ESTABLECEN EL REGIMEN DE INVERSION AL QUE DEBERAN SUJETARSE LAS SOCIEDADES DE INVERSION ESPECIALIZADAS DE FONDOS PARA EL RETIRO

Althoughtheaccommodationofpatients’racialpreferencesappearstocon- fersignificantbenefitstopatientsofallraces,170_{wemaystillbetroubledbythedif-} ficultyofdistinguishingbetweenlegitimateexpressionsofracialpreferencefor physicianraceconcordanceandthosebasedinracismorbigotry. Undoubtedly,

therearemanyreasonswhypatientsmayrequestordeclinetreatmentbyphysicians ofaparticularracialorethnicbackground. Thesereasonsincludepositivepriorex- periencesinraciallyconcordantrelationships,negativepastexperienceswithphy- sicianbiasinraciallydisconcordantrelationship,andracism—namely,bigotryor prejudicesaboutmembersofcertainracialandethnicgroupsotherthanone’sown.

Patientswhohavehadpositiveexperienceswithpeopleofthesameracialor culturalbackgroundmaybemoretrustingofandfeelmorecomfortablewithphy- sicianswhosharetheirracialorculturalcharacteristics.171

Thissenseofsharinga

commoncultureorsocialexperiencemayalsoleadpatientstobelieve(rightlyor wrongly)thataphysicianofasimilarracialgroupismorelikelytopromoteand protecttheirinterestsandtoexercisemoresensitivecarewithregardtotreatment.172 Negativeexperiencesmayalsodriveapatienttowardrejectingorrequesting aphysicianofaparticularracialbackground,aspreferencesmaybeshapedbylin- geringdistrustresultingfromone’sownorothers’priorexperiencesofracialbias,

Clause“createsanewsubstantivevalueof‘nonslavery’andantisubordinationtoreplacetheoldvalues ofslaveryandwhitesupremacy”);RevaB.Siegel,EqualityTalk:AntisubordinationandAnticlassification ValuesinConstitutionalStrugglesOverBrown,117HARV.L.REV.1470,1472–73(2003)(describ- ingtheantisubordinationprincipleas“theconvictionthatitiswrongforthestatetoengageinprac- ticesthatenforcetheinferiorsocialstatusofhistoricallyoppressedgroups”).

170. SeegenerallyCooperetal.,supranote20,at907;Cooper-Patricketal.,supranote143;LaVeist& Nuru-Jeter,supranote22.

171. SeegenerallyDavidH.Thom,PhysicianBehaviorsThatPredictPatientTrust,50J.FAM.PRAC.323 (2001).

discrimination,ordiscourteousorsubstandardcare.173

Whilesegregationandbla- tantracialdiscriminationarenolongerthenorminmedicine,numerousstudies reportthatmoresubtleformsofdiscriminationendure.174 _{Althoughmostpatients} aresensitivetotheinterpersonaldynamicthatoccursinmedicalencounters,black patientsmaybeacutelyawareofinterpersonalcuesfromphysiciansbecauseofhis- toricalandpersonalexperienceswithdiscriminationinhealthcareandinsocietyat large.175 _{Researchonracialstigmasuggeststhatindividualscopewiththethreatof} biasordiscriminationbyavoidinginteractionswiththestigmatizinggroup.176

Thus,

toavoidnegativeencounters,racialminorities(whoaremorelikelytoexperience discriminationwhileseekinghealthservices)maypreferphysician–patientracial concordanceorrejectphysicianswhoaremembersofaperceivedstigmatizing group.177

Finally,apatient’srequestfororrefusaloftreatmentbyaphysicianofapar- ticularracemayalsobeamanifestationofracism.178 _{Forexample,duringtheperiod} oflegallysanctionedsegregation,manywhiteprofessionalsandthelaypublicopen- lyexpressedthebeliefthatthemedicalcareprovidedbyblackphysicianswasnec- essarilyofpoorquality.179

