Dr Sanjay Gupta Gets Medicine and Race Exactly Wrong

I’m not a Sanjay Gupta fan. As an Indian-American medical student who has an interest in communicating medicine to the public, the comparison comes up from time to time.

He’s got a 2 minute short up on CNN.com here. Read the URL, it’s more than a little sensational, referring to “medical apartheid,” and the video itself isn’t much better.

 

It tells the sad story of Rev. Gary Spears, who had an infected paper cut. He also had diabetes, undiagnosed, and untreated. The video implies that Rev. Spears wasn’t diagnosed with diabetes, and consequently, didn’t receive appropriate care because he’s black.

They even cite a study pointing out that doctors DO let race influence their decisions – there are studies that show that if shown videos of two patients with the same symptoms, doctors are more likely to run more tests on the white patient. Personally, I don’t doubt that doctors let race influence their decisions – we are merely human – but that study in particular is somewhat contrived.

I’ve always said, no medical advice online – because I can’t see, question, and examine the patient myself. These studies rely on videos so that doctors can’t ask more questions, and can’t examine the patients. This is not our routine, this is not our job. We do not diagnose video tapes. We diagnose people, who are in front of us. When not doing our actual job, I suspect that hidden biases like race prejudice would be more likely to influence our decisions. Even if you accept this study, it may not say anything about Rev. Spears. Please note, I don’t deny that race CAN inappropriately play a role in health care decisions. I just deny that this is an obvious case of such a problem.  

Rev. Spears went to the ER for his papercuts. The video says he went to the ER, twice, and was directed to an outpatient clinic run by the hospital. To my ear this means one of two things.

  1. Some ERs run a side-clinic to treat non-emergency issues. My own institution has one of these. These clinics are NOT primary care clinics.
  2. He went to the ER and was discharged, with followup to an outpatient clinic with a primary care doctor. I doubt this one, because if he had been directed to a primary care doctor after the first ER visit, why would he have gone back to the ER? 

In scenario 1, it’s not surprising that his diabetes wasn’t diagnosed. If you go to the ER with an infected finger, it’s just an infected finger. Why would I run extra tests to check for diabetes? Rev. Spears has insurance, and should follow up with a primary care doctor after we discharge him anyway. The ER is not a primary care clinic. ER doctors are not primary care doctors. Their job is to stabilize the patients who would otherwise die, and to diagnose and treat acute issues.

Lots of people get diagnoses of chronic diseases like diabetes in the ER. However a finger infection isn’t a complaint that makes me think “oh he’s a diabetic,” it’s a complaint that makes me think “oh he has an infected finger.” Certainly, it’s possible that the doctor should have asked more questions and elicited that diagnosis. Their failure to do so doesn’t strike me as racist. Let’s not attribute to racism that which can be attributed to apathy or limited scope.

In scenario 2, if he WAS followed up with a primary care doctor (which this video doesn’t  really say), this doctor absolutely should have diagnosed the diabetes. Almost all inlet forms for primary care practices involve questions about the symptoms of diabetes that Rev. Spears had – polyuria (peeing a lot) chief among them. Most primary care doctors seeing a patient for the first time will explicitly screen by history for diabetes, hypertension, and heart/arterial disease, among other things. If they didn’t, this too doesn’t imply racism. Let’s not attribute to racism that which can be attributed to incompetence.

 Sanjay Gupta should know all of this. He’s a doctor. He’s a neurosurgeon so this isn’t exactly his bread and butter, but he’s a doctor. He knows the division of labor in the health system, and he should at least check on the standard of care for a situation before reporting on it. 

 

 

Incidentally, I hope to make this the first in a new feature that I’m calling “Exactly Wrong.” In “Exactly Wrong”, I’ll be calling out public figures in the media telling it like it isn’t, or (humor me) getting it exactly wrong about medicine.

