A look at how power shapes care in military hospitals

Power is an all-pervasive force woven into all aspects of social life, which makes it difficult to study. But by using doctor’s and patients’ military rank differences, two researchers were able to measure how power dynamics in healthcare settings impact the quality of care patients receive.

After examining data from 1.5 million assignments in military emergency departments across the country, the researchers found that patients who outrank their doctors receive more effort and resources than patients of equal or lower rank. 

“Throughout the process, we saw that if the patient was higher rank than the physician, there was this sort of two to three, maybe 4% increase in total resources being used. That, no matter how we ran it, was consistent,” Stephen Schwab, an organizational health economist at the University of Texas at San Antonio and the study’s co-author, told Federal News Network.

The researchers also looked into how resource allocation occurs when doctors simultaneously care for both powerful and low-power patients. They hypothesized that all the patients would be better off in this scenario — if a physician gives more resources to one patient, it might spill over to all the patients they are caring for in an “order tests for one, order tests for all” type of approach. Another hypothesis was that high-power patients would get more resources without impacting other patients.

However, the study concluded that reallocating resources and effort came at the expense of lower-power patients. This reallocation of effort had negative effects on patient outcomes—low-power patients had a 3.4% greater likelihood of showing back up at the emergency department or being admitted to the hospital within the next 30 days. 

At the same time, high-power patients were 15% less likely to be admitted to the hospital after their emergency department visit.

“The powerful may unwittingly “steal” resources from less-powerful individuals,” Schwab and Manasvini Singh, a health and behavioral economist at Carnegie Mellon University and the study’s co-author, wrote. 

Race and gender also played a role in these power dynamics. 

While white doctors respond to powerful patients equally regardless of their race, Black physicians tend to treat their lower-power patients similarly but give “off-the-charts” treatment to high-power Black patients.

Schwab and Singh speculated that it is due to the fact that fewer Black individuals are in positions of military power, but the hypothesis is hard to prove.

When the researchers added gender dynamics, they found that, on average, doctors provide greater care for high-power than low-power patients of either sex.

But male doctors are a lot more responsive to patient power than female doctors.

Male physicians also give more resources and care to their female patients regardless of their power than to their male patients.

“We speculate that male physicians may provide more “kitchen-sink” type female care, e.g., pregnancy tests, pelvic exams, and other procedures,” Schwab and Singh wrote.

“But within this sample, we can certainly see that female physicians are giving their female high-power patients additional resources. Now, males also do the same. And for the males, it is actually significant — the female high-power patients get a lot more care and maybe double the difference with female physicians,” said Schwab.

The researchers also analyzed the patient’s retirement date to better understand whether patients get preferential treatment because of their status or because of their authority since patients maintain their status but lose authority after retirement. 

“The reason that we looked at retirements is we were truly trying to understand is this, ‘I am a colonel, you will do what I want you to do, sort of demanding,’ or is this a status thing,” said Schwab.

The study findings show that patients continue to receive preferential treatment for up to 5 years after they retire.

“We found that as suggestive evidence that this was really about status. It’s not about this command authority — you will do what I want you to do,” said Schwab.

Power imbalances persist in both military and civilian healthcare settings, Schwab said. It’s just easier to study power dynamics in military hospitals given the hierarchal structure of the military. 

“We show power to matter in the doctor-patient relationship, which, unlike other social contracts with power imbalances, often evades scrutiny because of a feature specific to medicine: the expectation that the physician is a perfectly altruistic agent for the patient and will thus be resistant to any distortionary effects of power,”  Schwab and Singh wrote.

Laura Nimmon with the University of British Columbia said Schwab and Singh’ discovery is of “serious concern to society at large.”

“These findings might be dismissed as distinct to the US military health care context because of the pronounced and ritualized power dynamics at play. However, Schwab and Singh point to egregious violations of the physician-patient contract also occurring in civilian settings,” Nimmon wrote.

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