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« Back to Has Medicine Gone PC? main page   Transcript for: Has Medicine Gone PC?MR. BEN WATTENBERG: Hello, I’m Ben Wattenberg.In recent years medical experts have been studying the effects of social and economic conditions on health care. Many studies have grabbed headlines, accusing providers of economic bias, racism and sexism. Are these the appropriate subjects of the medical profession? Or, have the tenets of political correctness infected medicine? To find out Think tank is joined by Sally Satel, psychiatrist, lecturer at Yale University’s School of Medicine and author of “PC, M.D.: How Political Correctness Is Corrupting Medicine.” And, H. Jack Geiger, professor emeritus of community medicine, City University of New York Medical School and founding member of two Nobel Peace Prize winning organizations. The topic before the house, 'Has political correctness infected medicine?,' this week on Think Tank. Medical breakthroughs have led to improvements in health care for most Americans. However, even though life expectancy has gone up for all groups in the American population over the past century, there has been a consistent disparity in terms of race and ethnicity. For example, in 1996 life expectancy at birth for black men was 66 years and 74 years for white men. This same sort of disparity exists with ailments such as diabetes, cancer and heart disease. Some experts conclude that socio-economic status, racism and gender bias are fundamental causes of disease and advise addressing social problems to reduce health inequalities. But a new book by psychiatrist Sally Satel disagrees. She warns of the error and danger of studies like these and charges that the purveyors of this politically correct medicine have embraced an ideology that only makes things worse. In her book, Satel says that clinical teaching is being politicized, the importance of personal responsibility for one’s health is being undermined, and differences in health outcomes between groups are uncritically accepted as evidence of bias in the health care system. Well, do social conditions cause disease? Is there subconscious prejudice among practitioners? To sort out the conflict and consensus, we turn to our distinguished guests. Ladies, gentlemen, doctors, thank you for joining us. Sometimes on these programs we sort of have our guests kind of clustering around the middle and we’re sort of saying on the one hand, on the other hand. Something tells me that’s not what we’re going to be doing today. Sally, you’re driving the bus for the moment. You have the new book out. What’s your problem? MS. SALLY SATEL: My problem is that there is a cadre of what I call public health elite who are insisting that health is so powerfully at the mercy of social forces. such as income inequality or racial or sex bias that there’s virtually little the individual can do to safeguard his or her own health. I think this is a very dangerous message because there is an enormous amount individuals can do. For example, between one-half and two-thirds of all premature deaths -- that’s death defined as before age 65 -- is either postponable or preventable. And three particular variables account for much of that postponable or preventable death. That’s cigarette smoking, over-eating and drinking too much. MR. WATTENBERG: What about that? MR. H. JACK GEIGER: Nobody here is going to argue that personal behaviors aren’t important, that tobacco smoking and alcohol, obesity and lack of exercise, all of these personal behavior lifestyles are important. Sally’s book, to me at any rate, gave the impression that that had all been abandoned and that the only thing that was happening was that people were looking at social, economic, politically charged causes of these disparities in health status. And that’s simply not true. The overwhelming bulk of public health activity, and indeed preventive medicine and clinical activity in this country today, we are overwhelmed with warnings about cigarette smoking, about good diet. MR. WATTENBERG: Okay, hold on. You would not disagree with that? MS. SATEL: Oh, no, I agree. MR. WATTENBERG: Okay, that’s a gimme. That’s a slam-dunk. That’s what most of medicine does is concentrate on things that you would both agree that medicine should do. MS. SATEL: Right, and it’s the march of political correctness through the institutions and out through the doors of the public health institutions that I’ve written about. MR. WATTENBERG: That it’s beginning to change. So you’re talking about 'X' percent being fine, but a growing proportion of attention to things that you have some problems with? MS. SATEL: Yes. MR. WATTENBERG: Okay, good, stipulate it. MR. GEIGER: There's a very good reason for that. One of the things that is not in Sally’s book, unless I missed it, is a seminal article by Dr. Paula Lance and her colleagues a couple of years ago in the Journal of the American Medical Association looking at attributable risk. What that means in English is, what they demonstrated is very clearly that all of those things, four of them -- tobacco, alcohol, lack of exercise and obesity among the poor, account for one-third, or a little less than one-third of the disparity in health status between the poor and those who are better off. So, yes, it’s important. It’s a third. If all of those things got changed their health would presumably improve by a third. That leaves two-thirds in the social and economic and environmental arenas, which is just what Dr. Satel seems to object to our studying. And