A surgeon takes aim at bias in health care

A surgeon sees disparities in treatment and a solution in the creation of more diverse medical teams.

By Cathy Shufro

If you log onto MEDLINE and search for papers by Augustus A. White III, M.D., Ph.D., HS ’66, most citations will be what you’d expect from a prominent orthopaedic surgeon, with titles like “Effect of Screw Diameter, Insertion Technique and Bone Cement Augmentation of Pedicular Screw Fixation Strength.” But among the recent articles, you’ll also find one with a very different focus, “Our Humanitarian Orthopaedic Opportunity.” In the March 2002 issue of The Journal of Bone & Joint Surgery, White addresses topics that have increasingly preoccupied him during four decades as a surgeon: the racism that has denied equal health care to African-Americans and the healing potential of cultural sensitivity among doctors.

Unless physicians fight their conscious and unconscious biases, White says, they will widen the gap between the quality of health care provided to the privileged and what’s offered to the marginalized. Infant mortality rates show that things are getting worse, says White, the Ellen and Melvin Gordon Professor of Medical Education at Harvard, where he is also a professor of orthopaedic surgery. In 2000, 14 of every 1,000 black babies died in their first year, compared with 5.7 per 1,000 white babies. That ratio of 2.5 black deaths for each white death has increased over the past 20 years, from 2.0, according to the Centers for Disease Control and Prevention. “Bias is thoroughly interwoven into the very core of Western medical culture,” says White, former orthopaedic surgeon-in-chief at Boston’s Beth Israel Deaconess Medical Center.

Even after adjusting for education and access to care, studies show similar gaps. African-Americans are less likely than whites to have coronary angiography, drug therapy for HIV, kidney transplantation and even routine care. Bias even seems to influence the decisions of African-American physicians themselves. A 2001 Yale study by Jersey Chen, M.P.H. ’98, M.D. ’00, and Harlan M. Krumholz, M.D., professor of medicine, and others showed that after an acute myocardial infarction, white patients were significantly more likely than blacks to be given cardiac catheterization, even when the African-American patients were treated by African-American doctors. “Does anyone still have doubts about the momentum for bias in our medical heritage?” White asks.

He says that when the physician workforce represents a variety of ethnic groups, health care improves for those less likely to get good care. Physicians from minority groups are more likely to set up practices in underserved areas; simply including them on a team improves care, says White, who is African-American. “Over time, you’re going to have a team that’s less ethnocentric.”

White believes that awareness of cultural differences is slowly emerging. At Harvard, first-year medical students now attend an all-day discussion of cultural differences in medicine. He describes his Yale mentor, Wayne O. Southwick, M.D., professor emeritus of orthpaedics, as a leader in fostering gender and racial diversity. Southwick received the 2003 Diversity Award from the American Academy of Orthopaedic Surgeons for his commitment to achieving greater diversity in the field.

White experienced racism in medicine firsthand when he graduated from Brown University in 1957 and sought a summer hospital job. At the “white” hospital in his hometown of Memphis, he would have been restricted to a menial job. To find a job with responsibility, White had to apply to a hospital for nonwhite patients; there he was allowed to work as a surgical technician. Since then, “the theme of diversity and the value and importance of diversity” has been “a recurrent theme in my mind, like a Bach concerto.

White is co-author, with Manohar M. Panjabi, Ph.D., a Yale professor of orthopaedics and mechanical engineering, of the widely used reference Clinical Biomechanics of the Spine and author of the popular book Your Aching Back: A Doctor’s Guide to Relief. Although White no longer performs surgery, he still does consultations, writes about orthopaedics and lectures both at Harvard and at national conferences. He has won many awards, including the Bronze Star for service as an Army surgeon in Vietnam. A former Brown University corporation trustee and fellow, he was selected in 2000 as one of Brown’s 100 most influential 20th-century graduates, chosen from among 75,000 alumni. When asked what honor has given him the greatest satisfaction, White replied, “What’s clearly the most gratifying is the positive feedback from patients, spine fellows, professional colleagues.” He said he was reminded of his purpose when he read The Art of Happiness: A Handbook for Living by the Dalai Lama, adding, “Our purpose here on Earth is to be happy, and the way to be happy is to help others.” White also finds happiness listening to the music of Duke Ellington, Quincy Jones and Nina Simone at home in Weston, Mass., where he lives with his wife, Anita, and two of his three grown daughters. (The third daughter is working in Sweden, where White studied and met his wife.)

In his article on race and medical care, White asks physicians to approach every patient based on the “double F criterion”—that is, to ask themselves: “Is this the way I would treat my friend or my family?” Do this, writes White, “and we make a tremendous contribution toward the elimination of health care disparities.”

Cathy Shufro is a contributing editor of Yale Medicine.

