By T. Corwyn. Le Moyne College.

Even though whites constituted a greater percentage of the population (35 percent) than blacks (27 percent) buy coumadin 2 mg with visa, three and a half times as many blacks (185 purchase coumadin 5mg,000) as whites (53 buy coumadin 2 mg on-line,000) were arrested for possessing small quantities of marijuana (Levine and Small 2008). Because drug purchase and use are consensual, drug arrests are not a response to victim complaints but result from police decisions about resource allocation. In practice, police have focused on low-income, predominantly minority neighborhoods and have ignored other more upscale and white areas even though there is no evidence that drug use is less prevalent there. Police and prosecutors say increased attention to the poor minority neighborhoods is necessary to combat higher rates of violent crime and disorder in those communities and to respond to community complaints about drug trafficking. Some see low-level drug arrests, including arrests for marijuana possession for personal use, as justified by the “broken windows” theory of law enforcement. The circumstances of life and the public nature of drug dealing in poor minority neighborhoods make drug arrests there less difficult and less time-consuming than in middle- or upper-class neighborhoods. In the former, drug transactions are more likely to take place on the streets, in public spaces, and among strangers (Beckett et al. In white neighborhoods, drug transactions are more likely to occur indoors, in bars and clubs, private homes, and offices, and between people who already know each other. Here is how former New York City Police Commissioner Lee Brown explained the police concentration in minority neighborhoods and the consequent racial impact: In most large cities, the police focus their attention on where they see conspicuous drug use—street-corner drug sales—and where they get the most complaints. Conspicuous drug use is generally in your low-income neighborhoods that generally turn out to be your minority neighborhoods…. It’s easier for police to make an arrest when you have people selling drugs on the street corner than those who are [selling or buying drugs] in the suburbs or in office buildings. The end result is that more blacks are arrested than whites because of the relative ease in making those arrests. In a mixed-race drug market in Seattle, Beckett and her colleagues found that 4 percent of drug deliveries involved a black seller, but 32 percent of drug delivery arrestees were black (Beckett, Nyrop, and Pfingst 2006). Disproportionate drug arrests of minority suspects also reflect political and legal considerations. William Stuntz observed, “the law of search and seizure disfavors drug law enforcement operations in upscale (and hence predominantly white) neighborhoods: serious cause is required to get a warrant to search a house, whereas it takes very little for police to initiate street encounters” (Stuntz 1998, p. Residents of middle- and upper-class white neighborhoods would also most likely object vigorously if they were subjected to aggressive drug law enforcement and, unlike low-income minority residents, they possess the economic resources and political clout to force politicians and the police to pay attention to their concerns. The bottom line is that it is “much more difficult, expensive, and politically sensitive to attempt serious drug enforcement in predominantly white and middle-class communities” (Frase 2009, p. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs A self-fulfilling prophecy may be at work. If police target minority neighborhoods for drug arrests, the drug offenders they encounter will be primarily black or Hispanic. Darker faces become the faces of drug offenders, which may also contribute to racial profiling. Extensive research shows that police are more likely to stop black drivers than whites, and they search more stopped blacks than whites, even though they do not have a valid basis for doing so. Similarly, blacks have been disproportionately targeted in “stop and frisk” operations in which police searching for drugs or guns temporarily detain, question, and pat down pedestrians (Fellner 2009). Although police generally find drugs, guns, or other illegal contraband at lower rates among the blacks they stop than the whites, the higher rates at which blacks are stopped result in greater absolute numbers of arrests (Tonry 2011). Race becomes one of the readily observable visual clues to help identify drug suspects, along with age, gender, and location. There is a certain rationality to this—if you are in poor black neighborhoods, drug dealers are more likely to be black” (1998, p. Katherine Beckett and her colleagues showed that drug arrests in Seattle reflected racialized perceptions of drugs and their users (Beckett et al. Although the majority of those who shared, sold, or transferred serious drugs were white, almost two-thirds (64. Black drug sellers were overrepresented among those arrested in predominantly white outdoor settings, in racially mixed outdoor settings, and even among those who were arrested indoors. Three- quarters of outdoor drug possession arrests involving powder cocaine, heroin, crack cocaine, and methamphetamines were crack-related even though only one-third of the transactions involved that drug. The disproportionate pattern of arrests resulted from the police department’s