Service members who outrank their physicians are more likely to receive better quality care at military hospitals than lower-ranking troops, a new study found.

The researchers, who published the findings in the journal Science on May 16, studied power dynamics in the physician-patient relationship. Specifically, those researchers from the University of Texas at Austin and Carnegie Mellon University in Pittsburgh, Pennsylvania used data from military hospital emergency departments where some patients outrank their physicians and vice versa — and how that impacts the quality of patient care.

“We provide careful, rigorous evidence of the ‘long shadow’ of power: the idea that power in one domain of life can spill over to unrelated domains (here, from the military to the clinical), causing distortions in behavior and resource allocation in both,” researchers noted. “We show that the powerful may unwittingly ‘steal’ resources from less-powerful individuals, in line with other research showing negative spillovers from dominant to marginalized groups in shared spaces.”

Researchers used active-duty service members from the ages of 18 to 64, and they monitored physician effort and resource use. The study considered physician effort as a “measure of total resources or effort expended by a physician when treating a patient.” Resource use pertained to seven “tangible measures” used on patients during appointments with their physician: any opioid prescription, intensity of evaluation/management code used, number of diagnosis codes, number of treatment codes, any test ordered, any imaging order and any procedure performed.”

The study, using data from 1.5 million emergency department assignments, compared service member patients of the same rank with physicians whose rank was either higher or lower than them, otherwise considered “higher-power” or “lower-power” patients. Patients who outrank their physicians received 3.6% more effort by their physician and more resources expended, researchers found.

“It’s good that it’s not huge,“ Stephen Schwab, a University of Texas at Austin Professor and retired Army veteran, told Military Times. “Most physicians are trying to do everything they can for their patients within the bounds of the resources they have, the time they have those patients. We think that this was really an implicit bias rather than an explicit, although there’s no way of testing that.”

Schwab said a chief of an emergency department told him it was a matter of human nature kicking into drive, where “you’re just a little bit more careful when the stakes are higher.”

How does that 3.6% difference materialize? In a “little bit more time and effort,” Schwab said. Physicians could spend more time talking about the problem that brought a service member into the emergency department in the first place, take more time to write up a more thorough family history or order one additional test.

Those same patients who outranked their physicians also had better medical outcomes than their lower-ranked peers. Those patients were 15% less likely to be readmitted to the emergency department 30 days after their initial treatment.

Findings when those high-power and low-power patients were simultaneously treated by a physician also showed negative correlations for patients whose physicians outrank them. Physicians exerted 1.9% less effort on patients they outranked than on patients who outranked them, and outranked patients had a 3.4% greater likelihood of visiting the emergency department within 30 days or being admitted to the hospital, researchers found.

Researchers also looked into how race and gender determine physician effort among different ranks. Physician effort was greater for all higher-ranked service members than their outranked peers, regardless of race, according to the study. The study found Black physicians provide “off the charts” effort to Black service members that outrank them, and white physicians exerted less effort on Black patients.

Schwab did note that the study wasn’t indicative of whether civilian or military hospitals are necessarily better, rather it looked at the power that can be at play regardless.

“We’re not comparing the military to civilian health care, because all of our, sort of, anecdotal evidence is that the military is probably more fair than the civilian sector,” he said. “What we’re showing is that even in this situation, there’s still an issue and we can learn something about human behavior from this study.”

Schwab added that “these sort of power differences play out in many ways throughout society, and sometimes people don’t even realize the power that they’re wielding.”

Defense Health Agency spokesperson Peter Graves said the agency is reviewing the content of the study.

“The Defense Health Agency remains committed to delivering the highest quality of care to all of our patients, regardless of rank, race, color, sex, gender identity, religion, age or any other demographic,” Grave told Military Times in an email. “We always expect the same high standards to be applied to every patient in an exceptional way, anytime, anywhere, always.”

Researchers suggested a number of ways physicians could close disparities in treatment between high and low-power patients. Solutions include “task shifting, algorithmic support, increasing diversity in the provider workforce, bias training and patient advocacy, in minimizing these disparities and ensuring a health system that provides equitable care to all,” researchers wrote.

Zamone “Z” Perez is a reporter at Military Times. He previously worked at Foreign Policy and Ufahamu Africa. He is a graduate of Northwestern University, where he researched international ethics and atrocity prevention in his thesis. He can be found on Twitter @zamoneperez.

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