COLUMN ONE : Treating Doctors for Prejudice : Medical schools are trying to sensitize students to ‘bedside bias.’ Studies show that the effects on women and minorities can mean ruder treatment and less access to better care.

When Althea Alexander broke her arm, the attending resident at Los Angeles County-USC Medical Center told her to “hold your arm like you usually hold your can of beer on Saturday night.”

Alexander, who is black, exploded. “What are you talking about?” she demanded. “Do you think I’m a welfare mother?”

The white resident shrugged: “Well, aren’t you?”

Wrong. Alexander was a top official at the USC School of Medicine, where the resident was studying.

In response to such incidents, medical schools including pioneers USC and UC San Francisco have launched efforts to tackle a malady that may undermine the health care of women and minorities. Aimed at curing doctors of “bedside bias,” these schools are prodding their pupils to recognize their prejudices and learn to keep them out of the examination room.

The actions follow recent studies that show that even when minority and female patients have the same health insurance and income as white men, they are much less likely to receive lifesaving medical treatments.

Although the studies suggest that such gaps may in part be caused by cultural factors or physical differences, most raise the specter of bias.

In a state where minorities make up 43% of the population, California medical schools have been in the forefront of such reforms.

Some deride the schools’ programs as political correctness run amok. “I can’t see how people can change their prejudice,” scoffs one white USC medical student. “I don’t see how this will change anyone.”

Medical school officials emphasize that doctors are not more inclined to exhibit bias on the job than other groups, but say that physicians have a special duty to keep prejudices in check because their patients rely on them not only for their health, but for their very lives.

“The kind of information a doctor gets from you, how long they spend with you, the kinds of treatments they offer--all are affected by bias,” said Herbert Nickens, vice president for minority health education and prevention at the Assn. of American Medical Colleges.

“Discrimination and bias are very prevalent,” said Judith Barker, a UC San Francisco medical anthropologist whose students discuss cultural barriers to treating black patients. “It is quite insidious. It comes in tiny pieces. But those tiny pieces add up.”

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Recent studies have shown that the toll bias can take on female and minority patient care:

* Older whites are 3 1/2 times more likely than older blacks to get potentially lifesaving surgery to bypass blocked arteries, said a 1992 study of 86,000 patients under Medicare, the government’s health insurance program for the elderly. The gap widens in Southeastern states, where whites are more than six times as likely to have the operation.

* Asian American, Latino and African American patients of the same income levels and health insurance as whites are 20% to 50% less likely to get three critical types of heart procedures, a 1993 UCLA study found. Women are 30% less likely than men to get the procedures.

* Black kidney patients are 45% less likely than whites to get transplants, a 1991 New York State Health Department study found.

* Latino patients who arrive at UCLA’s emergency department with arm and leg bone fractures are half as likely as whites to get pain medication, a 1993 study found.

Although women visit their doctors more often than men, a gender gap in health care is equally clear, a survey by the American Medical Assn.’s Council on Ethical and Judicial Affairs found:

* Women ages 46 to 60 undergoing dialysis are half as likely to get a kidney transplant.

* For patients with similar smoking habits, physicians were twice as likely to order lung cancer tests for men.

* Men are 6 1/2 times more likely to be referred for cardiac catheterization, where a tube is inserted into the heart to check its condition, even though men are only three times as likely to have heart disease. Women are much more likely to have their heart pains attributed to emotional causes.

In some cases, bedside bias may be deadly. Death rates from coronary heart disease between 1980 and 1991 dropped about 34% among whites, far outpacing the 25% drop in deaths among blacks, a gap many attribute in part to physician bias. Coronary heart disease kills nearly 500,000 people each year in the United States. Blacks remain twice as likely as whites to suffer cardiac arrest, and more than three times as likely to die from it, a recent University of Chicago study found.

Women are more likely to die during bypass surgery or when they have a heart attack, evidence that their cardiovascular disease is not diagnosed or treated early enough, said the AMA’s Council on Ethical and Judicial Affairs. Half of women who have heart attacks die within a year, compared to 31% of men.

At the root of gender disparities in treatment, the American Medical Assn. said in its review of the data, is the sense that men are more valuable and contribute more to society than women.

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USC’s battle against bias began six years ago, when Carletta Bullock, an African American medical student, noticed that a white male colleague looked shell-shocked as he made his first rounds at County-USC Medical Center. There, 90% of patients are minorities. “I feel like I’m on Mars,” he confided.

She surveyed fellow students and found that half felt unprepared to handle the cultural barriers they faced. Bullock started an informal four-hour workshop in which students talked about coping with biases and when it is appropriate to refer a patient who triggers such biases to another physician.

In a trial program just completed in conjunction with Los Angeles’ Museum of Tolerance, USC’s second-year medical students swapped clinical discussions of cell biology and anatomy for heated exchanges about race.

Sitting in a circle at the museum, Los Angeles’ monument against prejudice, 10 students squirmed as their professor asked them to confess biases that may affect their patients’ care. Two white women confided that they rush through physical exams of “scary looking” black men. A third student voiced anger at Latinas on welfare who have baby after baby.

