This kind of bullshit just proves what I've known for years. Most doctors suck, and many seem relatively psychopathic.

I rely on Medicaid and SSI. I've seen the policies, and they pretty much imply that the less money you have, the more expendable you are. Did you know that to the state of IL, a phone isn't a necessity, therefore, they don't supply extra money to pay a phone bill? I guess if you need to call for help, you're shit out of luck. And have fun making appointments of any kind. And I've also noticed a large lack of respect from doctors and nurses because of my situation. I'm told that I don't know what's wrong with me, or that it's all in my head. I have antidepressants pushed on me for everything. They don't want to treat me. They want me to shut up and go away. Things weren't like that when I didn't rely on the state.

If I was in the situation like the one in the original post, I'd DEMAND that I get treated with an adequate dose. Those filthy cocksuckers have absolutely no right to do that. That could very well fall into the category of eugenics.

Exposing this kind of appaling misconduct is why public health research is so important as a feminist cause.

Too bad the researcher attributed the bad practices to a lack of "shared culture" instead of calling what it is, sizeism and classism.

I certainly agree that the idea that giving fewer health resources to people of lower SES is absolutely abominable, but there's somewhat of a misreading of intention in this research.

For one, it's not surprising to see that oncologists are skeptical to give guideline doses of chemotherapy to obese patients, primarily because most chemotherapeutic agents do not necessarily respond in a directly linear way to those with a greater proportion of adipose tissue. It's hard to give a patient a large dose of a chemotherapeutic agent knowing how toxic those medications are. Oncology, while largely protocol driven, is also a specialty of balancing risks and benefits. Give patients too much chemo, they can't tolerate it, they have to stop, and whatever benefits posited in the protocol are null. If a physician's clinical experience suggests that such large doses lead to poorer outcomes, then that clinician does have some leeway in interpreting guidelines and trying to balance harm and benefit. That's certainly not based on some sort of hatred for a patient.

That's not to say I agree with excessive freelance interpretation of protocols, but to imply malintent upfront is a bit alarmist.

A similar argument can be made for the lower SES patients, though admittedly not as compellingly. To imply eugenics as motivation is a little, say, nuts. I'm sure the previous commenter has had terrible experiences in a broken health care system, and those experiences aren't uncommon. But the article doesn't even say that the dosing isn't adequate, as "adequacy" is defined only in protocols which are typically fluid for any given patient.

It's not like docs are saying, "hey, this woman is poor, let's let her die of cancer." And that's not what this research is even getting at. Further work needs to be done to find out the why. And that why most certainly isn't the sort of blatant classist misogyny that some of you might wish to embrace so quickly.

this might be a tad off topic, but this seriously hits home for me right now. cuz its not just chemo, and they dont stop at women...its also little kids.

im close to my boyfreinds family and his 8 year old sister has been going through serious hell because of this. first they just rushed her into surgery and took out her appendix for stomach pain without doing any tests(those cost money). and of course that wasnt the problem...she has kidney stones. so they do another surgery, end up completely fucking it up (a balloon that is not supposed to burst ruptured and injured her more). theres actually alot more fucked up shit but ill stop there. the doctors keep trying to send her home and basically do nothing because they dont have insurance. shes been screaming in pain so horribly her parents have no choice but to take her back. this is so ridiculously horrible, to make an 8 year old go through this all cuz they dont have insurance.

there suing the shit outta them tho

I'm not an oncologist, but if you are correct, GS, and patients' heights and weights are insufficient inputs for correctly dosing chemo, then the guidelines themselves are unfair to folks with a greater proportion of adipose tissue. Relying on the clinical experience of oncologists to determine that the guildlines are wrong for certain groups of people is putting those folks at grave risk because of their size. That's sizeism.

And saying that people with lower SESs (or in this case from lower SES census tracts) are less able to deal with the side effects of chemo IS classist. It is an assumption based on (among other things) stereotypes of poor people as incompetent in their own care and as isolated in their communities.

And as a point of disclosure, I'm writing this from the basement of the U-M School of Public Health, writing this between my biostatistics and designing clinical research class. So Dr Grigg's work is at least proximal to me :0)

I'll finish my MD from U-M in May 2008, before I start residency in psychiatry. And don't worry, my future research is how to improve care for poor kids with neurocognitive disorders.

So I have a really hard time believing that overt sizeism or classism is to blame here when there are plenty of other factors that make a lot more sense, even if they don't satisfy a thirst for blood. That doesn't mean I don't think that we need full-court press efforts to rectify what is an OBVIOUSLY unacceptable situation. But calling those with the prescription pads "eugenicists" doesn't exactly do ANYTHING to help poor women getting screwed by a system that doesn't meet their needs.

