By Suhas Gondi
in-Training, July 18, 2016
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.”
– attributed to Martin Luther King, Jr.
[PNHP note: The “Letter to our Patients on Racism” cited in the last paragraph of this article has been signed by more than 3,000 physicians and medical students as of July 19.]
In December of 2014, one week after the non-indictment in the case of Michael Brown, in-Training published an article entitled “A Lack of Care: Why Medical Students Should Focus on Ferguson.” In it, Jennifer Tsai argued that the systemic racism rampant in our law enforcement and criminal justice systems also permeates our health care system, affecting both access to care for black patients and the quality of care black patients receive. Lamenting that the medical community was largely absent from the Ferguson controversy, she cited startling statistics of disparities in health and health care as part of her call to action. In light of the events last week in Louisiana, Minnesota, and Texas, it’s time to revisit this message.
The deaths of Alton Sterling and Philando Castile re-galvanized the Black Lives Matter movement, which began in Ferguson and has since spread to every corner of this country. Besides spurring impassioned advocacy, they serve as a reminder to us all of the systemic racism is still ingrained in our society. The seemingly innate biases so many of us carry have not eroded — they still abound in our daily lives and the world around us.
These events should also serve as a reminder to every physician, medical student and premedical student of the ways in which our health care system is subject to those biases. While the white coat has come to represent the profession’s humanity and morality, the evidence decisively shows it is not impermeable to prejudice.
The published literature supporting the existence of racial disparities in health care is vast. The seminal report on the subject was published in 2002 by the Institute of Medicine (IOM), which found that a large body of research highlighted the presence of real disparities. It concluded that even after controlling for insurance status, income, age and severity of conditions, minorities receive a different level of care than white patients. They were less likely to be prescribed appropriate cardiac medications, undergo bypass surgery or receive kidney dialysis and more likely to undergo “less-desirable procedures” such as a lower limb amputation due to complications from diabetes.
Since 2002, when the IOM report brought widespread attention to such disparities, researchers have published hundreds of studies that shed more light on the differences in the way black and white patients are cared for by their doctors. One analysis published two months ago examined nationwide trends for racial disparities in cardiac interventions after a heart attack before and after the 2002 IOM report, finding that disparities persisted well after the report. Some of these disparities have been well-studied and widely cited. Black patients face a two-thirds higher risk than white patients of not receiving an analgesic (a pain medication) when in the ER for a long-bone fracture, even after controlling for confounding variables. Minorities are also less likely than white patients to be prescribed opioid medications for a comparable set of symptoms. This disparity is most significant with conditions that have less objective findings, like a migraine. When patient assessment and test results do not point to a conclusive diagnosis, the effect of inherent biases on clinical decision-making is greater.
The federal government has also published its own studies on the topic. The 2015 National Healthcare Quality and Disparities Report reported that black patients received worse care than whites for about 40 percent of quality measures, a statistic almost identical to the 2011 report, the first annual publication. Even in special populations, such as senior citizens over the age of 65, with similar health problems and the same insurer, racial disparities persist. Black Medicare beneficiaries are, on aggregate, less likely to receive recommended care than white ones.
These differences, along with variation in the social determinants of health across race, contribute to the serious health inequities observed between blacks and whites. While the gap in life expectancy has narrowed over the past several decades, a white baby born today can still expect to live, on average, four years longer than her black counterpart. Although disparities in health outcomes such as longevity are largely the product of structural factors, it is difficult to believe that the lower quality of care delivered to blacks versus whites does not play any role in explaining these gaps.
Clearly, the medical community has a stake in the national conversation around systemic racism and police brutality re-launched by the deaths of Sterling and Castile. The evidence overwhelmingly suggests that physicians are just as vulnerable to the inherent biases that affect police officers. The biases that are blamed for higher arrest rates among blacks for crimes that whites commit more often are the same biases that lead to black patients receiving timely and aggressive intervention far less often than white patients in a cardiovascular emergency. These are distinct symptoms of a single underlying cause. The assumptions that cause well-intended police officers to stop-and-frisk blacks five times as frequently as whites are also harbored by physicians. These ingrained stereotypes are not profession-specific. They are universal.
The tragic deaths of five police officers in Dallas last week points to another parallel with the medical establishment. The tension between police officers and the communities they protect is mirrored by a tension between physicians and the patient populations they care for. The skepticism of black patients toward the medical community, especially in the area of clinical research, is well-documented. A Johns Hopkins study reported that a full quarter of black patients, 10 percent more than whites, believe that their physician would ask them to participate in a study even though the study might harm them. 6 percent more blacks than whites felt their physician would willingly expose them to unnecessary risk. Most striking, almost 60 percent of black participants, well over twice the proportion of whites, thought that physicians use medications to experiment on people without the patient’s consent. Evidently, doctors and police officers share the challenge of serving populations that sometimes put little faith in them and their professional authority.
