I think it is important to publish race related studies because it may help to correct individual or group normative behaviour. We all have our blind spots and we only become aware of them once they're pointed out by someone we respect and/or love.
Doctors and medical practitioners are humans too. So, regardless of how tedious the topic of race relations has become, it is critical that disparities are studied and publicised so that any implicit biases may be addressed. Unfortunately, we are all biased and we tend to bond with those who share common values with us. These may be political affiliations, moral values, religious beliefs, sports affiliations, hobbies, musical tastes, food, parenting, race or place of origin.
Fortunately or unfortunately, we are visual beings and skin colour is the first trait or value that we encounter when we meet another person. It's no surprise that our ingrained bias, based on stereotypes, immediately kicks in until we gain further insight about the person we are dealing with. I am a black male who is more relaxed with my Asian doctor than I was with the impersonal white doctor that preceded him. At the same time, I am more bonded with a few white friends, based on shared values, than with my own blood siblings. It's weird but it's the way we are.
I had a black partner in the practice. It was remarkable how often I would end up seeing black patients and often they would tell me or the ladies at the front desk that they would only/rather see a "Jewish" doctor. The whites tended not to care which doctor they saw. 200 years of bias has affected the views of black people as well as whites. Racism will be with us until the entire population intermarries, including the Ashkenazi Jews, and everyone is the same color....and same religion. Perhaps the government should consider financial incentives to encourage that.
7
It’s possible that your partner didn’t have an attractive personality. I’ve only encountered 4 Black physicians, but found 3, like female physicians, more engaged than average white, male doctors and 1 not a good person. It happens.
2
Would these findings be true of doctors from all cultures and ethnicities, i.e. do all doctors show a bias toward treating people like themselves?
Where I live in California, the vast majority of doctors are of Asian descent. In fact, I don't think I've been treated by a non-Asian physician in the last several years. I think they are all fine doctors, but I don't feel particularly bonded with them. It's definitely not like the close relationships I remember our family doctors when I was growing up. I see them for discreet issues with various body parts, and that's it. We never have a personal conversation. However, I don't know how much of that is that the health care system has become very depersonalized and basically everyone treats their patients now like widgets.
3
@Sarah I have found the same situation you describe since a recent move to Ca. ( I lived here for 42 years previous to a move back to Ohio. During my previous stay her I had a doctor with Kaiser in walnut creek who was Black and always respected his judgement and felt happy with his care. Moved back to Ohio and had several Doctors (all Caucasian) who I was just as comfortable with! Spent Time In the Cleveland Clinic and found the same!Returned to California and am being treated by an array of Physicians all of whom are Asian ( Chinese, Filipino, Indonesian)and most of the nurses and healthcare workers fall into this Bracket also! It has been my experience that they are all great people and are being unfairly criticized as a group! This article should have been directed to only the medical profession so that they could address the occasional bigot or Racist within their group!! Addressing it to the public is simply inviting those dissatisfied with their care an excuse for crying Racism! We have too much of that already!
1
@DwightCutter. Did you not look at the IOM study highlighted in this piece? It is as close to objective as one can find. Racism at all levels of healthcare is a fact. Its effect on black patients and providers continues to be a problem. Healthcare has no immunity from racism which also affects education, justice, employment, finance, politics and every other human service in the USA and beyond.
4
I've written several articles on racism and mental health for an independent global publication. According to the National Alliance for the Mentally Ill, depressed and traumatized African-American patients are more likely to be diagnosed with severe disorders like schizophrenia, even when presenting with similar symptoms to White patients. They are given medications with harsh side effects that exacerbate rather than treat their concerns; and then are labeled resistant or non-compliant when they refuse a regimen they never needed in the first place.
Only up to 4% of people interviewed across the 37 national and state-level Adverse Childhood Events research studies (linking trauma and poor health outcomes), were African-American. Black people represent 13% of the general population and are more likely to experience trauma than other Americans.