yet that’s where two-thirds of the difference lies. MR. WATTENBERG: Well, the argument, it seems to me, is not whether there can be political remediation of difficult situations for Americans, but is it the professional realm of the medical practitioner to play in that league? That’s what I do for a living, you know. But I’m not a doctor and I don’t go around, you know, looking down somebody’s throat or in other places and saying here’s your medical problem. MR. GEIGER: But the idea that medicine is removed from social concern is as incorrect and historically false as the idea that patients are removed from those environments. No good physician fails to pay attention to the social and economic and environmental circumstances of the patient and to look for causation. Dr. Satel quite properly quotes Rudolph Verkow (ph) the father of all this, who went to an epidemic in Silesia of typhus, and whether or not the bacterium was known then I don’t remember, but said, “Hey, what needs to be done about this to make this population healthy is decent food, decent housing and decent incomes.” So this is not something new. It’s something that we have been doing for a long time. I think we quarrel about the balance. MR. WATTENBERG: But let’s just go to -- you said decent incomes. MR. GEIGER: Yeah. MR. WATTENBERG: Okay. How do you get decent incomes? MR. GEIGER: I have some ideas that are non-medical ideas. I have my own political views. My job as a physician and an epidemiologist is to tell you that there is an index of the difference between the top and the bottom in income in any society. Some have called it the Robin Hood index. If we go state by state in the United States and look at the size of that gap, how big is the difference in income between the top and the bottom, the bigger the difference, the bigger the death rate in that state. The same is true for countries. The smaller the difference, the better the health of -- MR. WATTENBERG: Hold on. Okay, we got your point. MS. SATEL: Yeah. Actually there’s a fair amount of debate about the extent to which income and equality correlates with life expectancy. Certainly the relationships in their surface may be true for some countries, but there are exceptions. For example, Japan has one of the longest life expectancies, but one of the most rigid social hierarchies. Denmark has one of the shortest life expectancies and yet one of the most shallow income gradients. So there are exceptions. Also, there’s another explanation for it, which is that pockets of poverty -- and our country does have more pockets of poverty than countries with more robust safety nets -- is what pulls down that average life expectancy. MR. WATTENBERG: Sally cites some people in her Atlantic Monthly article, which was sort of the preview of the PC MD book. She cites the medical economist Robert G. Evans, and he says, “For those of us on the left health differentials are markers for social inequality and injustice more generally and are further evidence of the need to re-distribute wealth and power and restructure or overturn the existing social order.” I mean, is that what’s bugging you, that kind of rhetoric? MS. SATEL: The rhetoric doesn’t bother me, if that’s what one wants to pursue on their own time. But, yes, if they bring that into their classrooms and consider this to be a health prescription it very much bothers me. Another quotation is from the Harvard School of -- the former Dean of the Harvard School of Public Health, Harvey Fineberg, who said, “A school of public health is like a school of justice.” Now I guess we disagree on this. I think this is more of a trend that’s coming in and I can give you -- MR. WATTENBERG: The politicization of medicine. MS. SATEL: Yes, the politicization of -- MR. WATTENBERG: That’s sort of the topic here, is that right? Or that’s what she wants the topic to be, and you’re saying that's a little tiny bit of it. MR. GEIGER: That's what she wants the topic to be. No. No, I’m saying, in terms of the representation of this as the dominant force in schools of public health, that’s not so. But I’m saying something else. I’m saying medicine has always been political in the sense of medical reformers, in the sense of calling attention to the threats to our environment. MR. WATTENBERG: Right. No question. And Sally acknowledges that. We all. I mean, public health, clean drinking water waters, all that kind of stuff. MS. SATEL: And I don’t disagree with that. The key is direct cause. When you mentioned Verkow, that’s why I quoted him. And I agree. I can understand that very eloquent point, the physicians at least in the late 1800s being the natural attorneys of the poor. MR. WATTENBERG: The natural attorneys of the poor. That’s a wonderful phrase. MS. SATEL: It is, and if you’re living in a damp, broken down, heat-less house you’re going to get TB. Or there’s going to be – but that’s a direct cause. And many of the concerns that, what I refer to as indoctrinologists in my book -- MR. WATTENBERG: I-N, indoctrinologists? MS. SATEL: Indoctrinologists, sort of people who will diagnose social injustice or look for the power struggle behind every health problem and prescribe social transformation as the remedy. When they talk about changing the upstream social problems, like income inequality or racism or sexism and injustice, those are not direct causes. And that’s why I object to their taking this on as a profession. If they want to take that on in their own time that’s fine. MR. WATTENBERG: Let me ask a question. Jack, let’s stipulate that increases in