiogram, the surgeon decides to recommend an operation, which will occur only if the patient consents. Of these essential presurgical steps, only the decisions to accept the referral and recommend operative care based on the clinical indications are within the surgeon’s discretion. A number of factors can cause this process to fail and leave a patient without needed surgical revascularization. The affected individual might endure his or her pain without consulting a physician. The absence of medical insurance or other means to pay might similarly discourage a potential patient from seeking care. The patient might have silent ischemia and be unaware of a developing disease process. The sufferer may have insufficient insight into the consequences of remaining untreated, fear or mistrust of the medical system, be unaware of system entry points, or visit a provider who fails to diagnose the disease. Accumulated data indicates that both minorities [6] and the uninsured [13] present themselves for care with more advanced illnesses, suggesting that they procrastinate or have difficulty finding timely care. The presence of more, or more severe, comorbidity than seen in white counterparts could negatively influence the physician’s decision to operate. Furthermore, demographic and utilization studies have shown that minority patients may obtain care from less-skilled physicians [14] or at poorly equipped community hospitals [12] closer to home, particularly for surgical therapy. Black people delayed seeking care significantly longer than whites for acute myocardial infarcAddress reprint requests to Dr Jones, Department of Surgery, University of Missouri, M580 Health Sciences Center, Columbia, MO 65212; e-mail: jonesjw@health.missouri.edu.