emphasis on the outdoor drug market in the racially diverse downtown area of the city, its lack of emphasis on outdoor markets that were predominantly white, and, most important, its emphasis on crack. Crack was involved in one-third of drug transactions but three-quarters of drug delivery arrests; blacks constituted 79 percent of crack arrests. The researchers could not find racially neutral explanations for the police emphasis on crack in arrests for drug possession or sale, or for the concentration of enforcement activity in the racially diverse downtown area rather than predominantly white outdoor areas or indoor markets. These emphases did not appear to be products of the frequency of crack transactions compared to other drugs, public safety or public health concerns, crime rates, or citizen complaints. The researchers concluded that the choices reflected ways in which race shapes police perceptions of who and what constitutes the most pressing drug problems. Blacks are disproportionately arrested in Seattle because of “the assumption that the drug problem is, in fact, a black and Latino one, and that crack, the drug most strongly associated with urban blacks, is ‘the worst’” (Beckett et al. In 2010, as Table 4 shows, cocaine (including crack) and heroin arrests accounted for 22. Blacks were more likely than whites to report using heroin, but the percentages are quite low: 1. The proportion of drug arrests for cocaine and heroin thus seem to bear only a slight relationship to the prevalence of their use. Boyum, Caulkins, and Kleiman (2011) observe that the enforcement of laws criminalizing cocaine accounts for “about 20 percent of the nation’s law enforcement, prosecution, and corrections” (p. Subscriber: Univ of Minnesota - Twin Cities; date: 23 October 2013 Race and Drugs Table 4 Arrests by Type of Offense, Drug, and Race, 2010 White Black Native American Asian Total Sales Cocaine/Heroin 34,787 45,635 346 351 81,119 42. All other things being equal, one would expect the racial distribution of prisoners sentenced for particular crimes to reflect the racial distribution of arrests for those crimes. Blumstein showed in 1982 that about 80 percent of racial differences in incarceration in 1979 could be accounted for by differences in arrest (Blumstein 1982). In the case of drug offenses, there was a significant difference between the racial breakdowns of arrests and incarceration. Racial disparities in imprisonment for drug crimes are even greater than disparities in arrest. There are significant racial differences at different decision points in criminal justice processing of cases following arrest. Those differences compound, ultimately producing stark differences in outcomes (Kochel, Wilson, and Mastrofski 2011; Spohn 2011). In Illinois, for example, even after accounting for possible selection bias at each stage of the criminal justice system, nonwhite arrestees were more likely than whites to have their cases proceed to felony court, to be convicted, and to be sent to prison (Illinois Disproportionate Impact Study Commission 2010). After controlling for other variables, including criminal history, African Americans in Cook County, Illinois were approximately 1.

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It is also present in tests com- monly considered to be the gold standard such as the interpretation of tissue samples from biopsies or surgery generic 1 mg coumadin with visa. There are many potential sources of error and clinical disagreement in the pro- cess of the clinical examination trusted 2 mg coumadin. A broad classification of these sources of error includes the examiner buy generic coumadin 5 mg on line, the examinee, and the environment. The examiner Tendencies to record inference rather than evidence The examiner should record actual findings including both the subjective ones reported by the patient and objective ones detected by the physician’s senses. The physician should not make assumptions about the meaning of exam find- ings prior to creating a complete differential diagnosis. For example, a physician examining a patient’s abdomen may feel a mass in the right upper quadrant and record that he or she felt the gall bladder. This may be incorrect, and in fact the mass could be a liver cancer, aneurysm, or hernia. Ensnarement by diagnostic classification schemes Jumping to conclusions about the nature of the diagnosis based on an incorrect coding scheme can lead to the wrong diagnosis through premature closure of the differential diagnosis. If a physician hears wheezes in the lungs and assumes that the patient has asthma when in fact they have congestive heart failure, there Sources of error in the clinical encounter 235 will be a serious error in diagnosis and lead to incorrect treatment. The diagnosis of heart failure can be made from other features of the history and clues in the physical exam. Entrapment by prior expectation Jumping to conclusions about the diagnosis based upon a first impression of the chief complaint can lead to the wrong diagnosis due to lack of consideration of other diagnoses. This, along with incorrect coding schemes, is called premature closure of the differential diagnosis, and discussed in Chapter 20. If a physician examines a patient who presents with a sore throat, fever, aches, nasal conges- tion, and cough and thinks it is a cold, he or she may miss hearing wheezes in the lungs by only doing a