January 11, 2018

"There’s more and more emphasis to thinking about the ways bias shapes the way we hear our patients."

A quote from Dr. Elizabeth Howell, professor and director of the Women’s Health Research Institute at the Icahn School of Medicine in New York, that ends the NYT article "For Serena Williams, Childbirth Was a Harrowing Ordeal."

The details of the complications of childbirth for Serena Williams really are harrowing, and there is some reason to think the medical personnel were not appropriately responsive to her needs:
On Sept. 2, the day after giving birth to her daughter via cesarean section, Ms. Williams was having trouble breathing and “immediately assumed she was having another pulmonary embolism,” the [Vogue] article says.

She alerted a nurse to what she felt was happening in her body, but the nurse suggested that pain medication had perhaps left Ms. Williams confused, according to Vogue. Ms. Williams insisted, but a doctor instead performed an ultrasound of her legs.

“I was like, a Doppler?” Ms. Williams, 36, told the medical team. “I told you, I need a CT scan and a heparin drip.”

When the ultrasound revealed nothing, she underwent a CT scan, which showed several small blood clots in her lungs. She was immediately put on the heparin drip. “I was like, listen to Dr. Williams!” she told the doctors.
Can you imagine having Serena Williams under your care and giving her the very best treatment? Reading between the lines, I can see that it's possible that she was such a demanding and bossy patient that they didn't jump at every single thing she said. But the NYT uses the story to speculate about racial bias in the delivery of medical care. I'm not saying that's not an important issue — it is! — and having a celebrity face on a medical problem is often what you need to get attention.

Click through on the Vogue link for a great cover photograph of Serena and the baby.

49 comments:

Tim at large said...

It’s not always about race. This is just moral preening. Medicine is hard, and “hospitalists" are an abomination.

Enlighten-NewJersey said...

The bias is the one medical professionals have against patients, not against their race, gender, age, etc.

rehajm said...

I'm confused by the story. Ultimately she got the CT scan. So the complaint isn't that she didn't receive the care she needed but they performed other tests first, therefore racism?

Also nurses always roll their eyes.

Fernandistein said...

"racial bias in the delivery of medical care [is] an important issue"

It feels that way because "logic is dull".

David Begley said...

Instead of racial bias in treating the patient could it be celebrity bias?

Ron Winkleheimer said...

Doctors and nurses go through years of arduous education and training. Patients in a hospital are usually in pain and afraid. Not everything is about race. I remember way back when. A guy I knew was eating fried chicken and got a bone stuck in the back of his throat. He went to sick call and told the doctor what had happened. The doctor totally discounted what he said. Patients are not competent to diagnose themselves you see. It was only after a couple of visits and an infection started forming that the doctor actually realized that the patient was correct and removed the bone.

Doctors are assholes a lot of the time.

Also, there was a headline about Serena planning her tennis comeback. She's 36. Its not happening.

Compassionate Libertarian, MD said...

In many cases, ultrasound is an appropriate first test for pulmonary embolism as most blood clots start in the legs and the migrate to the lungs. Ultrasound also avoids radiation and contrast exposure that carry additional risks for the patient. Also, starting heparin without a confirmed diagnosis or very high suspicion places patients - especially post partum patients at high risk for uterine bleeding - at unacceptable risk of bleeding complications.

Finally, the physician who wrote this story knows very well that it is not a Labor Nurse's job to diagnose their patients' complaints - that is thr physician job. Unless the nurse totally disregarded Ms. Williams' complaint it sounds like the care team was acting appropriately.

None of these details sound inappropriate nor do they demonstrate racial bias with what was written. It sounds like the standard of care was met and they did come to a diagnosis in an appropriate time. Patients disagree with their physicians all the time and regardless of their race.

Virgil Hilts said...

There are cultural differences that relate to expression of pain and doctors/nurses who take complaints of extreme pain from hispanic patients less seriously. This may in part have caused the tragedy some years ago in Phoenix when a 13 year old Gricelda Zamora died of a burst appendix while her parents were trying unsuccessfully to get her proper medical treatment.
OTOH my wife gave birth in a maternity pod where several hispanic women were also giving birth. I have never heard as much screaming in my life.

dda6ga dda6ga said...

rich, entitled, very few people have ever refused her requests, demands.

Big Mike said...

It’s not racial bias, too many women of my acquaintance, and women I have read about, have had difficulties with doctors assuring them that potentially serious medical issues “are all in your head.” I suspect that there is something wrong with the way medical personnel, nurses as well as doctors, are trained. Women are not small men, and no, embolisms are not all in their minds.

Ignorance is Bliss said...

They don't feel pain the way we do...