Thesourceofpatients’racialpreferenceswithrespecttotheirchoiceofphy- siciansshouldplayapartindeterminingappropriatepolicysolutions. Standard

173. SeeVanessaNorthingtonGamble,UndertheShadowofTuskegee:AfricanAmericansandHealthCare,

87AM.J.PUB.HEALTH1773,1776(1997)(arguingthatblackAmericans’distrustofthemedical

professionisrootedinalonghistoryofexploitationanddisrespect,epitomizedbytheTuskegee

study,whoselegacy“endures,inpart,becausetheracismanddisrespectfor[b]lacklivesthatiten- tailedmirror[b]lackpeople’scontemporaryexperienceswiththemedicalprofession”).

174. SeeCalman,supranote127,at172–74(explaininghowracialprejudicesaffectandlimitpatients’ healthcareopportunities);Perez,supranote127,at628,633,636–37;Schulmanetal.,supranote 127,at618,623–24(discussinghowraceandsexinfluencephysicianrecommendationsinthetreat- mentofcardiovasculardisease);Toddetal.,EthnicityandAnalgesicPractice,supranote153;Toddet al.,EthnicityasRiskFactor,supranote153;vanRyn&Burke,supranote106(findingthatdoctors’

opinionsregardingtheirAfricanAmericanpatientstendtobemorenegativethanthoseregarding

theirwhitepatients);Williams,supranote127,at177–80;Williams&Collins,supranote127,at 405–07.

175. SeeCooperetal.,supranote20,at913;LaVeistetal.,supranote106,at151;vanRyn&Burke,

supranote106.

176. SeeAlvinN.Alvarez&LindaP.Juang,FilipinoAmericansandRacism:AMultipleMediationModel ofCoping,57J.COUNSELINGPSYCHOL.167(2010);ElizabethBrondoloetal.,CopingWithRacism: ASelectiveReviewoftheLiteratureandaTheoreticalandMethodologicalCritique,32J.BEHAV.MED. 64(2009);VettaL.SandersThompson,CopingResponsesandtheExperienceofDiscrimination,36J.

APPLIEDSOC.PSYCHOL.1198(2006).

177. SeeCOLLINSETAL.,supranote144,at18,21.

178. LaVeist&Nuru-Jeter,supranote22,at303(“[R]aceconcordantpatientpreferencemaybeamani- festationoftheinternalizationofbroadersocietalracism.”).

medicalpracticerequiresthosewhoexpressthesepreferencestoundergoanethics consultationtodeterminenotonlythestrengthoftheirconvictionbutalsotoim- pressonthepatienttheadvantagesofworkingwiththeassignedphysician.180 _Yet inalife-threateningsituationorwhenthepatienthasnoalternatevenueformed- icalcare,isfirminherdecision,andcannotbedeterred;EMTALA,battery,and medicalethicsrulescounselthatthepatient’spreferencesberespected.

Still,thenotionofwhitepatientsrejectingminorityphysiciansforbigoted reasonsinemergencydepartmentsandotherhospitalsettingsisdeeplytroubling anduncomfortablyreminiscentofthetypeofdiscriminationthatthecivilrights statutesweredesignedtoeliminate. Thisconcerncomplicatesemergencydepart- mentphysicians’dutytoprovidenecessarytreatmentandtheireffortstouphold theirpromiseundertheHippocraticOathtodonoharm. Italsounderscoresafun-

damentaltensionbetweentheirrolesashealersandasconservatorsofwidelyshared moralprecepts.181

Thereality,however,isthatthisproblemmayseldomarise,asarecentstudy foundthatrequestsfortreatmentbyaphysicianofaparticularracearemostoften accommodatedwhenmadebyracialminoritypatients.182

Thispracticemaybe

180. SeePadela&Punekar,supranote68,at71.

181. UndertheAMACodeofEthics,physicianshave“ethicalobligationstoplacepatients’welfareabove theirownself-interestandaboveobligationstoothergroups,andtoadvocatefortheirpatients’wel- fare.” Opinion10.015,supranote109.