A Princeton study found that therapists were less likely to call back a middle class Black male seeking services than a White patient with lower income and less comprehensive insurance.
Black mentally ill persons are more likely to be incarcerated than Whites, even though they do not commit any more crime. As someone who works across racial and health justice fields, I am stunned by the number of White & Asian patients l've encountered who have admitted to serious crimes but never spent a day in jail. Black patients have spent months on Rikers for disorderly conduct.
Yes, America, we have a race and health problem.
15
I am an eighty-three-year-old retired orthopedic surgeon. I spent my whole life in academic medicine educating both medical students and residents. There are a few things that laypeople should keep in mind.
Physicians are people. They come from the general population. In general, they are more intelligent and test well. That doesn’t make them more just, kind, or unprejudiced.
We tried to teach them that making snap judgments about people does not lead to good decision-making. Rich people lie. White people take drugs. Nice white ladies who go to church get gonorrhea. Those are just facts.
Medical educators try to make our students the most effective physicians we can. We will never perfectly succeed. We will hopefully always get better. Please don’t be too hard on us.
Think about the unintended good consequences of racial thinking. It’s unequivocally true that black people are given less access to narcotics than white people. It’s becoming increasingly evident that the indiscriminate prescribing of narcotics to young people is a great cause of our opioid addiction problem. So sometimes being white isn’t great for your kids.
Healthcare is complicated. Physicians are human beings. We will always make mistakes. We are doing better. People are living longer healthier lives. If we work together and keep studying the problem. We can continue to improve the outcomes.
11
Doctors are mortal flawed human beings. Medicine is part art, part business and part science.
3
Since my health insurance expires today, I'd be happy to see any physician. I just want the right antibiotics to stop the infection from metastasizing to my body and alleviate the swelling. I like to think that is their primary interest, too. Implicit bias is real; so are cognitive heuristics--mental short cuts someone might take after a 60-80 hour week--all too common in the profession. They are "just like us" because they are people, like us.
2
My medical advice: First consult Google. Or a good medical center website. These are colorblind. And free.
Also, the internet doesn’t order unnecessary tests and procedures.
funny..i suspect you'll sing a different tune when the chips are down
1
No, there are LOTS of studies now revealing that the way algorithms are coded by (mostly) White men, actually racializes even Google searches.
Do a search for "Asian women" or "Black women" for example, and see how horribly vile and racist the top results are. Howard Stevenson (brother of Bryan Stevenson) has done some prominent national level work on this concern but there are many others. Americans have a problem with racism that we must all reckon with. You don't have to be White to internalize and practice White supremacy. @BL
6
We are a French family. I am white, my husband is Asian, my kids are I guess both.
Two anecdotes:
- my husband is prescribed a drug that requires his liver function be monitored. The doctor's office tells him over the phone that he has to avoid a painkiller, but my husband, whose mastery of English is not perfect, and who is at work only gets the end of the molecule, 'ophen.' I had to phone the doctor's office to ask whether it was acetaminophen or ibuprofen. It was only lucky I knew European paracetamol is acetaminophen. Clearly, spelling or, better, putting it in writing too would have been in order. This of course should be normal procedure, not everybody has medical knowledge.
- my husband did not get the proper diagnosis for a foot problem because, in the ER, a doctor decided the skin was not red without comparing the two feet - he was examined by a doctor teaching student doctors, so. yes, rather appalling. When I reported to his physician that, being Asian, his skin did not look as red as, say, mine, we quickly got heard.
I can't believe we pay those insane prices and I have to do crazy medical homework to just get basic treatment.
Before that, I I faithfully ticked the 'race' boxes, knowing from experience that origins may matter when attempting to diagnose a disease. Obviously, nobody cares. I now tick 'other' and write down human.
10
I’m not certain how your knowledge that paracetamol is analogous to “acetaminophen,” directly affected this case.
Perhaps you failed to include in your comment relevant details of your interactions with the doctor’s office when you called to clarify the medication in question.
