What military doctors can teach us about power in the United States

Power is invisible, but its effects are visible everywhere, including in the medical records of active duty military personnel.

Examining the details of 1.5 million emergency department visits to U.S. military hospitals across the country, researchers found that doctors invested significantly more resources in patients who outranked them than in patients of equal or lower rank. . The extra clinical effort devoted to powerful patients came at the expense of younger patients, who received poorer care and were more likely to become seriously ill.

Military rank was not the only form of power that resulted in unfair treatment. Researchers documented that patients fared better when they shared the same race or gender as their doctors, a trend that tended to favor white men and caused black patients in particular to be harmed by their doctors.

The results were published Thursday in the journal Science.

The findings have implications far beyond the military, said Manasvini Singh, a health and behavioral economist at Carnegie Mellon University who conducted the research with Stephen D. Schwab, an organizational health economist at the University of Texas at San Antonio.

For example, they can help explain why black students do better in school when taught by black teachers, and why black defendants receive fairer treatment from black judges.

We think our results apply to many contexts, Singh said.

Disparities caused by power imbalances are easy to spot but difficult to study in real-world scenarios.

It's just hard to measure power, Singh said. It's abstract, it's complicated.

This is where military health records come into play.

The military health system operates 51 hospitals across the country. The doctors who employ them are active-duty personnel, as are most of the patients they treat. Comparing their ranks gave Singh and Schwab a practical way to assess the power differential between doctors and the people they care for.

The researchers limited their analysis to patients who sought care in emergency departments, where patients are randomly assigned to doctors. This randomness made it easier to measure the influence of power on the treatment received by patients.

To further isolate the effects of power, the researchers made comparisons between patients of the same rank. If they exceeded their doctor, they were considered high-powered patients. Otherwise, they were classified as low-power patients.

Medical records showed that doctors spent 3.6% more effort treating high-potency patients than low-potency patients. They also used significantly more resources such as clinical tests, scans and procedures, according to the study.

These additional resources translated into better care: High-power patients were 15% less likely to get sick enough to be admitted to the hospital over the next 30 days.

To see if they could replicate their results, Singh and Schwab focused on doctors who treated patients within a year before or after those patients were promoted to a higher rank. Researchers found that doctors spent 1% more effort on patients after their promotion, as well as more medical resources. These differences may have been small, but they were statistically significant, Schwab said.

Then the two men reflected on what happened to the low-power patients while the high-power patients received special attention. One hypothesis was that ordering additional tests for one patient might prompt doctors to order the same tests for everyone being treated that day. It was also possible that the decisions doctors made for their high-functioning patients had no impact on their other patients.

Neither proved to be the case. Instead, the extra effort spent on high-power patients was diverted away from low-power patients, who received 1.9% less effort from their doctors. Additionally, their risk of needing to return to the emergency room or being admitted to the hospital in the next 30 days increased by 3.4 percent, the researchers found.

The powerful unwittingly steal resources from less powerful individuals, Schwab and Singh wrote.

Outside of the military, doctors and patients cannot use their official rank to measure their power against one another, but they must contend with the effects of race and gender. This led the researchers to investigate whether the doctors in their study treated patients differently if they shared these attributes.

White doctors devoted more effort to white patients than to black patients across the board, the researchers found. The gap was the same whether the doctor had a higher or lower rank than the patient.

However, white doctors increased their efforts to treat high-power patients by the same amount, regardless of race. As a result, white doctors on average treated high-power black patients the same as low-power white patients.

The story was different for black doctors. When they outperformed their patients, they essentially gave the same amount of effort to everyone. But on the rare occasions when they encountered a higher-ranking black patient, they increased their efforts more than 17 times more than when they treated a higher-ranking white patient.

It is not clear what explains this unusual effort, the researchers wrote. They hypothesized that because black service members were underrepresented among the high-status patient group, black doctors were particularly sensitive to their status.

The effects of gender were more difficult to determine, because biology dictates that men and women require different types of care.

Doctors, both men and women, invested the most effort with female patients, who outperformed them. But male doctors improved their care for high-functioning patients of both sexes to a much greater extent than female doctors. And unlike female doctors, male doctors devoted more effort to female patients overall.

Finally, the researchers wondered whether doctors gave preferential treatment to high-status patients because of their high status or because these patients had the power to create problems if they were unhappy with their care. To draw conclusions about this, they compared the treatment of retirees (who retained their status but had relinquished their authority) to the treatment of active duty patients (who still had both).

Schwab and Singh found that high-status patients continued to elicit additional effort from doctors up to five years after retirement, suggesting that status was an important factor.

I think it's really, really cool that even after retirement you still feel these effects, said Joe C. Magee, a professor of management and organization at the NYU Stern School of Business who studies the role of hierarchy. He sees this as a strong sign that status has always been the driving force behind doctors’ decisions.

What these people are able to show is that this has real health consequences, Magee said.

Eric Anicich, professor of management and organization at the USC Marshall School of Business, called the study impressive and its findings important.

Although a 3.5% increase or 1.9% decrease in physician efforts may seem small, their cumulative impact is significant, especially when it comes to something as crucial as patient care. health, he said.

The inequalities documented in the study are not unique to doctors or the armed forces, Schwab and Singh said. The mathematical model they developed to describe behavior in military emergency rooms also helps explain why, in all kinds of situations, people give preferential treatment to people who are similar to them: it can help minimize effects of societal disparities.

In a commentary accompanying the study, Laura Nimmon of the Center for the Study of Health Education at the University of British Columbia wrote that the ephemeral and unobservable nature of power made studying it extremely difficult. But she said it was worth it to ensure doctors exercise their power more equitably.

The disparities reported by Schwab and Singh are of serious concern to society as a whole, she wrote.

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