Familiar Faces

For NASA veteran, alumni post offers chance to help students reach their goals

Howard Minners

When Howard A. Minners, M.D. ’57, M.P.H., was a boy growing up in Garden City, N.Y., his parents hoped he’d aspire to be a doctor. But Minners had other ideas. Living on Long Island near Roosevelt Field, where Charles Lindbergh launched his dramatic flight across the Atlantic Ocean, he dreamed of doing something related to aviation. Minners did succeed in combining the two aspirations, becoming a flight surgeon for the astronauts in the early days of the space program. (As a flight surgeon, Minners took a mandatory jet qualification course, but never flew solo.)

“It was a matter of being in the right place at the right time, and having the right training,” says Minners, who was recently named chair of the board of trustees of the Yale Medical School Alumni Fund. After graduating from medical school he spent a year getting a master’s degree in public health at Harvard. Next came a year at the U.S. Air Force School of Aerospace Medicine in San Antonio, followed by a year of supervised residency training in aerospace medicine, eight months of which were spent with the NASA Space Task Force, then located at Langley Air Force Base in Hampton, Va.

As a flight surgeon for more than four years with NASA in Houston, Minners tended to the everyday health care of the astronauts and their families. On launch days he conducted a final medical exam and helped the astronauts suit up. He also conducted immediate postflight medical exams, often aboard an aircraft carrier.

One of his fondest memories is of John Glenn’s 1962 Project Mercury flight, which had to be temporarily scrubbed for technical reasons. After lying supine in his spacecraft for nearly four hours, Glenn returned to the astronauts’ quarters to remove his space suit. With yet another mission postponement, there was public concern about the astronaut’s mood. “John liked music, and suddenly I heard him singing, so I harmonized with him,” Minners recalls. “With the whole world waiting, there we were singing. It was a delightfully private experience uncomplicated by all this stuff that was going on.”

But there were also stressful experiences, like the time an astronaut missed his landing site. “There’s a period during spacecraft re-entry when, due to atmospheric ionization, you have no communication, so we didn’t know where he was,” Minners says. “It turned out fine, but for a while we were very concerned.”

While working with the space program, Minners researched orthostatic hypotension—the lightheadedness you may experience if you get up quickly after you’ve been lying down—to see if it was accentuated after flight in space. In part as a result of his early work, exercises have been developed for astronauts to perform while they’re in space to maintain cardiovascular fitness.

After leaving the space program in 1966, Minners joined the U.S. Public Health Service at the National Institutes of Health, first in the Office of International Research and two years later at the National Institute of Allergy and Infectious Diseases. He worked in vaccine development, immunology and tropical medicine. He went on to become chief of the World Health Organization’s research office in Geneva before serving as an assistant surgeon general and deputy director of the Public Health Service’s Office of International Health. He spent the last 10 years of his career as science advisor to the head of the Agency for International Development, with oversight for agricultural, environmental, energy and natural resources research, as well as biomedicine.

Minners says his education at the School of Medicine prepared him well for a career in the sciences. He cites as an example the research he did for his medical school thesis. “Having been a chemistry major at Princeton before coming to Yale, I was trying to develop a chemical process whereby we could accurately and more simply measure urinary estrogen levels,” he says. “We couldn’t come up with what we were trying to do, but that in itself is part of the learning process.”

As chair of the medical alumni fund, Minners wants to make the kind of education he received at Yale more affordable.

“When I learned that the scholarships we offer aren’t always as competitive as at some other medical schools, I decided then and there that we need to [do more],” he says. Three years ago he established the Howard Minners Family Scholarship for medical students. “I still believe that the education you receive at Yale, and notably, under the Yale System, is better than anywhere else. But it doesn’t come inexpensively.”

—Jennifer Kaylin

Working on a broad canvas, physician-artist finds perfection amid life’s many flaws

It is 5:30 a.m., and the sun hasn’t yet risen on this fall day in Providence, R.I. On the third floor of an old house in the historic East Side of town, Cheng-Chieh Chuang, M.D. ’95, holds his watercolor brush in his hand.

This is how Chuang begins each day—in his studio. The meditative focus of painting prepares him for the hectic pace of his solo family practice in Taunton, Mass., a blue-collar town just across the state line. It allows him to work as an artist, a lifelong interest and parallel career to medicine.

Painting also serves as a philosophical foundation for Chuang. When he chooses a subject for his detailed, nearly photographic watercolors—usually something from nature—he does not avoid objects that seemed flawed, like a maple leaf with a scaly patch. “All those scars are beautiful in themselves. Nothing is perfect in this world,” says Chuang. He tries to retain this perspective when meeting with patients. “I try to see them as perfect beings, despite their imperfections.”