Although I don’t recall you mentioning it, perhaps the staff was unable/unwilling, etc. to directly spell out and/or otherwise clarify the name of the verboten medication.
If so, your knowledge that acetaminophen/paracetamol are analogous painkillers that can affect the liver helped you ask the relevant question (“acetaminophen or ibuprofen?”) that otherwise couldn’t/wouldn’t have been answered.
Otherwise, I don’t see what role “luck” or “required homework” truly played in identifying the medication in question.
Just because you happened to know that clarifying between acetaminophen & ibuprofen was likely germane DOESN’T indicate that your own prior expertise was required for you to receive an appropriate response.
If it was, please make such things explicit so it doesn’t appear that you aren’t inappropriately and/or unfairly impugning others.
If the office communicates electronically with patients, he could have emailed, requesting they clarify the drug. Or during the call, asked them to mail/email the information as well.
It’s unfortunately not realistic for most healthcare offices etc. to automatically provide written copies of all information.
1
Unfortunately these biases are not limited to the medical profession. These same individuals serve on juries.
17
Everybody has their biases. Even you Vanessa.
As a young doctor, I think that we should be mindful of is how medicine is tested and the bias presented through testing questions. Many of the USMLE questions (a major exam that can determine a lot of a MD's early career) when they include race are down right offensive. We should look quite hard at these questions that are so foundational for people who are becoming doctors and how it reinforces and furthers racial stereotypes.
4
Yale per chance?
If so, I know that you’re smarter than the rest of us combined, and this has certainly NEVER been your experience on such exams, etc. but given that certain illnesses/conditions/practices, etc. are more common in individuals of certain ethnicities, cultures, races etc., it’s not terrifically unusual for the test writers to include certain such clues, cues in question stems.
There is also the whole “cultural competency” issue that has put pressure on instructors etc. to include info that gives the impression of creating/reinforcing stereotypes, may actually do so, but also simultaneously provides potentially culturally relevant information.
Heck, including such scenarios could even be part of the test makers’ strategies to attempt to combat “unconscious bias” nowadays. I certainly don’t recall any such stereotyping on my national exams & I was fairly attuned to such m
They may want folks to get used to dealing with their unconscious biases because in most average urban American hospitals one trains in, one is going to come across dozens of situations that evoke either unconscious bias or reflect someone’s conscious bias about some type of person/group that it’s better to start dealing with it earlier rather than later.
I hope you’ve heard, for example, about how certain medical “professionals” refer to many people with mental illnesses/addiction (in my experience, some of the most egregious are mental health & addiction providers, counselors, etc.
1
As a physician I know, like everyone else, I have my biases, whether it be related to race, gender, sexual orientation, etc. I try and be cognizant of my biases when I think about cases and try to 'check myself,' i.e. question whether my decision making process is because of bias or because of the facts. I find this very helpful, and it would be great if this was taught in medical school and residency. I'm by no means perfect but I feel (and hope) I'm giving everyone the care that they deserve.
16
@Eric Diversity, equity and inclusion is being taught across University of California health professions schools. Our attention to this aspect of care is serious and will continue to be.
1
"There is still a long way to go in how the medical field treats minority patients, especially African-Americans."
This is a two way street in that patients also have a long way to go in their treatment of minority doctors and nurses. I have worked in the field and saw the racism first hand.
19
We need more doctors of color, doctors who speak the languages of their patients, and doctors from different cultures.
In Daly City, CA, for example, where many patients are Filipino, many of the doctors are also Filipino. These doctors speak the same language as their patients and also understand the culture.
The more diversity there is in physicians, the easier it is for patients to find a doctor who understands them.
7
I am sure that race plays a role in how a patient is judged and we certainly educate physicians to avoid such a bias. Socioeconomic status, by far, can easily explain almost all the disparities in healthcare. Instead of addressing that elephant in the room we keep finding excuses. If we can improve socioeconomic status of individuals and clinicians decrease errors due to cognitive reasoning we would make substantial progress.