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20 Comments on “Dr Sanjay Gupta Gets Medicine and Race Exactly Wrong”

  1. MXH Says:

    Sanjay Gupta is a doctor, but he’s also a media personality. There are lots of people pressuring him to make a story “news-worthy.” I don’t like physicians in the media because of the fact that getting better ratings always trumps being an objective physician (and for that matter, I don’t like the media in general, because the same applies to an objective journalist). So, none of this is surprising, Gupta has done similar stories where he leaves out the entire story before.


    • I lost what respect I had for Gupta when he spent an entire segment speculating wildly on Ana Nicole Smith’s death.

      There is a certain lack of integrity in doctors who go into the media, and politics. In both cases medicine really is set aside to manipulate others.

  2. leigh Says:

    maybe he sees one of those chiropractor-PCPs like you mentioned in your last post.


    • oh if only I could blame the alt-meddies for this too. Sadly, my profession creates some of its own problems.

      For some reason most people cant be a “Doctor AND…”

      In my experience people who are “doctors AND businessmen” are usually businessmen with degrees. Some of the worst are MD/MBAs, who go from prioritizing the patient to prioritizing the bottom line.

      “doctors and journalists” are generally journalists who get paid better and spent wayyy too much time in school

      I’m sure I could extend the pattern ad infinitum for any number of other professions, and I’m sure I’m overgeneralizing, but as a general concept it works.

  3. Papa Tales Says:

    I agree whole heartedly about combining business and medicine. They should never be mixed. Unfortunately the entire health care reform debate (at least from the point of view of people on the right) is more about making it a business.


    • I beg to differ. I combine the two, and I am convinced I am ethical and moral. I know too many physicians in the pharmaceutical and medical device industries who always make the right choices. The best of them stand up to the “profit over medicine” choices as best they can. Since they sign off on launches of products, they have the last say, especially since they can be held both criminally and civilly liable for their decisions.

      The debate over healthcare reform is specifically about insurance, which needs to be reformed for many reasons.

      So, I take umbrage at your comments. Dr. Gupta is a media whore, and comparing him with a medical director at Merck is unfair.


      • Actually, my dad, and my self, aren’t referring to doctors who work for a for profit company.

        We’re referring to the care of individuals in the system a for profit enterprise.

        Right now, the incentives for physicians working in private practice are to bill as many tests as possible, and be as specialized as possible to bill as much as possible, rather than to take care of our patients.

        I discussed this phenomena a while back with a discussion about Gawande’s New Yorker Article.

        That’s really the specific point about MD/MBAs as well. They are often brought to a hospital not to improve care, but to make a hospital profitable.

        In these two situations, the basic morals and ethics of a doctor are in conflict with their economic incentives, or their actual job description. This is in contrast with a medical director at merck, who can morally say “i think this product will help people,” or “I’m shutting this one down.”

        So the comparison being made here is to the doctors in the Gawande article overbilling and costing the system a TON of money, rather than a medical director at Merck.

        I hope the assuages your umbrage.

  4. endomd Says:

    I am not sure who the medical student is who wrote this blog, but I would suggest more studying and less blogging. I watched the report, and Mr Spears had an 80# weight loss, frequent urination and excessive thirst, as Gupta stated in his piece. Those are classic signs of diabetes. If you are a so called medical student, make sure to get some endocrinology studying in as well, in the midst of your grand pursuit of calling out public figures. Your Dean should be so proud of you. Oh, and very nice of you to identify yourself. Guess you dont wish to be called out yourself…


    • Oh, and very nice of you to identify yourself. Guess you dont wish to be called out yourself…

      … “endomd” is calling me out for being pseudonymous? That sound you heard was my ironymeter breaking.

      I am not sure who the medical student is who wrote this blog, but I would suggest more studying and less blogging.

      I would suggest that an anonymous endocrinologist go to the ER and see 15-20 patients per hour, and understand the standard of care medicine before talking smack about missed diagnoses.