CJinPA said...

In many cases, ultrasound is an appropriate first test for pulmonary embolism as most blood clots start in the legs and the migrate to the lungs.

But a newspaper quoted a doctor who never saw the patient, and she said the ultrasound was racist. So...

Charlie Currie said...

Based on my experiences over the past dozen years with my almost 99 year old mother, I don't believe it has anything to do with racial bias, and everything to do with arrogance.

Jim McKee said...

Based on my (white) wife's experiences over the last couple of years, it sounds like typical behaviour of medical staff.

Fernandistein said...

A surprisingly large percentage of people can't understand the labels on their pill bottles or figure out when their next appointment is.

Intelligence: Is It the Epidemiologists’ Elusive “Fundamental Cause” of
Social Class Inequalities in Health?


Over half of the 1.8 billion prescriptions written annually are taken
incorrectly by patients.

Noncompliance of all sorts is particularly a problem in low-income clinic populations, where rates frequently exceed 60%. Expense is seldom a barrier, but regimen complexity is.

Henry said...

My first son was born after a harrowing labor in a hospital full of inattentive nurses and on-call doctors that never made an appearance. It happens. We switched practices for the next birth.

cubanbob said...

What has race, celebrity or culture have to do with anything here? Is it too much to expect doctors and nurses to take a patient's complaint of difficulty breathing seriously?

tcrosse said...

I had a hell of a time trying to get a correct diagnosis for pulmonary embolisms, and I'm a doddering old white nobody.

holdfast said...

A professional athlete is much more likely than a non-athlete to be in touch with how their body is working, or not working, and remember how similar symptoms were treated in the past.

Also, based on my wife’s two childbirth experiences, doctors and nurses of both sexes tend to think that pregnant women and new moms are a little hysterical and unreliable. This may be correct in some cases, but it also leads to ugly mistakes.

So definitely biases, but probably not racial.

William said...

Some people don't like Serena because she's black. Some people don't like her because she's high handed. Does anyone know of someone with sufficient impartiality to delineate this? .......She has a cute baby, and she looks very attractive and glowing iin that Vogue picture. I have heard of thornier problems than those faced by Serena.

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Lucien said...

Sounds like Ms. Williams was using an availability heuristic, and got a "good" draw.

mockturtle said...

Other articles report that Serena was simply experiencing the kind of dismissive attitude of many busy medical facilities toward patients every day. She knew of her condition and knew what would be required to prove it in order to get the required anticoagulant treatment. Good for her that she boldly pressed her case. She saved her own life.

Birches said...

I don't believe there is a racial bias, there is a poor bias and that can look racial. I've always had very attentive nurses when I gave birth, but I know being on medicare meant crap treatment for some of my friends.

Birches said...

I always had insurance. I think that makes a difference.

James said...

Isn't increased risk of pulmonary embolisms associated with steroid use?

mockturtle said...

Isn't increased risk of pulmonary embolisms associated with steroid use?

Pulmonary embolism is a risk associated with childbirth.

James said...

Isn't increased risk of pulmonary embolisms associated with steroid use?

Pulmonary embolism is a risk associated with childbirth.


Which doesn't mean that it isn't also associated with steroid use.

Google 'Serena Williams drug test panic room' for more

David said...

Serena did what any wise patient does. She took ownership of her own care. It's a huge advantage if you can do it, and she had the force of personality to pull it off in potentially life saving fashion.

Good medicine is all about asking questions. A good doctor benefits if the patient does not leave that task solely to the medical professionals.

David said...

" Medicine is hard, and “hospitalists" are an abomination."

Hoo boy is that right. Do not get me started.

Pillage Idiot said...

Heparin as an anticoagulant. It is certainly contraindicated after a major surgery, unless even more dire circumstances require its usage.

The proper treatment for a pulmonary embolism immediately after a C-section is almost certainly different than the treatment for an embolism that occurred when Serena was in playing shape.

She was correct to state that her body felt like it was reacting in a similar fashion to her previous embolism. She was foolish to push for a particular treatment based only upon that feeling.

Freeman Hunt said...

It's not a race thing, it's a pregnant woman thing. Medical care for pregnant women needs to be overhauled. It's awful. The working assumption seems to be that all pregnant women exaggerate everything which is total nonsense. And most practices now expect pregnant women to "meet" all of their doctors by having the patient rotate with each appointment. Who meets someone new with a pelvic exam?

(I always refused to rotate. "I am not going to do that." "Uh... You're supposed to meet all of them." "That is not how I meet people." "What if someone else has to deliver your baby?" "I'm sure only qualified doctors work here. If that happens, I'll meet the person then." "I don't know if we can do that." "You can. I. Will. Not. Rotate.")