I actually agree Garrett. I am not a big fan of freaking out before finding out more. While this happening doesn't necessarily surprise me, I am still hesitant to immediately scream conspiracy. Your hypothesis on why they are worried about obese women is true as well.

This does not surprise me. I had a friend, much younger than me who had breast cancer. Because she didn't have insurance and was poor she received bare bones care. She didn't make it and she did not have one of the really nasty strains. It really makes me angry that she was denied treatments others could have gotten.

If we finally had national healthcare it would level the field a bit for the patient. We would all have the same kind of insurance.

Actually, my reading of the research summary here is not that doctors are being evil eugenicists, but that they are making classist assumptions. That they may have a sociopathic lack of empathy in some cases, but that they are overcompensating rather than undercompensating.

After all what's happening is not "let 'em die" but "I know I can explain to someone like me what's gonna happen if they get the higher dose of chemo, but how do I explain that to 'one of them'".

The net result may be just as bad in terms of patient outcome, but if you want doctors to change their ways, it helps to acknowledge that here they may largely mean well, at least.

Also, likely important is the fact that more educated, higher SES types are more likely to question their care and thus get better care. My mom grew up in a working class family/neighborhood, and people just didn't question the doctor. It was quite a culture shock for her being married to a quasi-medical professional (an optimetrist), going to religious services with various physicians, etc. She now knows that it's good to question, and the good doctors welcome it. But if she remained at the same SES she grow up with, she might not be receiving adaquate medical care simply because she didn't know she had to question things, etc.

So the educational aspect of public health is actually very important.

Regarding the issue of obesity: IIRC, a lot of dosages for chemo are calculated based on height^2 ... i.e. what matters is not the weight you are but the weight you "should be" (the much, and in some cases rightly, BMI theory) ... so I'm not sure if that's an issue per se, although perhaps there are worries about health problems that are correlated to obesity, at least as most physicians understand things.

So I can't get my hands on the original article without paying $19, but the abstract doesn't mention race at all. I hope this data is included somewhere in the paper, because given the conflation of low education, povery, obesity, and race, as well as black women's tendency to get more aggressive/less treatable types of breast cancer there's a lot that hasn't been explored.

It is a travesty when women receive substandard care because of a physician's biases, but it would also be terrible if the researchers failed to elucidate the real reasons for the discrepancies in treatment.

I don't know katie & Garrett - have you ever been in Tokaia's position? I have been and now I am not. I can tell you, being poor results in doctors treating you like sh*t. I have been told I would be healthier of I stopped shooting up (huh???where the HELL did that come from - honors student, went to college on scholarship, but hey, I am poor - so I MUST be on drugs) or stopped sleeping around (I was celebate) OR that I needed to see a psychologist about the blinding pain in my stomach, vagina, and urethra. Now that I am upper middle class, my problems are taken VERY seriously. Classism is alive and well in the medical community.

"When it comes to obese patients, the researchers suggest that doctors reduce the chemotherapy dose because they do not want to give those patients the large dose that their weight would indicate. The motivation is to avoid potential severe and harmful side effects in their patients. For those patients of lower socioeconomic status, doctors may be anticipating the patient's attitude toward treatment, the researchers suspect."

This is the key paragraph to me. I went through two rounds of chemo for testicular cancer in 2005 and it is not pleasant (duh!). Higher and more prolonged doses always bring more risk of permanent side effects. I was warned that temporary side effects would include loud ringing in my ears (and pain), tingling and loss of sensation at my extremities, and loss of taste and smell. I also would experience temporary disorientation and loss of some short-term memory abilities for some time afterwards (chemo-brain, as they call it). And these were the side effects for a generally healthy, young male on a low dose. Long term I can expect to have a heart attack about 5 years earlier than average.

The higher the dose, the more likely side effects like these are to become permanent. People who receive heavy doses could have permanent hearing loss and numbness, loss of taste and smell, and so on. It's toxic stuff. I suspect that it also affected my GI system, as I've had trouble with that ever since. And this was all from what is considered a "light" dose. So, I can see why doctors would be hesitant to administer heavier doses to larger patients--the risk of permanent and damaging side effects goes up pretty steeply, and the tradeoff between that and less therapy becomes more of a question if they aren't certain that the cancer cells are still in the patient (adjuvant treatment--it may be there, but they can't see it, so they treat you anyway to improve your odds).

*I would just like to note that body mass is very important whenever major procedures are being conducted. Overweight people carry much more risk with them into the surgical room or into procedures like chemotherapy. That aspect of it, at least, is simple fact and has nothing to do with physician bias.*

I can also "see" why they may be hesitant to administer larger doses to people who aren't as educated--they worry that these people, who are likely to have less general knowledge of biology and health, would (behaviorally) respond to their treatment poorly.