4
@SridharC You’re not wrong. Barriers to care that are a result of social and economic inequalities need to be addressed. But I think you’re also missing the point. Even when you control for socioeconomic factors disparities still exist. If a college-educated Black woman in the middle class, from a “good” neighborhood goes to a hospital to deliver her baby she is more likely to suffer from complications than a white woman with the same level of education and insurance. In fact, she is more likely to suffer complications of pregnancy and delivery than a white woman with a high school education.
That is not someone making an excuse. I don’t know why people are so quick to discredit minorities in discussions like this even when there is data and evidence that supports what these groups have been saying for years.
20
I agree completely that there is disparate treatment at the point of care that affects outcomes.
There is however, at least one other possibility that might partly explain some of these disparities, though unfortunately it still involves unequal treatment overall.
Actually, one hypothesis to potentially explain such disparities in perinatal outcomes suggests that NOT ALL women of color are consistently treated less well, etc. in the perinatal period etc.
The hypothesis is more or less that the chronic stress of dealing with systemic racism, etc. leads even “better off” women of color etc. to be more vulnerable to poor outcomes given the tremendous adverse effects that chronic stress (of many different types) have on the body’s many systems.
@SridharC I am a black female Ivy League graduate with a white collar, six figure senior job in government. I have still been treated poorly by clinicians. I had a doctor who assumed I eat junk food all the time and was surprised when I said I cook healthy foods and don’t drink soda. I never set foot there again. The fact that I am in a higher income bracket didn’t matter. This phenomenon transcends socioeconomics and based on race alone. Particularly as a black female IMO.
1
One only has to look at the obituary page and realize that Black Americans die at a much younger age than white people from common diseases that are often manageable. It is pretty clear that we haven’t moved forward as a country when it comes to equal access to healthcare, and people like the current governor of Virginia are to blame.
5
The entire African continent is full of doctors and their patients. Within these African countries doctors treat tribes differently, wealthy folks get better treatment and so on. This is a human problem. Bias prejudice partiality. Doctors are supposed to be above bias, they are supposed to have higher standards but they themselves were raised with biased conditioning. They watched their parents nonverbally behave prejudiced. This is human state, today in 2019 as it was in 1960.
14
I am appalled that readers should think that including race in a patient's description at intake would be prejudicial. Certain groups have greater tendencies toward medical diagnoses. (i.e. AfroAmericans have higher percentages of sickle cell anemia and Jewish women have higher rates of breast cancer). This is not bigoted but helpful in arriving at diagnosis and medical treatment. It would be negligent to otherwise exclude this. If the liberal community thinks that is helpful then they are the bigots. I would hope that certain tests ARE ordered to rule out disease!!
20
It’s not that including race is objectionable, the truth is it has not helped to achieve better health outcomes. My previous white male doctor (40 ish) objected to me identifying side effects of medications he prescribed. It mattered not that we were in the same economic status. He was clueless to the side effects and blamed the side effects on me, needless to say he’s no longer my doctor. My new white male doctor (60 ) understands my concerns and has done his job to address them.
9
@Jane I think that the issue is not including information about race. I think the issue is that the mere knowledges of a patient’s race should not change the quality of care that an individual receives. Yes, individuals of African descent are more likely to have sickle cell disease. But as a member of the medical field if a person comes to me with illness or pain, no matter who they are, they should receive the best care that I can offer. And if my beliefs about a certain group does not allow me to offer that care, than I shouldn’t be taking care of people, period.
4
@Bola. Yes, I agree. Of course treatment should not be biased or compromised due to race. However, my criticism was addressed to healthcare professionals in this Comments Section who, in fact, proposed eliminating one’s race or ethnicity in the intake writeup. That is important medical and genetic information!
1
Sometimes a disparity ... is just a disparity.
It is a scandal how complacent we are today when the professionalism and fairness of good people are casually smeared.
