Do Canadian primary care offices really discriminate against the poor?

A new study purports to demonstrate that primary care physician offices in Ontario discriminate against the poor by being less likely to offer them appointments. I saw an article about the study in the Los Angeles Times ("Canada’s universal healthcare may not be so universal after all") and was a bit puzzled. Here’s what is said:

The researchers posed in each call as one of four types: a wealthy banker in good health, a wealthy banker with diabetes and back problems, a welfare recipient in good health, or a welfare recipient with diabetes and back problems.

Overall, the callers were 50 percent more likely to be offered an appointment when they posed as bankers than when they posed as welfare recipients.

"Staff at physicians’ offices may hold negative attitudes toward this group, especially toward people receiving social assistance," the authors wrote. "Physicians have been shown to perceive patients with low socioeconomic status more negatively in terms of their personalities, abilities, behavioral tendencies and role demands."

Certainly the results sound bad and are consistent with the general notion that rich people get away with things while the poor get the shaft. But do Canadian primary care offices routinely try to assess the socioeconomic status of patients? It seemed odd to me.

So I read the original study (which is not linked to in the article) and my assessment is that the methodology is biased. Researchers were given scripts to use when calling the doctor’s office and were told to read them neutrally. Even if we assume they were able to be neutral (which I doubt) the language is biased in a way that throws the results and conclusions into question.

Let’s compare the wording of the two questions:

“Hi, I was just transferred to Toronto with [name of major bank], and I need a family doctor for my diabetes and back problems. Is Dr. ____ accepting new patients?”


“Hi, I’m calling ’cause my welfare worker told me that I need a family doctor for my diabetes and back problems. Is Dr. ___ accepting new patients?”

The researchers assume that the only important difference between these scripts is the information about whether the person is employed in a highly paid job or is on welfare.

I disagree. In particular, the first patient sounds like a self-motivated individual who is calling because s/he is conscientious and is making an effort to be responsible and take care of him/herself.

The second patient sounds like someone who is calling because they were told to, not because they wanted to. And why on earth does the script say “’cause” instead of because? Now imagine switching around the script so the banker is calling “’cause my wife told me I had to” and the second calls to say they needed a doctor and doesn’t make it sound like someone else told them to do so.

My guess is that the main driver of the results is that office staff are giving priority to a patient who is motivated to show up for appointments and be compliant with therapy rather than one who sounds like they’re calling just so they can tell their welfare worker that they did what they were told. If the caller hadn’t told the office of their profession or welfare status, I doubt the office would have raised it.

David Williams blogs regularly at the Health Business Blog.