182. SeePadelaetal.,supranote3,at468. Moreover,whitephysiciansaccountforapproximately78.4 percentofemergencyphysiciansintheUnitedStates. ASS’NOFAM.MED.COLLS.,DIVERSITYIN

THEPHYSICIANWORKFORCE:FACTSANDFIGURES2010,at75tbl.9(2010),availableathttps://

members.aamc.org/eweb/upload/DiversityinthePhysicianWorkforceFactsandFigures2010.pdf.

Therefore,whitepatientswhoseekaphysicianofthesameracetendtohavelittledifficulty

locatingone. SeeBenton,supranote3,at23;TotalPhysiciansbyRace/Ethnicity—2008,AM.MED.

ASSOC.,http://www.ama-assn.org/ama/pub/about-ama/our-people/member-groups-sections/min

ority-affairs-section/physician-statistics/total-physicians-raceethnicity.page(lastvisitedNov.17, 2012). Thisisnotthecaseforracialandethnicminoritypopulations,whicharetwiceaslikelyas whitestorelyonphysiciansinemergencydepartments,hospitalclinics,oroutpatientdepartments fortheirregularcareratherthanonaprivatephysicianorotheroffice-basedprovider. SeePadela& Punekar,supranote68,at69(findingthattheemergencydepartmentisoftentheprimaryvenuefor underservedethnicandracialminoritiestoaccesshealthcare);seealsoROSENBAUMETAL.,supra

note138,at115;MarshaLillie-Blanton&CayaB.Lewis,PolicyChallengesandOpportunitiesin ClosingtheRacial/EthnicDivideinHealthCare3(KaiserFamilyFound.IssueBrief,2005)(“28%of Latinosand22%ofAfricanAmericansreporthavinglittleornochoiceinwheretoseekcare,while only15%ofwhitesreportthisdifficulty.”). Researchshowsthatpeopleofcolorhavelessaccessto

healthcarewhencomparedtowhites,asthelevelofuninsuranceis34percentamongHispanicsand

21percentamongblacksversus13percentamongwhites. NicoleLurie&TamaraDubowitz,Health DisparitiesandAccesstoHealth,297J.AM.MED.ASS’N1118,119(2007). Moreover,minority womenaremorelikelytoavoidavisittoaphysicianforfinancialreasons. CARAV.JAMESETAL.,

KAISERFAMILYFOUND.,PUTTINGWOMEN’SHEALTHCAREDISPARITIESONTHEMAP:

justifiedtotheextentthatracialandethnicminoritypatientsarestatisticallymore likelythanwhitepatientstoexperiencediscriminatorytreatmentinaraciallydis- concordantphysician–patientencounter.183 _{Moreover,thechanceofexperiencing} suchdiscriminatorytreatmentisheightenedinthehospitalenvironment,whichis “ripeformisunderstandings,stereotyping,andpoorcollaboration,”asphysicians whoworkinhospitalemergencydepartmentsareoftenfatiguedandmustoperate undersignificanttimeconstraints.184 _{Researchindicatesthatindividualsoftenrely} onunconsciousbiasesandstereotypinginsuchcircumstancesasthesecognitive processesallowindividualstoevaluatecomplexinformationquicklythroughthe useofsocialcategories.185 _{Thenegativeconsequencesofthisbehaviorarelikelyto} haveadisproportionateeffectonblacksandLatinos.

Noneofthisistosuggestthatweshouldnotremainconcernedaboutracist motivesamongpatients. Nevertheless,substantialempiricaldataatteststothemed- icalsignificanceandbenefitsofaccommodatingpatients’racialpreferences,andto theextentthatevidenceshowsunequivocallythatitimproveshealthoutcomesand maycontributetothereductionofrace-basedhealthdisparities,thenweshould respectpatients’racialpreferencesinthehospitalcontext.