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A 400-Year-Old Crisis: Medical bias based on race

Healthcare in the U.S. has always been unequal. Medical racism, unequal care and poor health outcomes especially for people of color occur at nearly every stage in healthcare from birth to death. Everybody plays a role in its improvement. What should health care professionals do?

Based on an article by Matt Schur from the AMT Pulse, Summer 2020.

A History of Inequality

From property ownership to voting to education, inequality for Black people in the United States has existed since the first enslaved people were brought to the country’s shores more than 400 years ago. Survival, much less healthcare has almost always been perilous: explicitly so throughout slavery when (among other atrocities) physicians conducted excruciating experiments on enslaved people. Non-existent or inadequate healthcare continued into and throughout the Jim Crow era, which allowed for legally segregated care that fed the false belief that Black people would die without slave masters. Subpar or no treatment included denial of emergency services and poor health outcomes.

Today, medical racism, unequal care and worse health outcomes continue, if less explicitly egregious. People of color have worse health outcomes at nearly every stage in healthcare, from birth to death. False assumptions about Black people from flawed science have further complicated matters and still permeate the medical world. For instance, in a 2016 study, nearly half of all first- and second-year medical students believed old myths about Black people, including a false notion that they had thicker skin than white people.

And while Black people and Native Americans have the lowest life expectancy based on race in the U.S., according to the CDC, that isn’t to say other groups don’t experience unequal treatment. Hispanic people, for instance, have the highest uninsured rates for any racial or ethnic group in the country and more frequently go without care due to high costs.

Underlying Causes

Fully dismantling all of healthcare’s inequalities and inequities will take a sweeping effort on par with what should have been Reconstruction-era attempts to right the wrongs of slavery, says Susan Reverby, PhD, Marion Butler McLean Professor Emerita in the History of Ideas; Professor Emerita of Women’s and Gender Studies, Wellesley College, Wellesley, Massachusetts.

“To improve healthcare, we have to address issues of structural racism,” Dr. Reverby says. “In large part, it’s addressing economic concerns: lack of job opportunities, no sick pay or benefits, someone having to take three buses to get to a clinic or not being able to buy fresh vegetables. It’s also about expanding access to affordable care, helping people feel more comfortable when they do get care, more community-based care, more public health outreach.”

The people suffering the most have the least access to care,” says Melissa Martin, MPH, Director of the Chicago Area Health Education Center at the Health and Medicine Policy Research Group, Chicago. “They’re more likely to have closed hospitals, closed clinics, less physicians and healthcare workers in those areas.

“We need a deeper understanding of how social determinants impact health,” Martin says. “I don’t think people receive enough career and school training of the determinants.”

Understanding Bias

All this isn’t to say that small efforts won’t help. In particular, allied health professionals, and all health professionals, need to address their own biases, both explicit and implicit.

“Healthcare workers go into the profession because they want to help people,” says Janice A. Sabin, PhD, MSW, Research Associate Professor, University of Washington, School of Medicine, Department of Biomedical Informatics and Medical Education; Adjunct: Research Associate Professor, School of Social Work, UW Medicine, Office of Health Care Equity, Seattle. “Most providers want to provide the best care.” But, as humans, our own thoughts, feelings, personal histories—the sum of our lived experiences—affect every encounter.

Take the area of pain as a medical issue. It is subjective, and providers rely on patients for guidance. That’s where biases come in: Black patients are 40% less likely to receive medication for acute pain compared to white patients.

“There’s a long history of people describing lower back pain, and doctors viewing Black patients as if they’re just seeking drugs,” Dr. Sabin says. “That could be because of a bias or stereotype influencing how the provider is seeing the legitimacy of a patient’s pain.”

Interrogating Your Own Biases

A discriminatory experience can have a cascade of effects, Dr. Sabin says. If someone has, say, diabetes, and they don’t want to go in for screening because of a biased experience, the lack of preventive care could be fatal. “If I felt bad during my experience, like people were judging me, I’m not going back to the doctor,” Dr. Sabin says. “That interrupts the continuity of care.”

Step one for healthcare professionals should be a thorough self-assessment, says Kevin Sloss, MHA, RMA (AMT). “Ask yourself: Where am I making mistakes? What interactions am I excelling at? Where can I improve? Ultimately, how can I understand my patients’ experiences, and what can I do to overcome my biases in understanding their needs for care. Biases are something we have to acknowledge, but it’s also fixable,” Sloss says.

The healthcare experience begins the moment a patient walks in the front door, from the front desk worker to a medical assistant taking vitals. A lot of bad experiences can be subtle, too: not making eye contact when someone is telling a personal story, discouraging body language, a lack of warmth.

With every single person harboring their own biases, it’s impossible to stamp out every bias, Dr. Sabin says. Instead, health professionals should be aware that biases exist, and then take steps to mitigate their impact.

Organizations, of course, have a role to play in equity, too. They need to monitor patient experiences and train people to be on alert if a particular group is not having a good experience, whether that be based on race, age, gender or otherwise, Dr. Sabin says. “

Broader Representation

Greater representation is also key to building healthcare equity. Take the issue of heart disease, which is the leading cause of death for most racial and ethnic groups in the U.S., according to the CDC. Yet, only roughly 3% of cardiologists are Black, according to a 2015 report from the American College of Cardiology.

“Having diversity promotes health outcomes,” Martin says. “African Americans and Hispanic people are more likely to work in underserved communities, be more reflective of their patients and be more sensitive to their needs.”

Opening the Field

Broader representation requires removing the barriers to get into healthcare careers, Martin says. Part of her organization’s work includes outreach to schools to show different paths into healthcare, including nonlinear paths.

“I think it’s really important to share the story that not everyone has to go from high school to college to medical school with an exact plan,” Martin says. “We end up missing a lot of students going into certain careers because we have ingrained in people that if you’re not on track for medical school by sixth grade, you shouldn’t even make an attempt.”

Removing all the barriers to get into the medical field, including exorbitant costs, is a multifaceted approach that requires deep investment and needs to be addressed far beyond lip-service diversity initiatives, Martin says. That includes tackling bias in admissions, making sure minorities are supported in school, having a medical faculty representative of the larger population and ensuring that support and representation continue into the field.

But smaller measures can be effective, too, such as healthcare professionals finding opportunities to mentor and speak to young people. “We need to give people from diverse communities the opportunities to grow and go into various fields,” Martin says.

 

For more information about medical racism, bias, healthcare disparities and more, visit the CDC’s article about health equity concerns, which also includes links to additional resources: cdc.gov/coronavirus/2019-ncov/community/health-equity/race-ethnicity.html.

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