Only toward the end of this article does Carroll hint that -- just maybe -- there may be some perfectly innocent reasons for disparities. Even then his account is just perfunctory, and he quickly reverts to the "narrative."
"Physicians sometimes had a harder time making accurate diagnoses because they seemed to be worse at reading the signals from minority patients, perhaps because of cultural or language barriers." Carroll seems not to grasp the implication of the word "minority." It is not racist if a physician finds it easier to read symptoms that he or she has seen before in contexts he or she is familiar with. (When I shop for pants, I find it more difficult to find ones that are the right size for me, because I am an outlier. Does that mean that I am a victim of bias?).
"Then there were beliefs that physicians already held about the behavior of minorities. You could call these stereotypes, like believing that minority patients wouldn’t comply with recommended changes." Why doesn't Carroll address if these stereotypes are statistically valid? And if they are valid, then wouldn't it be grossly unprofessional not to take them into account?
17
In 2001, my Fundamentals of Nursing text described presentations of clinical symptoms. Problem: It described them as observed in caucasians. Then, at the end of whichever description would be added, "In African Americans......the sclera.....the nailbed.....the mucosa..."
I brought this to the attention of the program director who dismissed it. But she, dismissed me, in general, as she had a bias against older students.
Our uniforms, in 2001, were polyester, with short puffy sleeves, and Peter Pan collars. Our text regarded African Americans as an afterthought. And Asians?
County College of Morris, Randolph, NJ
I was at the top of my class academically, in part, because as an older nursing student, I'd lived much of that which was taught, but also because my retention was superior.
But, one can become a medical professional with just passing grades. Insight, and knowledge of subjects is not necessary to graduate, nor to practice.
8
@Pat
I think it's actually impressive that your text even included variations in appearance of skin/nails of different skin tones. a lot of times in training you don't get that variation.
Well this isn't terribly surprising when one race is historically taught to believe another race is not "really human" and doesn't "feel" as they do. Just this week I had a bad experience with a white healthcare worker when I went to get fitted for new leg braces. I thought the session was going rather well until out of left field the woman became totally hostile and seemed to accuse me of thinking she was a mind reader. I never gave any indication I was unhappy with her treatment so that comment was unwarranted. The session got awkward and went downhill from there until I opted to leave. I have no plans on going back and situations like that make me pine for black doctors of my own race.
14
Bias can work against any group. My wife has Sarcoidosis. She has had issues with it in multiple organs. She was told by one of her previous pulmonary Doctors not to worry about the disease because she is white. My wife also has some Native American ancestry that isn’t readily apparent just by looking at her. My point is that Doctors do at times make rash judgements on important medical decisions based on appearance in a medical examination.
4
Indeed. I recently had an appointment and complained of symptoms consistent with hypothyroidism. My doctor, who is the one to notice the correlations between symptoms and ailment, dismissed the possibility out of hand as I, a male, am not likely to have hypothyroidism. He did, however, suggest that I could be suffering from Low-T and ordered a blood panel. I tested positive for Epstein-Barr which is more common than either hypothyroidism or Low-T and has many of the same symptoms. I now need to find a new doctor.
10
@WoodrowWhat exactly did the doctor do wrong? Just asking.
2
Implicit bias is one thing, but explicit bias remains and is often documented in the patient record.
As a physician with 40 years in clinical practice, some in a direct teaching capacity, I am distressed with the frequency with which colleagues and medical students start the opening lines of the History and Physical narrative with: "Mr. so-and-so is a 45 year old African American male who presents with...," even when race or ethnicity has nothing to do with the medical issue at hand. Rarely is Mr. so-and-so described as "white"or "caucasian," although "Asian" and "Hispanic" are also common, again with little relevance to the patient's clinical problem.
Medical teaching institutions need to be the most aggressive in rooting out racial bias and this obvious example is a good place to start.