prosperity are related to better health. Suppose I told you I have a fantastic solution to encourage prosperity, not only in America, but around the world, and it involves a greater role for free market capitalism, and it involves specifically, as we’re sitting here today, tax cuts. You would not buy that. MR. GEIGER: No, I not at all think that's the case. MR. WATTENBERG: You would buy that. MR. GEIGER: If one is concerned not just with what is going on with this patient, one by one by one, which tends to be more of Dr. Satel’s focus, but concerned with the health of a given population or a given community, then, yes, there is a reason, I think, for physicians to say it’s important to take steps that will raise the income of this poor community. MR. WATTENBERG: Right. But for that problem, short-handed, we say there are two sets of remedies. There are liberal remedies and there are conservative remedies. So do doctors have any more standing than I do or that the congressman does or that any op-ed writer has about how to deal with those problems? MR. GEIGER: No, nobody gave doctors the power to write prescriptions for a sick society. MR. WATTENBERG: Right. MR. GEIGER: Doctors do have the responsibility, in my view, to talk about the relationships between how the society is organized and their apparent consequences for health. MR. WATTENBERG: Even if they do it in right-wing think tanks? MR. GEIGER: Yeah, of course. That’s why we’re here arguing. MR. WATTENBERG: You are sitting -- we normally don’t let guests on the set with props, but you have received a moderator’s exemption. And I know that involves what you were talking about. Tell us -- MR. GEIGER: We come to the data about discrimination in treatment, disparities in diagnosis and treatment. This is not disparities in health status, blacks are sicker than whites, or whatever. This is, given the same disease, given the same insurance, given the same presence or absence of other disease, given the same everything, are people treated differently by race or ethnicity? This is a stack of 181 articles from the literature of the last 50 years on cardiac disease alone. And only about two of them are discussed at any length in Dr. Satel’s book, and there may be three or four others in the references. It is grossly incomplete. MR. WATTENBERG: One hundred and eight one studies. You only cited two extensively and three more or less -- MS. SATEL: I cited a number. The reason I didn’t cite 181 studies is because I cited the ones with large sample sizes, the ones in major journals and the ones that tended to be review studies as well, sort of met analyses. But, clearly, it’s a huge literature. And I’m not necessarily refuting the fact that there are differences. What I’m refuting is that these differences are inevitably due to some sort of bias. And there was a very large study, a sample of 34,000 patients, in The Journal of the American Medical Association, which looked at mortality rates comparing black and white patients after 30 days and 60 days. And not only did they not find a difference, they found that actually the mortality rate was lower in the African-Americans. MR. GEIGER: There’s a remarkable study on eight major teaching hospitals in New York doing coronary bypass surgery and the like. The physicians were interviewed as to why they had made the decisions they had made. They did not know that race was the focus of the inquiry. MR. WATTENBERG: Right. No, I read that. Right. Yes. MR. GEIGER: And it turned out that they judged on the basis of a 12 minute interview mostly devoted to looking at EKGs and angiograms and X-rays, and so on, that it turned out that the doctors had judged those African-American patients as being less intelligent, less likely to take part in a cardiac rehab program, having less family supports, which they knew nothing about, having a less stressful job. This is bias of the kind that is, Lord knows, common enough in this society and from which physicians are not immune. MR. WATTENBERG: Is that -- you’ve been a hands on physician. Are you guilty of that? MR. GEIGER: No. MR. WATTENBERG: No, you did not? MR. GEIGER: No, but I’ve been in civil rights for 50 years. MR. WATTENBERG: You’ve been in what? MR. GEIGER: In civil rights and concerns for these types of stereotyping for 50 years of my professional life. And so I am sensitized to that. Now, the fact that it is these less than conscious biases, not clinical situations, is what counts. MR. WATTENBERG: Okay now, we can’t go on. Less than conscious discrimination. Do you buy that? MS. SATEL: I wouldn’t call it discrimination. I do call it making judgments based on some past experience. And let me give you an example. There've been a number of studies showing that physicians in some studies, not all, but are likely to approach the family of a recently deceased patient to ask if they would consider donating the kidney. Now that’s probably true. In many cases they haven’t been asked. But the question is why? Is it out of bias? It’s most likely because there’s a higher rate of refusal among African-Americans. And also, and this is something I don’t have raw data on, but I have interviewed a few of the people who do the requesting for these, that the families -- so sometimes it’s the death of a young man who’s gotten killed in a violent urban setting -- the family is so distraught and hysterical, understandably, they feel it would be cruel to approach them and ask at this time. Now, I’m not saying that we should not -- there are times we should think before we infer that perhaps there’ll