In military medicine, study shows rank and race affect care

Higher ranking military officers receive more resources and better care than low ranking military officers, according to an analysis of 1.5 million military ER visits published Thursday in the journal Science.

The study also showed that white physicians expended less effort on Black patients, even when rank was taken into account: Higher ranking Black officers received care from white physicians that was similar to that received by lower ranking white officers.

“Simply being Black significantly reduces the effort provided by white physicians,” wrote the authors, who used a large data set of health encounters in the Military Health System, which provides care to active duty military, their families, and military retirees, to examine both resources and time expended by physicians on patients. (The study did not include data from the Veterans Administration, which serves veterans and their families.)

The study, examining what the authors call the “long shadow” of power, uses real-world data to examine an issue that’s been largely invisible until now: how power differentials and race can influence the time and resources patients receive, and how those patients fare afterwards. The results, the authors said, demand attention — and may apply to civilian health care as well.

“This finding that white physicians exhibit a preference for prioritizing care for white patients over Black patients, irrespective of power status, underscores the need for ongoing efforts to address implicit biases and systemic inequities in the healthcare system,” wrote the authors, Stephen Schwab, an organizational health economist and assistant professor at the University of Texas, San Antonio, and Manasvini Singh, a health economist and assistant professor at Carnegie Mellon. “Of course we’re concerned,” Singh said during a press briefing describing the results. “Are we surprised? No.”

Overall, higher-ranking patients received 3.6% more physician effort and more resources, such as tests, imaging, or procedures, prescriptions for opioids, or use of more complex treatments, and they were 15% less likely than lower-ranking patients to have a poor outcome.

Lower-ranking patients seen by doctors attending to higher-ranking patients at the same time were 3.4% more likely to have poorer outcomes, such as being hospitalized or needing to return to the ER within 30 days, the study found. The study found that the higher the differential between the doctor’s and patient’s rank, the less effort and resources expended by the physician.

Schwab, a retired Army Lt. Col. who formerly worked as a chief financial officer at a military hospital, said discussions with health providers revealed that providing higher-status people better care was an open secret inside the hospitals.

“If a colonel is coming in they’ll receive a text message from a superior or a colleague saying ‘Know that a colonel is coming in, make sure to not have him wait,’” said Singh. Schwab said a nurse midwife told him spouses of wealthier officers were also given preferential treatment. “They know this is happening,” he said.

He said leaders of the Military Health System were very supportive of the study, provided the data, and said they hoped the research would help reduce health disparities. “They said, “Yes, this is an important question and we really want to know the answer, even if it’s something that we don’t necessarily like. But we can’t do anything about it unless we know the answer,” he said, adding he was speaking for himself and not on behalf of the military. “Everyone I’ve talked to has said, ‘Yeah, we sort of know, but we don’t know what to do about it.’”

When asked about the study, a spokesperson for the Defense Health Agency, which oversees the health system, did not respond directly to the findings but said the agency “is committed to delivering the highest quality of care to all of our patients, regardless of rank, race, color, sex, gender identity, religion, age, or any other demographic. We always expect the same high standards to be applied to every patient in an exceptional way, anytime, anywhere, always.”

Studies have shown while there are health disparities within military care, they are generally less than those in the general population.

The study was conducted within a military context, where rank provides a clear way to measure power, but the authors said the findings might be generalizable to health care outside of military settings. They speculated that disparities could be worse in populations that are generally less healthy than active-duty military personnel and receive care in settings that lack the sense of kinship and shared mission of service members, which may mitigate some of the power differentials observed in the study.

As evidence, the authors pointed to care at the emergency room at New York University, where doctors felt pressure to provide preferential treatment to VIP patients, whose donations or relationships with hospital executives were noted in electronic health records. “The prevalence of ‘VIP patients’ and ‘concierge’ or ‘red-carpet’ care for the affluent and influential in civilian health care suggests that the divide between military and civilian settings is narrower than expected,” the authors wrote.

Schwab said he suspected the same findings from the military study would extend to the general public since the military reflects that public. “In a military that’s drawn from the general public, the same general societal issues exist,” he said.

The study highlights “systemic injustices” related to power and racial differentials that run throughout medicine, including non-white patients reporting poorer care when being seen by physicians who do not match their race or ethnicity, Laura Nimmon, an associate professor at the University of British Columbia who studies the effects of social networks within health care settings, wrote in an accompanying editorial.

Lisa Cooper, a researcher and physician who directs the Johns Hopkins Center for Health Equity, told STAT she wasn’t surprised by the findings. Her research, and that of others, has shown that when doctors and patients share a racial background, they receive better care and have better outcomes. She said the study mirrored findings in the civilian world, including the fact that patients with less education are often treated more poorly, and added, “it is disturbing that we continue to see disparities in how patients are treated, based on their social standing and their race.”

The different treatment of patients due to their social status or race may have gone largely unscrutinized because a myth persists that “the physician is a perfectly altruistic agent for the patient” and not corrupted by power, the authors suggested.

They pointed to several ways to address care differences, from diversifying the medical workforce to finding ways to shift tasks away from overloaded physicians. Blaming physicians for being biased is not the answer, the researchers said. “They are doing incredibly difficult taxing jobs. Let’s not make it harder for them by holding them to an impossible standard, then be surprised when they are displaying extremely human behaviors that all of us are susceptible to,” said Singh.

The study unearthed a number of novel findings regarding gender and race. Female physicians were less likely to be affected by the rank of a patient, and male physicians provided more resources to female patients than female physicians did, possibly, the authors said, because they generally provide more “kitchen sink” care such as pregnancy tests and pelvic exams than female physicians. It also showed that male physicians were more responsive to high-ranking female patients than female physicians.

Black physicians were found to treat lower-ranking patients equally regardless of their race. However, they provided “off-the-charts” effort for high-ranking Black patients, possibly, the authors said, because of an emotional response to the lower numbers of Black individuals in positions of power in the military. Previous studies have shown Black patients fare better in general when treated by Black physicians and that the presence of Black physicians improves population health in the counties where they work.

Cooper said the study helps make the case that “diversifying the health care workforce with regard to race, social class, and lived experiences could reduce health care disparities and improve care for everyone.”

In her editorial, Nimmon noted that the response to power starts early in medicine; one study showed first-year medical students favored white and high-status individuals. She asked whether medical students were being “supported to confront deeply entrenched systems of power in the clinical encounter.”

More research is needed, she said, including examining how other racial and ethnic groups, including Hispanic, Native American, and Asian patients, fare under the power dynamics of the military, and whether physicians feel “moral distress” when forced to prioritize high-status patients.

This is part of a series of articles exploring racism in health and medicine that is funded by a grant from the Commonwealth Fund. Our financial supporters are not involved in any decisions about our journalism.