cursory examination of the chest. This occurs because the physician didn’t expect the wheezes to be present in a cold, but in fact, the patient may have acute bronchitis which will present with wheezing. In any case, the symptoms can be easily and effectively treated, but the therapy will be inef- fective if the diagnosis is incorrect. Bias Everyone brings an internal set of biases with them, which are based upon upbringing, schooling, training, and experiences. If a physician assumes, without further investigation, that a disabled man with alcohol on his breath is simply a drunk who needs a place to stay, a significant head injury could easily be missed. Denying pain medica- tion to someone who may appear to be a drug abuser can result in unnecessary suffering for the patient, incorrect diagnosis, and incorrect therapy. Biologic variations in the senses Hearing, sight, smell, and touch will vary between examiners and will change with age of the examiner. As one’s hearing decreases, it becomes harder to hear subtle sounds like heart murmurs or gallop sounds. Many clinicians don’t ask newly diagnosed cancer patients about the presence of depression, although at least one-third of cancer patients are depressed and treating the depression may make it eas- ier to treat the cancer. Treatment for depression will make the patient feel more 236 Essential Evidence-Based Medicine in control, thus less likely to look for other methods of therapy such as alter- native or complementary medicine to the exclusion of proven chemotherapy. Many physicians don’t ask about sexual history, alcohol use, or domestic violence because they may be afraid of opening Pandora’s box. On the other hand, most patients are reluc- tant to give important information spontaneously about these issues, and need to be asked in a non-threatening way. When asked in an honest and respectful manner, almost all patients are pleased that these difficult questions are being asked and will give accurate and detailed information. Simple ignorance Physicians have to know what they are doing in order to be able to do it well. For example, if a physician doesn’t know the significance of the straight leg raise test in the back examination, he or she won’t do it or will do it incorrectly. This can lead to a missed diagnosis of a herniated lumbar disc and continued pain for the patient. If the physician doesn’t personally like taking risks, then he or she may try to minimize risk for the patient. On the other hand, if the physician doesn’t mind taking risks, he or she may not try to minimize risk for the patient. Physicians can be classified by their risk-taking behavior into risk minimizers or test minimizers. Risk-taking physicians are less likely to admit patients with chest pain to the hospital than physicians who are risk averse or risk minimizers. They may order more tests than would be necessary in order to reduce the risk of missing the diagnosis. They are more likely to order tests or recommend treatments even when the risk of missing a diagnosis or the potential benefit from the therapy is small. Test minimizers may order fewer tests than might be necessary and thereby increase the risk of missing a diagnosis in the patient. They are less likely to recommend certain tests or treatments, thinking that their patient would not want to take the risk associated with the test or therapy, but will be willing to take the risk associated with an error of omission in the process of diagnosis or treatment. The test minimizer projects that the patient is willing to take the risk of missing an unlikely diagnosis and would not want any additional tests performed. Additionally, use the communica- tions techniques discussed in Chapter 18 to maximize understanding, informed consent, and shared decision making with the patient. If things aren’t working right because of personal issues, such as a fight with your spouse, kids, or partners, problems paying your bills, or other issues, don’t take it out on patients. Physicians must learn to overcome their own feelings and not let them get in the way of good and empathic com- munications with patients. The examinee Biologic variation in the system being examined The main source of random error in medicine is biologic variation. People are complex biological organisms and all physiological responses vary from per- son to person, or from time to time in the same person. For example, some patients with chronic bronchitis will have audible wheezes and rhonchi while others won’t have wheezes and will only have a cough on forced expiration. Some people with heart attacks have typical crushing substantial chest pain while oth- ers have a fainting spell, weakness, or shortness of breath as their only symptom. Understanding this will lead to better appreciation of subtle variations in the his- tory and physical examination. Effects of illness and medication Ignoring the effect of medication or illness on the physiologic response of the patient may result in an inaccurate examination. For instance, patients who take beta-blocker drugs for hypertension will have a slowing of the pulse, so they may not have the expected physical exam findings like tachycardia even if they are in a condition such as shock. Memory and rumination Patients may remember their medical history differently at different times, which results in a form of recall bias.

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