      Key point that you missed in my post:

      Rev. Spears went to the ER for his papercuts

      The video says Rev Spear went to the ER for his infected papercut. The video does NOT say “Rev. Spears went to the ER complaining of weight loss, excessive thirst and polyuria,” which is an obvious “check a blood sugar.”

      If a patient presents to the triage nurse with an infected finger it is NOT normal for the triage nurse to screen for diabetes. Triage nurse would then triage the patient to acute ambulatory care or outpatient clinic referral.

      An ER doctor in acute ambulatory care is expected to see a patient every 5 minutes, and is given a chief complaint from the triage nurse, such as “likely cellulitis” or “red hot swollen finger”

      It is NOT standard of care for finger infection to screen for diabetes. If the doctor walked in the room said “what’s the problem” and Rev. Spears held up his finger, why would the doctor ask about diabetes?

      Furthermore, because we lack a consistent EMR in this country, and medical records are generally not available in the time before an EM doctor sees a patient, when Rev Spear went to the ER the second time, the doctor there would not necessarily understand that this was a recurrent infection, and had concern to check for secondary causes of an infection not clearing. Nor have any reason to suspect that diabetes was responsible for the infection not clearing since the patient carried no such diagnosis, and didn’t go to the ER for those symptoms. While Sanjay Gupta gift-wrapped you a diagnosis at the start of the video, that’s not what showed up on the chief complaint. and I’m betting it’s not what Rev. Spears told the doctor.

      I love my patients, but I don’t depend on them to come in and say “well doc, I’ve lost 80 pounds, i’ve got polyuria, polydipsia and a nonhealing infection on my finger here, that was once a papercut… and I think I may have some peripheral neuropathy.”

      Such a story is 20/20 hindsight.

      I watched the report, and Mr Spears had an 80# weight loss, frequent urination and excessive thirst, as Gupta stated in his piece.

      Ah, and what did Mr Spears tell the doctors in the ER? It says he went to the ER for his papercuts. Not his weight loss. How many patients do you think attribute their papercut infections to their diabetes-that-hasn’t-been-diagnosed-yet? How many patients then bring that up when talking to their doctors about what they see as unrelated complaints?

      How many emergency room doctors have a 20 minute office visit to sit down and tease out a more full history for a paper cut?

      Those are classic signs of diabetes.

      Indeed, I didn’t say “they didn’t miss the diagnosis.” I said ” it was not ER standard of care for infected finger, possible incompetance on the part of a PCP, but probably not racism”

      If you are a so called medical student, make sure to get some endocrinology studying in as well

      Yep, clearly my post indicates that I don’t understand endocrinology… wait wait no that’s wrong, you just didn’t read my post.

      , in the midst of your grand pursuit of calling out public figures.

      You read less than one post, and purport to understand what I’m doing here? Read around some more, this blog is about patient communication. Here I’m debunking an overblown news story that claims racism where the story hardly implies racism.

      I train at a tertiary care center, every day I see patients, black and white, whose diagnosis was missed at the community hospital they were referred from. It’s not racism, it’s how medicine works.

      Your Dean should be so proud of you.

      Ah, so I’m to be chastised for acknowledging the problems forced on ER doctors by overcrowding. A problem forced by a lack of primary care doctors?

      I’m to be chastised for pointing out what the standard of care is? Because of hindsight being so obvious that even you, anonymous endocrinologist, could make the diagnosis after Sanjay Gupta wrapped it up and told you at the very begining of the segment?

  5. endomd Says:

    Wow, a moronic and insecure medical student with a blog that 12 people read last week. You have a bright future. As far as the 80 pound weight loss, most doctors would elicit that on a “history.” It’s not a gift wrapped diagnosis, it’s part of doing your job. Again, less blogging and more studying, even at your very impressive “tertiary care” hospital. I can only hope that you choose to pursue blogging full time, because I would hate to run into you as an MD.
    Good luck.

    • Papa Tales Says:

      When you can’t reason, start calling names …


    • Well I, for one, would love to have you as my endocrinologist. It’s so rare to find a doctor who really believes in communication via ad hominem.