44
As an Asian-American MD, I include the race of the patient because it can affect diagnosis and management positively. For example, we know that Mediterranean familial fever is more likely to affect people with that background and that Blacks respond better to thiazide for high blood pressure. It is not necessarily prejudice.
9
@Anthony Asians are much more likely to cough on ACE-Inhibitors, and Blacks don't always get adequate blood pressure results with ACE-Is or ARBs alone.
I don't know, I was with you until here:
"Physicians sometimes had a harder time making accurate diagnoses because they seemed to be worse at reading the signals from minority patients, perhaps because of cultural or language barriers. Then there were beliefs that physicians already held about the behavior of minorities. You could call these stereotypes, like believing that minority patients wouldn’t comply with recommended changes.
"Of course, there’s the issue of mistrust on the patient side. African-American patients have good reason to mistrust the health care system; the infamous Tuskegee Study is just one example."
You seem in part to be blaming doctors for what are in some cases the limitations of the patients.
20
I'm a rural physician in Georgia. A new PA student is with us, and showed me the template the school requires her to use to enter information about patients she's seen. It includes age and gender, which do inform medical history to a considerable extent, and also race/ethnicity, which usually do not. She has stopped checking that box.
4
@Susie
race and ethnicity do matter in some situations. for example in rheumatologic conditions where certain racial groups have been documented to have more severe or difficult to control disease. it's not being racist to point out someone's race. it's racist to think the person is inherently bad/less smart/etc because of their race.
1
In an ideal world, I shouldn't worry if my doctor gives me less medical treatment because of my race or gender. However, doctors are people and some people who are doctors are racists and will give less care to people of color. It's a fact. My health is important to me, and I want the physician to be a partner with me in managing my health. If a physician has an issue with treating me, I would rather he/she refer me to someone who will instead of giving me inferior medical care. And the more I read about patient bias, the more I want to seek out medical treatment from people of my own race.
6
Male doctors often consider women to be hypochondriacs and take their symptoms lightly.
36
@getGar
Do you have any evidence of this? (This is a genuine question.)
5
It is common! My wife had a herniated disc causing excruciating pain and was not even given an MRI for months. She believes it is because her pain was not taken seriously because of sexism. Conversely, she thinks being a woman she is trained to not “be a bother” so she used a calm, polite tone when describing her severe pain. After an MRI doctors sent for immediate fusion surgery because the herniation was pressing her spinal cord, a life/paralysis risk. She feels a man in her amount of pain would have gotten that MRI right away and I agree.
18
@getGar. @sceptic
There is truth to what getGar noted, but I would describe it as general air of disrespect rather than a specific claim of hypochondria. I am a white women, and I have numerous experiences of when male doctors were disrespectful to me in one way or another. Many times my medical issues weren’t taken seriously; other times the doctors were condescending or otherwise treated me like a child. I now see female doctors and dentists. I’m leery of male doctors but if I have no choice (for example if I am in the hospital) then I’m not afraid to respectfully assert my intelligence, self-respect, and equality if I sense they are treating me with disrespect, condescension, etc.
8
Hmm, I wonder if the biases from doctors were due to African American patients not complying with recommended treatment and so they observe this behavior which may formulate internal implicit bias. Of course medical school doesn't help as many doctors don't find the need to give African Americans anesthesia because of the stereotype that they "don't feel pain." What is definitely lagging is cultural understanding and history of the health care system and the African American community as well as the food deserts and fast food commercials often touted at African Americans through television programming aimed at them. The public health issue needs work and doctors need more understanding of the functions and dynamic of minority communities.
8
When I was in medical school “implicit bias” was known as transference and counter transference. We were cautioned to be aware of them least they interfered with patient care.
As a trauma surgeon I treat anyone who is injured from grandmothers to gang members. Everyone is a suffering individual who needs timely care and compassion. I am sure there is some element of racial and gender implicit bias by male, female, African American and white physicians toward patients who are unlike them. It’s what we do with that subtle undertone in order to provide appropriate care for everyone that matters.
