Military physicians give high-ranking military patients preferential treatment over lower-ranking patients

Military physicians give patients whose military rank is higher better treatment than those who rank lower, according to a new study involving 1.5 million patient encounters. The findings provide evidence that the powerful enjoy better resources and support in a clinical context, often at the expense of the less powerful. “Our concern does not lie with the doctor-patient power imbalance itself, which is likely necessary for effective physician performance,” write the authors. “Rather, it lies with the inequitable variation in how that power is exercised, with the most vulnerable patients likely bearing the burden of this disparity, as has historically been the case.”

Despite its pervasive force in nearly all aspects of human social norms and systems, power is profoundly difficult to study with real-world data, limiting our understanding of how power dynamics play out in real-world settings. One particularly relevant and high-stakes power dynamic is the relationship between doctors and patients. This power differential generally favors the physician, who commands knowledge, clinical resources, and legal authority over patients who are reliant on their care. It is founded on the societal expectation that the physician will always act altruistically and ethically toward all patients. Stephen Schwab and Manasvini Singh investigated how variation in the doctor-patient power differential affects patient care and outcomes in the US Military Health System (MHS) – a setting that has a clear and well-entrenched hierarchy of power and thus provides a novel way to understand and quantify the elusive power differential between individuals. In this system, both doctors and patients are active-duty military, and each is assigned a clear rank. As a patient’s rank nears or exceeds that of the physician, the power differential should narrow, potentially influencing physician or patient behavior and, consequently, the care provided and patient outcomes.

Using a dataset encompassing 1.5 million patient encounters in MHS emergency departments, the authors found that “high-power” patients – those who outrank their physician – received more effort and clinical resources from their physician and experienced better health outcomes than “low-power” patients of the same rank. Patient rank promotions increased physicians’ effort, and the preferential treatment for high-power individuals lasted for years after retirement. Further analyses show that those with power may unwittingly divert clinical resources and effort away from lower-power patients. Schwab and Singh also found that low-power individuals often received less effort from physicians who had seen a high-power patient just prior to their own visit. Another important finding from the study was insight into how these power dynamics are affected by patient race or sex. The authors found that White physicians consistently gave less effort to Black patients. This effect was mitigated when Black patients had a higher rank, although the higher rank still only elevated the care they received to being at par with low-power White patients. Sex differences also had an effect. “Efforts remain necessary to better understand facets of power, including the failures of education and health care systems to address the myth that physicians are perfectly altruistic and not corrupted by power,” writes Laura Nimmon in a related Perspective. “Perhaps it is this myth that prevents medicine from meaningfully addressing this pernicious issue through institutional, educational, and organizational initiatives.”

***A related embargoed news briefing was held at 11:00 a.m. U.S. ET on Wednesday, 15 May, 2024, as a Zoom Webinar. Recordings of the briefing can be found here.***