      I can only hope you are as cordial in person as you are online. Your sparkling bedside manner has made a great impression on me, and truely shown me how to talk to people for maximum effect.

      Truely, you are a Giant Among Men, and an Inspiration to us all.

      What’s fun about your comment was the way in you deftly avoided addressing the substance of my post, discussing standard of care, and what the law, ethics boards, insurance companies, and actual doctors in the field consider their job by defining an ER doctors job via your own opinion of what their job is.

      For example, in our ER do you really think you’d walk in the room and go “Oh you have a finger infection? Well have you lost any weight recently?”

      Also, you still failed to address the fact that the post is about RACISM, and whether THIS was racism.

      Still, I enjoy your rambling, so feel free to continue posting. Infact, had you provided a legitimate email address instead of the fake one you typed in to post here, I’d have emailed you encouraging you to post, but reminding you that we have rules on this blog, that you’d have known about had you read the disclaimers section on the sidebar.

  6. BB Says:

    Someone tell Rev Spears that this white woman just saw a new primary care physician (GYN) who failed to ask about previous surgeries, and whether she’s currently on prescribed meds or takes any supplements. It’s not racism, it’s plain incompetence.
    I’m looking for a new doc.

  7. Calli Arcale Says:

    Prejudice can take lots of forms, and I think the most dangerous one from a doctor isn’t racism but thinking you know the diagnosis ahead of time. I had a doctor (a PCP-type doctor, though not my own PCP, who was on vacation at the time) who, when I came in complaining of acute asthma symptoms, decided to have me tested for diabetes and thyroid problems instead, on the basis of one family member who had experienced a thyroid problem with different symptoms than mine. So there it goes the other way — if I’d gone in to an ER, I’d’ve been given a neb and perhaps a prescription for inhaled corticosteroids and a recommendation that I see my regular PCP as soon as practical. Instead, I got worked up for a nonexistant condition and I had to wait a week before seeing my regular PCP and getting the Pulmicort I needed in the first place

    So it can go both ways. There’s a very good reason why ER doctors focus on acute care, and not the diagnosis of chronic conditions. Yes, things can be missed that way. But the ER is not a place for treating or diagnosing chronic complaints. Dr Gupta is expecting the ER to be something that it is not.

    That said, I have to wonder how Rev Spears’ regular doctor didn’t notice the 80 pound weight loss. That’s pretty dramatic, even over the course of a year, and should elicit at least a few questions. Or was Spears not getting annual physicals? Was he expecting the ER to do his regular doctor’s job? Or was he uninsured, and thus unable to afford regular checkups?


    • In the video it explictly says that Dr Spears has insurance. It does NOT say that he has a PCP. It’s unclear on this point. I doubt that he had a PCP. Frankly, if he had a PCP, who he saw regularly, I think this segment would have been about the PCP – and about the malpractice suit. A PCP’s job IS to diagnose and manage these chronic issues. Even if he had a PCP who did not diagnose this, I would still fault incompetance, not racism.

      In real life, I see lots of well meaning people (not just in medicine) who just aren’t good at their jobs. Sure many people have prejudices, and that can affect anyones judgement. Still it’s a big jump to go from “I may have some prejudice” to “i’m a racist so I’m going to give you crappy healthcare.”

      Almost any problem with constitutional symptoms (i.e. weight loss)will get at least a basic chemistry panel which would have shown elevated sugars. Now that IOM guidelines include diagnosis of diabetes by A1C, it is not uncommon to have a PCP run a hemoglobin A1C as part of this workup. Hemoglobin A1C is basically a marker of your ‘average’ sugar over the past 3 months.

      You are indeed correct, the ED is not your PCP. An internal medicine resident rotating with me this month made the mistake of talking about referring for a screening colonoscopy and getting lipids on a patient in the emergency department with the flu – our attending laughed him out of the room.

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