17
Racial disparities still abound but patients and doctors should know that there is now suggestive evidence that disparities can be reduced. In a recently published study (Cykert S, et al, Cancer Medicine. 2019;1–8), researchers in showed that black-white disparities in curative treatment for non-small cell lung cancer could be reduced by a health care system-based intervention. that included: (1) a warning system; (2) "race‐specific feedback to clinical teams on treatment completion rates"; and (3) "a nurse navigator". A 10% disparity in curative treatment between blacks and whites was eliminated after by the intervention AND quality of care was improved for ALL patients. The study had limitations: groups were not randomly allocated to intervention or control and there were baseline differences between the intervention and control groups; differences between intervention groups were adjusted using statistical techniques but that would not control for unmeasured potential confounding factors. Clearly, further research is needed to confirm the findings. However, the results are promising and suggest that disparities in health services can be reduced through system-level interventions. Also, this study showed that reducing disparities did not require changing implicit biases of nurses and physicians (which is likely to be a harder nut to crack). Disclosure: I am at the same institution as some of the authors but I have no relationship to them or the study.
18
I believe this. There are many consciously and unconsciously biased people. Doctors are people. It only follows then, that there are many biased doctors. And if that's the case, how can it NOT impact your treatment?
Many years ago, in my mid-twenties, shortly after moving to Washington DC, I needed to have a physical. I found the first female doctor on my insurance plan that was taking new patients located near me and made an appointment. She was white.
We had what seemed like a very normal visit and examination. When I left, she gave me an order form to have some routine bloodwork done. As I was on the way to the lab, I was perusing the form and noted that she had ordered tests for several sexually transmitted diseases. At no point during the visit had she asked me about my sexual activity or even if I was in a relationship. As I already had an OBGYN, I had not requested any sort of female-related examinations. And, in point of fact, I was not sexually active at the time. So, why did she assume that I needed to be tested for these things?
At best, she was a crappy doctor who either did incomplete exams or billed insurance for unnecessary tests. At worst, she assumed that I was promiscuous and had been exposed to these diseases because of my race. I don't know which, but either way, I tossed the order in the trash and never went back. Since then, I review every order that I am given to make sure it doesn't happen again.
18
@Josie
Screening for sexually transmitted diseases, such as HIV, Hepatitis C, syphilis, and Chlamydia are a routine part of a medical intake evaluation. You were not being discriminated against, and the tests were not based on an evaluation of your character.
26
@A Doctor
Really? It surprises me to hear this. These have never been ordered on me, or at least none of my physicians have told me the results. Having a hard time believing this.
16
@Lina
Practices vary. You can find screening guidelines by searching the terms "screening guidelines for sexually transmitted diseases." As with all guidelines, there are small variations in the recommendations. As a general rule they are recommended for sexually active young patients. Clinicians may exercise their judgement, but my point is that it is unlikely that racial bias motivated the test ordering. Where I work, these tests are routinely ordered. Perhaps Josie's doctor should have discussed the test she ordered with her.
8
Aaron E. Carroll, MD, surely knows that the American concept of "race" as taught by the US Census Bureau has no scientific basis. What he is concerned with here is racism and at least the headline conveys this with its use of racial bias.
In an ideal America all people whatever their position in society as defined by using SES data and data on access to medical care would have access to medical care at as nearly uniform level as possible. This is not the case. A study of lung-cancer mortality framed as a study of the relationship between "race" and mortality was forced in the end to admit that the key variable was access to medical care. Period.
This is evident as concerns infant and maternal mortality among American women as compared with women giving birth in Sweden. We often read that American mothers-to-be classified as "black" have 3d world medical results. The focus is always on "race" whereas it should be on access as even Carroll recognizes.
Here in Linköping SE, 99% of all mothers-to-be enter maternal care at gestational week 12-14 and receive pre, peri, and post-natal care and support that results in one of the best records in the world.