But just because I can "see" these things doesn't make them right--especially in the case of lower income and less educated people. The doctors appear to be making choices that are rational from their point of view. They are ideally acting in what they perceive to be the best interests of their patients. But sometimes their perception may not be reality.

I think what this study documents is the fine line that doctors are trying to walk in these situations. Perhaps the line needs to be shifted.

But it's not a clear-cut case of doctor's blatantly discriminating against obese and low-income patients. There are underlying medical reasons for many of the choices made re: obese patients. Regarding the low income patients... yeah, that isn't as straightforward. I would guess it's a mixture of professional experience and class bias.

I agree with Garrett to some extent. To give a differential treatment to obese persons makes absolute sense. While people ought not to be judged morally by their appearance -- the fact is, obesity is unhealthy. Period. There's nothing unfeminist about saying it's good to take care of yourself, eat healthy, and get a reasonable amount of exercise. This doesn't make obese people "lesser" people or "bad" or anything -- but since, on the whole, obese people are less healthy than the general population, it would be malpractice for a doctor NOT to consider the obesity in treatment approaches.

However, I cannot see a reason for the differential treatment of women of lower social class. The only conceivable possible thing I could think would be if there is a worry of malnutrition -- if the doctor is concerned that when she leaves the hospital she will be going to a home where she cannot get adequate nutrition. However, in my mind the answer to this is not to lower the dosage, but rather to ensure she receives adequate nutrition. This is something hospitals and insurers are absolutely in a position to do, and litigation to cure this inequality might be called for.

Tried to look up the original article, but my school only has it in print, not online - and I'm too busy to go to the library. Can't comment on the income/demographics data (and I'm totally willing to thin that some out-of-touch docs are showing bias), but concerning the weight issue: Lots of drugs are dosed milligram per kilogram; but also have an absolute cutoff of toxicity. (Usually stated as 'give x mg per kg, not to exceed z mg in w hours') As patients get heavier you approach toxic doses. It could be that with heavier patients, doctors get nervous about playing near the line of toxic dosing, and reduce the doses that larger women get per kilogram. Don't know for sure - I want to read the original study to see if they comment on this, and whether they accounted for it in their analysis. Just a thought, though.

Seriously, some of you are being terribly naive. Have you ever heard the expression "watering down the liquor?" The poor women, whether they are obese or not, are being given watered down medicine. So the physicians can make more money; same concept as watering down the booze. Chemotherapy drugs are ULTRA-EXPENSIVE, and older lower class women are indeed seen as expendable. The fact that poor women are much less likely to survive breast cancer is an observable and measurable result of this sort of practice.

We speculate that physicians have concerns about a patient's ability to tolerate the side effects of chemotherapy and that the physician's uncertainty about a patient's tolerance increases with increasing social distance

I can see this happening, not that it's ok, but doctors (who are wealthy and well educated) view poor and uneducated patients differently.

Their assumption may be that poor women will be less willing to endure more severe side effects, which is ridiculous, but it's not unusual for wealthy people to view the poor as weak and helpless. Those docs may also assume that poor women have less financial resources (true) and less support from family and friends (questionable, but not impossible). Chemotherapy is painful and can be debilitating. A patient who doesn't have the financial resources to pay for counseling, alternative medicine, or other forms of support not covered by insurance, and a patient who doesn't have family or friends to rely on while undergoing treatment, will be more likely to stop treatment too soon. It seems like the real trick is to convince doctors that poor women are just as able to withstand chemo as anyone else.

I used to work in a doctor's office and their resistance to accepting or treating Medicare and Medicaid patients is related to reimbursement rates. I don't know about Medicaid, but Medicare reimburses 80 percent of the doctor's charges. There's a perception among doctors that Medicare pays significantly less than private insurance, which is ultimately untrue. Private insurance frequently pays less, and sometimes pays nothing at all. They also require reams of paperwork, forcing doctors to waste money on administrative overhead.

Can you put up some links or citations about the poor women being more likely to die? It's not that I don't believe you; I just picked my senior research topic (breast cancer marketting, particularly media images of the "typical" woman with breast cancer versus reality, with an emphasis on race, class, physical attractiveness, and marital status)

My comment is being held for approval - not sure why, as I have never been remotely trollish. Bad words, maybe? Anyway I am in complete agreement with Tokaia. I have been poor and am not now, and the difference in how doctors treat me is huge. I won't go into the crazy things docs used to say to me when I was poor, as maybe my orginal comment will be posted (?)

While I am loath to defend anyone in the Medical Establishment, consider the obese and those of lower SES frequently have co-morbidities that may limit their ability to tolerate chemo. That and the fact that physicians frequently don't give a damn for anything but money explains things nicely don't you think?

While it's true that chemotherapeutic agents are potentially dangerous if not used carefully, it's also true that they are VERY freakin' expensive!