For four years after his residency in family practice at Brown University, Chuang’s desire to travel and paint while practicing medicine led him down an unusual path. He spent half his time on the road doing locum tenens work and half his time at home in Providence, painting. He lived in a dozen communities for several months each, from Maine to Alaska and from Minnesota to New Mexico, where meeting patients gave him a more nuanced view than that of a tourist. In the fall of 2002 he settled full time in Providence and has established an Internet site to display his paintings and sell prints (See http://www.fromearthtosky.com/).

Chuang also combines his interests by teaching a course in art and medicine to Brown medical students. They explore how art can improve their powers of observation and enrich both their own lives and those of their patients. Chuang wants his students to view physicians in the way that he came to see them as a child growing up in Taiwan (where his adventures sometimes ended with a trip to the doctor): not just as scientists but as “renaissance men/women.”

Chuang is looking for a house near his practice in Massachusetts, where he hopes to combine his office with an art gallery and a “healing garden.” Having worked much of his career in subsidized clinics in medically underserved areas, he is tempered by the realities of private practice, of having to worry about the bottom line in addition to simply providing quality care. But he’s happy with the work. “Family practice constantly reminds me to be curious about everything in life, including the human condition.”

And he tries to see each day as a gift. “There is so much adversity. … But most of us go through daily life without any big problems. That in itself is a miracle. That’s something we take for granted, like the air.”

—Cathy Shufro

Online CME site, voted best of the Web, reflects the curiosity of its creator

In the mid-1990s, just as the Internet was starting to take off, Harry A. Levy, M.D., M.P.H. ’82, looked at the information available online for physicians and saw a virtual desert. “Not much was going on in health care on the Internet,” says Levy, 59. “I decided I could do better.”

So in 1996 Levy launched the first continuing medical education (CME) site on the Web and hasn’t looked back. His creation, Cyberounds (www.cyberounds.com), now has 125,000 registered users and a potential audience of more than a half-million physicians, as a result of the cooperative arrangements Levy has struck with major online publishers and professional societies. The website offers conferences in 15 disciplines, including cardiovascular medicine, geriatrics, genetics, psychiatry, rheumatology and women’s health.

Each conference provides a case study, diagnostic clues and a discussion by experts, usually highlighting emerging treatments. Conferences are moderated by faculty members from medical schools around the country, and physicians who complete the work can earn CME credit from the Albert Einstein College of Medicine in New York, the program’s academic partner. (Last year Einstein awarded a total of 20,000 CME credits to participants in Cyberounds courses.) As it approaches its eighth birthday, Levy’s brainchild has the longest track record in the online CME field, and last June it received a Nettie award from MD Net Guide as best CME provider.

“Doctors are busy people,” says Levy. “What we do for them is provide the experts to lead them through the information jungle.”

Levy and his collaborators at Cyberounds have also employed a playful approach to CME (Levy calls it “medutainment”). Two years ago, they launched “Cardio Country Club,” a Web-based golf game in which physicians compete against each other and advance through an 18-hole course by correctly answering questions about the management of cardiovascular disease. More than 3,800 online learners have played the game.

An NYU medical graduate, Levy trained at New York’s Mount Sinai Hospital in preventive medicine and studied public health at Yale. After starting and running several health care businesses in New York in the 1970s and 1980s, he decided he would need to make time for at least three careers. He sold his companies in 1991 and set a goal of writing five novels, then doing basic research in neuroscience.

He’s now at work on his third book (his second, a mystery novel titled Chain of Custody, was published by Random House in 1998), is writing a screenplay and expects to be slicing brain tissue by the time he turns 65. He figures the conventional age for retirement will be a good time to begin the next chapter in his professional life, however unconventional that may seem to others. (Levy notes that his great-grandfather lived to be 110 and that both his grandfathers reached 90.) “I think I can stick to my timetable,” he says, smiling. “At least I’m crossing my fingers that genetics will help me out.”

As for the future of Cyberounds, he says the company will turn its attention to developing courses serving the subspecialties. “We want to drill down deeper—beyond the general category of endocrinology, for example, to have focused modules in diabetes or thyroid disease,” he says. “We want to do more interactive programming, including games and decision-tree programs, courses customized to the user’s individual needs and interests.” Currently in the works are a triathlon game on rheumatoid arthritis and disease management software for doctors and patients.

Levy says the business (which includes a consumer site, TheDoctorWillSeeYouNow.com, and an e-scheduling site, MakeMyAppt.com) has been profitable for the past six years despite the bursting of the tech bubble. One factor in its success, he says, is that the company is doctor-driven and doctor-created, and it caters to what physicians want. “We owe our success to word-of-mouth among physicians. We haven’t had to advertise and instead were able to invest in innovative programs. You grow slower, but you become more useful to the medical community.”

—Michael Fitzsousa


			Originally published in Yale Medicine, Winter 2004. Copyright © 2004 Yale University School of Medicine. All rights reserved.