In another workshop, student T.J. Jirasevijinda angrily recalled how doctors at one medical clinic he worked at treated Asian Americans without their informed consent and did not explain prescription drugs’ side effects. When the professor asked if the doctors treated white patients better, Jirasevijinda tersely replied: “Yes.”

“There are people who are bigots and (the workshops) make no difference. But there are people in the middle who learn,” said Bullock, a physician at Albuquerque Indian Hospital.

At UC San Francisco, a mandatory workshop on ethnic identity is followed by a 10-week “cross-cultural communications” course that half its medical students take. Among other issues, they discuss the case of a Hmong patient who fled San Francisco General Hospital when staff prepping the boy for surgery cut off a rope bracelet he believed protected him from harm.

For two years, UCLA has used role-playing in which actors portray patients to test students for race and gender bias. The school also is considering making medical students take Spanish.

Chicago’s Rush Medical College offers a half-day orientation on diversity and bias. The course, which began last year, taps everything from Whoopi Goldberg comedy tapes to a video by the American Academy of Family Physicians with vignettes showing physicians’ biases.

In Rush’s “cultural competence” course, students air their stereotypes about which groups they see as being prone to laziness or welfare, or discuss why it is not a good idea to talk about a patient’s breast size when she is under anesthesia. Rush works to break down ignorance by thrusting students into minority communities--having them go door to door on immunization drives, or offer medical care in a housing project.

San Francisco General Hospital has created Latino, Asian and black “focus units,” wards where the staff receive culture and language training. This month, the AMA will recommend that the Joint Commission on Accreditation of Healthcare Organizations, which sets standards for hospitals, look for any gaps in care to women or minorities before accrediting medical facilities, said Dr. Frank Staggers, a member of the AMA’s advisory committee on minority physicians.

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Moving the students through the Museum of Tolerance displays, USC medical professor Erique Emel, 32, recalls the cases of bias he saw during his residency in Los Angeles. In the residents lounge, some students referred to blacks as “homeboy,” or “the knife and gun club,” even if they were victims of a drive-by shooting. Mexicans were cholos. When women complained of chest pain, “it was seen as hysteria until proven otherwise.”

“We come to the patient with all the things we have been programmed with our entire lives,” Bullock said. “It affects how far you go in treatment. There is basic treatment, and there is more.”

Some residents treating young black men with degenerative heart disease dismiss the possibility of a transplant, presuming that the patient does not have the family support to get through such a procedure, said Denise V. Rodgers, residency program director for family practice at San Francisco General Hospital.

Bullock has heard white colleagues confess to giving less aggressive treatment to “angry black male patients” they felt would not follow prescriptions; she has heard black physicians at Martin Luther King Jr./Drew Medical Center utter racial slurs at Latino patients.

“Quiet down! You shouldn’t have gotten pregnant in the first place,” USC medical professor Kenneth Misch said he heard one white resident in a Las Vegas hospital scream at a Latina crying out during labor.

Later, the resident consoled a white woman in labor, cooing: “Breathe deeply. You are going to have a great baby.” Minority women were slower to get epidurals during labor, Misch said. One colleague told Misch: “Let them suffer so they think about it when they are in the back seat of their car.”

Every day as patients arrive at the chest pain unit at County-USC, residents are much less likely to give women a cardiac stress test, said David Goldstein, chief of general internal medicine. “Just because this is a woman, it doesn’t mean she doesn’t have chest pains,” Goldstein scolds residents. “Just because her reaction is more animated doesn’t mean it’s in her head.”

The schools’ new training programs emphasize that unequal medical care often arises less out of overt bias than doctors’ ignorance of their patients’ culture or language. For instance, some people from India refuse medication that comes in certain colors, Barker said.

Rodgers said she watched one Cambodian child come to a New York City emergency room with a bad ear infection. Unable to speak the same language, a doctor had failed to tell the mother that the liquid antibiotic should be taken orally. She had put it into her child’s ear.

The courses stress that some differences in treatment are legitimate, or are caused by the patient. Women may be more likely to shy away from bypass surgery because studies indicate that they are half as likely to survive the operation, which may be linked to the fact that women’s hearts and arteries tend to be smaller, Carlisle said.

Blacks are more likely to turn down invasive procedures, Rodgers said, particularly if they are seen as experimental, a legacy of the infamous Tuskegee syphilis study between 1932 and 1972 in which black patients were not offered penicillin--a cure for the disease--by government researchers who instead watched them die slowly as part of their experiments.

As students learn about research studies that highlight gender and race gaps, treatment of minorities and women is changing, shifts that may help patients in many ways, said Miriam Shuchman, UC San Francisco Medical School assistant professor of psychiatry.

Studies show that patients who feel that their physician is supportive and caring are more likely to take their medications, return for follow-ups, and get better.

“We’re beginning to sensitize people,” Shuchman said.