be a refusal, but it’s not bias. MR. WATTENBERG: Let me ask you a question. Let’s go on to gender. Now the majority of Americans are female. It’s a pretty well known fact in the medical community that women go to doctors more often than men. Women live longer than men. And yet the case is made that there is not only a racial bias, but a gender bias. Do you buy that? MR. GEIGER: There are differences in the treatment of women for a given disease as compared to men. For some of them there is obvious physiological differences. For a very long time, and I’m sure Dr. Satel won’t dispute this, there was a -- I won’t call it a myth -- there was an incorrect perception, pervasive in clinical medicine, that women didn’t get coronary artery disease at the same rate, that it wasn’t as severe, that you didn’t have to be as aggressive in going after complaints. There may have been some bias built into that. MR. WATTENBERG: And there may have been some truth also. MR. GEIGER: Turns out that that misperception led to inadequate treatment for a lot of women until good studies began to show that, hey, this was wrong. MR. WATTENBERG: And you think….? MR. GEIGER: No I don’t think that was bias. I think that was -- we’re not going to get into semantics here as to what's bias. MR. WATTENBERG: But we’re into semantics; we’re deep into semantics. MR. GEIGER: That was a medically and physiologically incorrect perception. Now what was its origin? MR. WATTENBERG: What was its origin? MS. SATEL: Oh, I’ll tell you what its origin was, because I agree with what Dr. Geiger said. In fact, a lot of this was traced to the Framingham Study, which is really the first large NIH-funded study of heart disease. And it was started in 1948. In fact, it’s still going on. When that study started, 55 percent of the enrollees were women. But they were women of the same general age as the men in the study. And since it was a prospective study and since we’ve now learned that women are at risk for heart disease and myocardial infarction, heart attack, 10 to 20 years later than men, as they were following the subjects the men started having heart attacks first. So, subsequently, there were two interpretations from that. One, that perhaps women were not at risk, although I think anyone who practiced medicine actually knew that they were at risk. But that subsequent studies that wanted to look at interventions did look primarily at men because they were the group at highest risk at youngest age. And when you’re doing an initial -- MR. WATTENBERG: So you’re saying, in brief, there was not a sexist bias or pre-condition. MS. SATEL: No. MR. WATTENBERG: And you’re saying you think there might have been? MR. GEIGER: No, I raised the question as to the origin of the belief that women’s complaints weren’t as serious. MR. WATTENBERG: So you are saying that the problem with her diagnosis is not that it’s wrong, but that it’s unfairly selective. And you are saying that by the nature the way our political megaphone system works, this small thin group at the top of any profession gets an inordinate amount of attention. Are we agreed on that? MS. SATEL: They’re small and they’re growing. I think we do disagree -- MR. GEIGER: Right, small and growing. Right. MS. SATEL: -- on the nature of their influence. MR. WATTENBERG: But you both would agree that it’s small, and that you both would agree that they have an inordinate megaphone effect. MR. GEIGER: I think it has gotten better, in fact, rather than worse since we have had so much of a larger proportion of women graduating from medical school. MS. SATEL: We’re back on women. It’s ironic that you say that -- it's true. Now 44 percent of graduate medical students are women. Yet just two years ago the Office of Civil Rights, in its annual report -- this one was on health -- talked about pervasive sexism, that women are being pushed into the less prestigious residences. Well, (a), their facts were wrong. And, (b), one of the most pervasive myths enduring that I’m trying to puncture is that women have been excluded from or under-represented in clinical trials. MR. WATTENBERG: We have to end this very enlightening discussion. Let me ask the two doctors here, just as an exit question, briefly if you would, what should the medical profession be doing that it isn’t doing? MR. GEIGER: In terms of practice, I think we need to be aware that the biases that are pervasive, racial and ethnic and social class biases that are pervasive in the society may also influence physicians and the clinical behaviors and the clinical choices they make. And we need to take the kind of educational, as well as research steps, to see that that stops happening. MR. WATTENBERG: Okay. MS. SATEL: I think that when medical researchers present their raw data they should be very alert to the media and certain commentators taking these disparities out of context or interpreting them in ways that are not necessarily true. Again, interpreting bias when there’s no evidence for it. MR. WATTENBERG: Okay, thank you Dr. Jack Geiger and Dr. Sally Satel. And thank you. Please remember to send us your comments via email. For Think Tank, I’m Ben Wattenberg. [END OF PROGRAM.] Back to top  Think Tank is made possible by generous support from the Smith Richardson Foundation, the Bernard and Irene Schwartz Foundation, the Lynde and Harry Bradley Foundation, the John M. Olin Foundation, the Donner Canadian Foundation, the Dodge Jones Foundation, and Pfizer, Inc. ©Copyright Think Tank. All rights reserved. 
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