My mother has stage 4 breast cancer. (For the record, she is also obese and not well educated, but is fortunate to have decent health insurance.) A while back they cut back her dose of chemotherapy because she was supposedly improving and doing well. More recently she needed to have additional radiation to her breast because she was, actually, not doing well after being on this lower dose and there was large amounts of cancer growth there.

Hmm... did they totally not see that coming (decrease drugs increase cell growth), or is it at least possible they were trying to get by with the least amount of drugs (and thus, dollars) possible?

I'm not trying to generalize from my mother's case to all such cases. Doctor's aren't evil, but nor are they omniscent or omnibenevolent. I don't think it's overly cynical to be suspicious about the cause of these findings, but I do agree that more questions need to be asked before jumping to definitive conclusions.

And not to get all preachy, but *always* ask your doctors questions if you have even the slightest doubt about some treatment plan, test result, etc. They DO make mistakes.

or is it at least possible they were trying to get by with the least amount of drugs (and thus, dollars) possible

Not really. Doctors will bill insurance for everything (assuming the patient has insurance). Insurance companies are legally obligated to pay for all the costs (up to the maximum, typically around $1 million) of standard care. If insurance companies were telling doctors to withhold/water down treatment (they're not), or if doctors were scamming insurance companies by billing for medicine that wasn't administered (in which case, that's serious malpractice/fraud), then you might have a point about doctors trying to "save" money by administering less chemo.

It's also important to note that one reason poor women have higher cancer mortality rates because they are frequently diagnosed later. Many of them don't have insurance and can only go to the doctor if there's a serious problem. By the time cancer starts having a physical impact on the patient, it has often progressed to the point of no return.

"Not really. Doctors will bill insurance for everything (assuming the patient has insurance). Insurance companies are legally obligated to pay for all the costs (up to the maximum, typically around $1 million) of standard care. If insurance companies were telling doctors to withhold/water down treatment (they're not), or if doctors were scamming insurance companies by billing for medicine that wasn't administered (in which case, that's serious malpractice/fraud), then you might have a point about doctors trying to "save" money by administering less chemo."

Keshmeshi -
Just because the insurance companies may not explicitly tell physicians to 'withold/water down' treatment doesn't mean physicians aren't mindful of the bottom line. First of all, one way insurers can place pressure on physicians/practices by being selective about which health care providers they designate as 'preferred providers'. Many insurance companies require that you see specific health care providers - if those insurers remove that designation from a practice/physician, guess what? Fewer patients, less income.

Second of all, have you ever looked at an insurance statement? There is a HUGE difference between what the health care provider bills the insurance company for and what the insurance company decides they are going to pay. So just because the insurer is billed for the full amount doesn't mean the practice gets paid the full amount for that service. This means that physicians do not recover all of the costs associated with a full dose of treatment.

So yes, even with insurance involved, these kinds of things affect the money that the physician actually gets for providing services.

I'm a biostatistician, so I'm loathe to attribute causality where none has been shown. Saying that the findings of this study indicate prejudice is dependent neither on that being the intention of the study’s authors nor on the correlations described in it.

This study seems solidly designed, and while the intention surely wasn't to demonstrate prejudice, it appears to have done so quite well.

Taking the authors’ conclusions as correct still demonstrates a disturbing prejudice. The attributed cause of the difference in the ratio between dose administered and the dose recommended is itself classist. If the "distance" between doctors and their patients is causing doctors to prescribe differential treatments, cultural competence is clearly lacking. It is the job of health care professionals to serve the communities they treat with cultural competence.

Just to clarify about how medical "pricing" works. There is NO SUCH thing as a "price" for medical care in this country. Even a hospital couldn't really tell you how much it costs to deliver a baby or do a coronary bypass. Oh, they can tell you how much they charge (and they will charge different insurance companies different rates, depending on negotiated agreements), but that doesn't relate to cost. Medical care is all about cost shifting. Losing money on your Medicaid patients? Bill the private insurance companies more money. Can't cover your overhead in obstetrics? Do a few more high-margin procedures.

Aside from this persistent cost shifting, the other problem is that physicians aren't reimbursed for their time. You get paid the same amount for an office visit whether you spend 5 minutes with a patient or 30 minutes. Thus, physicians don't have an incentive to spend time educating their patients, even if it means better outcomes for the patient and fewer incorrect assumptions.

I just finished a Master's in Public Health and I know we were always criticizing what physicians did and how they responded to financial incentives. But it's wrong to think that physicians are driven exclusively by their bottom line, don't give a crap about their patients, and are systematically defrauding insurers.

There's a lot more to the health differentials than just physician care and access. (See, for example, the UK, where they have universal health care and poorer people are still sicker and die sooner than wealthier ones.)