Just as the distrust that many black men have for police is rooted in America’s history of racial profiling, the lack of trust towards physicians has been shaped by a long history of exploitation and experimentation on black bodies. The Tuskegee syphilis trial, which began in the early 1930s and lasted forty years, is perhaps the most infamous example. Government researchers deceived black patients suffering from syphilis into believing they were receiving treatment when, in fact, they were being observed to gain insight into the natural course of the disease. The legacy of Tuskegee is still reflected in the widespread mistrust that undermines doctor-patient relationships across the country.
In a national town hall this week, President Obama spoke on how trust between a community and its police officers is critical for police departments to do their job of serving and protecting. Distrust leads to bad outcomes, often in the form of unwanted violence. The same is true in medicine, except bad outcomes mean poor health. Evidence shows that high levels of distrust of their physicians among black patients contributes to health disparities by causing reduced utilization of preventive services, relative to whites. These services include routine checkups and preventive screening (e.g. mammograms), the most cost-effective and valuable health care services in promoting and preserving health. Distrust also discourages blacks from participating in clinical trials, which hinders the research of therapies targeted at African Americans and intensifies disparities in the quality of health care. Even in the absence of any true discrimination, perceived discrimination, perhaps based on statistics showing differences in how blacks and whites are treated, is associated with poorer health.
Physicians whose priorities are their patients’ health ought to pay attention to disparities in care, the mistrust those disparities breed and the poor health outcomes that are observed as a result. This pernicious cycle begins with subjective biases and often causes objective harm to black patients, perpetuating disparities in care and health.
Black Lives Matter is highlighting and combating the biases that are at the root of unequal policing practices. A medical community that is often impartial to issues outside its purview might find it easy to ignore such a movement. But that would be a grave mistake.
We cannot achieve equity in health care without achieving equity in policing. Both are symptoms that can only be addressed if we treat the underlying cause. We must acknowledge and combat our collective biases in all facets of life to truly cure the disease. Just as the problem is not health care-specific, nor is the solution. We must strive broadly for social justice, not only in the clinic but also in our communities, our neighborhoods and our police departments.
Closing racial disparities is a societal endeavor, and engaging with Black Lives Matter is a step towards that common goal for police officers and physicians alike. If we join the activism all around us and if we stand with this movement for social justice, we can begin to tackle the implicit prejudices that result in a black man getting Tylenol when he needs an analgesic and that result in the fatal shooting of that same man in the absence of any crime. We can begin to heal the underlying problem.
Everyone has a part to play. Physicians can do the challenging work of looking closely at their own patterns of prescribing and treating, searching for biases that are often imperceptible at an individual level but contribute to collective disparities. Medical students and residents can critically reflect on the education they are receiving, if it is imbuing them with stereotypes and ensure they are honing the skills to combat systemic racism. Premedical students, like myself, ought to enter our training understanding the issues at hand and being aware of the unconscious prejudices we, our peers and our mentors hold. It is difficult for us to be critical of the medical guild into which we are working so hard to gain entry, but we are the future of the profession and a necessary part of any solution.
It is natural to feel helpless in the face of the startling statistics of health care disparities and the horrific events of last week. However, there is reason to hope. Over the last few years, the medical community has shown signs of change. Nationwide medical student die-ins in protest of police brutality were a beginning, giving rise to national organizations such as WhiteCoats4BlackLives that consistently advocate for a more equitable future. Doctors for America has taken on racial disparities. Medical leaders, such as New York City’s health commissioner, have joined in the call to action, insisting that the medical community ought “not sit on the sidelines.” Medical education, too, is changing. The American Association of Medical Colleges has spearheaded efforts to incorporate diversity, inclusion and cultural competency as a core value of our nation’s medical schools. Even at the premedical level, the new MCAT encourages studying sociology and explicitly tests knowledge of the disparities in health and health care in an effort to reduce these disparities in the long run.
Perhaps most promising is the recent “Letter to Our Patients on Racism” which has been signed by over 2,600 physicians and medical students. Its authors acknowledge that “historically, physicians as a group have not yet taken adequate responsibility for confronting racism, in our work or outside of it.” They make five commitments: 1) to support Black Lives Matter, 2) to dismantling the structural racism embedded in our healthcare system, 3) to learn how to provide trauma-informed care, and to teach this approach to our students, trainees, and fellow providers, 4) to healing communities ravaged by discriminatory criminal justice practices through engaging public health systems and 5) to using our power as constituents and leaders to insist that every major medical society and association develop a policy on racial justice. These are difficult promises to fulfill, and they require that every one of us do our part.
Suhas Gondi is a pre-medical student at Washington University in St. Louis (Class of 2017). He is pursuing a Bachelor’s degree in Biology with a Neuroscience focus alongside minors in Economics and Healthcare Management. In addition to becoming a physician, he is interested in the systemic problems in American health care (e.g. cost, access, quality) and how we can use innovation and policy initiatives to solve them. A local of the Washington, D.C. metropolitan area, he hopes to pursue leadership in public service at the intersection of government and health care.