Freeman Hunt said...

I've never been to a maternity ward I liked when I've visited a new parent. Never.

On the other hand, pediatric units at hospitals seem particularly good. (Pediatric practices are often another story...)

Freeman Hunt said...

A doctor once recommended I try a homeopathic remedy for a child. I burst out laughing, and he looked offended.

"Sorry, I didn't know you were a witch doctor."

I did not actually say that.

Freeman Hunt said...

"I always had insurance. I think that makes a difference."

It does not make a difference around here when it comes to inattentive nurses.

Yancey Ward said...

Ms. Williams has had a pulmonary embolism before, so one might take that into account when she thinks she might be having another one. However, on reading about the treatment she received and what is recommended in such instances, I don't think she is right to complain about how it was done. You aren't going to get heparin just because you say so as a patient- from what I can tell, the steps taken in that order are, apparently, the best practice when someone makes the the general complaint Ms. Williams made about not being able to breath properly.

Howard said...

You need an advocate when you are in the hospital because that is the place where the least qualified medical people end up.

Begonia said...

Serena may have been a demanding patient. Or not. Either way, being demanding may have saved her life.

Her story reminded me of Shalon Irving's story, which is heartbreaking:

https://www.propublica.org/article/nothing-protects-black-women-from-dying-in-pregnancy-and-childbirth


I Have Misplaced My Pants said...

I don't believe there is a racial bias, there is a poor bias and that can look racial. I've always had very attentive nurses when I gave birth, but I know being on medicare meant crap treatment for some of my friends.

With all due respect, for the most part how would L&D nurses know, and why would they care, whether they were on Medicaid? The nurses are getting paid the same, regardless.

I can see doctors and hospitals having to struggle against resentfulness toward Medicaid patients ~ the reimbursements aren't worth the doctors' time (I worked for a psychiatrist and he received $33 from MC for a 30 minute medication check. That's going to settle those med school loans and pay his insurance premiums, hoo boy!) and as a group they are a giant pain in the ass. Their compliance is low, they make terrible lifestyle choices that complicate their care, they present a lot of administrative headaches, etc.

Pray for me, as this is evidence of my uncharitable heart, but I would love it if I could find an OB practice that only accepted private insurance or self pay. I can't help but be annoyed in the waiting room crammed with obese women covered in tattoos, reeking of cigarette smoke and surrounded by a clutch of badly behaved kids they already have and can't take care of properly and thinking about how my husband and I are paying for all that, including for the extra care they need due to their general poor ability to manage their health and make wise decisions.

n.n said...

Liberal diversity (i.e. denying individual dignity), color diversity (i.e. judging people by the "color of their skin"), is a clear and progressive problem, exacerbated by institutional or establishment diversity.

Martin said...

I cannot know what happened in Williams' case, but my wife, decidedly Caucasian, has had some truly harrowing experiences with doctors who make up their minds what is going on and then shut out anything to the contrary until their theory is proven false.

Fortunately, so far the "proving false" part has not required her to die. And she sees "top doctors" in prestige hospitals, not walk-in Medicaid/Workers' Comp mills where traffic volume is the most important thing.

Some of this may be driven by issues of whether insurance will cover an expensive step until everything else has been ruled out. It is no doubt complicated. Race may have played a part in Williams' experience, as she is a rich celebrity I doubt it. There are other reasons that should be considered, first.

There's a book, "How Doctors Think," that touches on this phenomenon (among others)

JaimeRoberto said...

In my wife's home country the nurses just tell the mother to shut up and stop crying, because the pain is not that bad.

JaimeRoberto said...

I would imagine that diagnosing a medical problem is a lot like getting tech support. You don't necessarily know the knowledge level of the person you are dealing with, so you need to start with the basics. Is it plugged in? Did you check the connections? That way you rule out the most simple and common causes of the problem. Reporters would be wise to follow a similar procedure before injecting race into an issue.

mockturtle said...

Reporters would be wise to follow a similar procedure before injecting race into an issue.

What??? Are you suggesting that reporters are after the facts, rather than a salable story? C'mon, Jaime. You weren't born yesterday.

wwww said...
This comment has been removed by the author.
JaimeRoberto said...

"What??? Are you suggesting that reporters are after the facts, rather than a salable story? C'mon, Jaime. You weren't born yesterday."

A man can dream, can't he?

openidname said...

Virgil: Did your wife ever give birth to a different child in a less Hispanic ward? You need a control group. Just sayin'.

openidname said...

Generalizing from any one case is invalid.

openidname said...

The latter comment directed atthe NYT, not Virgil.