The Ob-gyn researchers here for whom I work believe that women in Linköping born in the Horn of Africa do almost as well as the general population.
Access and continuity of care are what matter. End race-based medicine, begin Universal Health Care.
Only-NeverInSweden.blogspot.com
Citizen US SE
7
@Larry Lundgren
Please read the article more carefully. It fully acknowledged the issues related to availability of care, but went on to say that many of the racial discrepancies regarding to care persisted after controlling for education, social economic status, insurance coverage and availability of care.
For a give socio-economic status, availability is probably comparable for married men and women, yet studies have revealed that men and women are treated differently , men's symptoms taken seriously while women's are dismissed, and that this results in different outcomes for treatment, to women's detriment. (Not saying this is true or not true in Sweden. My recollection is that the studies were on American patients.)
4
@White Buffalo Thanks for excellent reply. I did read carefully. I was trying to find a way in 1500 characters to present what Dorothy Roberts devotes a whole book to and what Swedish researchers have reported on certain kinds of bias in medical care. The basic American problem is the way "race" is used, not just as something socially constructed but also as designating genetically distinctive groups. Larry
1
Physicians are human beings, just like the rest of us. That means we are subject to biases. The 'god complex' in medicine and our high expectations of physicians don't help any.
I recommend humility. Humans, know thyselves. And recognize we are aware of only the tip of the proverbial iceberg.
2
Coincidentally:
Bill Jenkins, Who Tried to Halt Tuskegee Syphilis Study, Dies at 73
https://www.nytimes.com/2019/02/25/obituaries/bill-jenkins-dead.html
After reading "Medical Apartheid" and thinking about Governor/Dr Northam's apparent inability to see blacks as human beings, I am reexamining my own doctors, most of whom are white, and considering replacing them with black doctors. The article says "the studies found an implicit preference for white patients, especially among white physicians." I am wondering if "especially among white physicians" means black physicians share this implicit preference or if it refers to nonwhite nonblack physicians such as Asians.
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@Lynn in DC I am white. Although it is racist and sexist, whenever possible I have used non-white and female providers because I figure they had to work harder to get into med school/internship programs so they are probably better than their male white peers.
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How many of the "experts" at the Agency for Healthcare Research and Quality work on the front lines of actual clinical care of patients? As FDR said, "There are as many opinions as there are experts". Especially those seeking data and truth with statistics.
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@Peter Olsson MD
AHRQ is an invaluable agency of HHS. I use a lot of their online cases for CMEs. They do great work. I think you are shooting the messenger.
I think we have gotten off in a different direction, aging vs race. When I brought up aging and kidney transplant, I was not speaking of the age of the possible recipient, but the number of hours the kidney had been out of the donor's body. I am not a transplant specialist but there is an optimal range of time before the kidney is no longer usable, and the fresher the better within that range. The comment I heard decades ago during a general discussion of racism in medical practice was that Black patients were more likely to get the older kidney in that range. I am sure the stats are obtainable from the national transplant organizations.
I don’t know how to put it exactly, but you feel as if you’re being examined and evaluated intellectually and emotionally as well as physically—and this isn’t a case when “holistic” is a good thing.
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We learned that being in medical school is not correlated to juvenile antics
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Someone should also check the comparative age of kidneys offered for transplant into Black vs White patients. The older kidneys are more likely to fail.
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@Karen Seniors of all races are not offered kidneys.
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@me You misunderstood the comment. It has nothing to do with seniors or the age of the kidney recipients. It refers to the age of the kidneys.
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70 years old used to be the cut off for getting a kidney transplant. That is no longer the case, although it can vary depending upon the transplant center. Patients in their 70s who are in reasonable good health can qualify for a kidney transplant. I know of a patient who got a kidney transplant at the age of 80.
As a former nurse practitioner and (later) a clinical psychologist, I have primarily worked with under served populations- both inner city and rural. I would like to believe that implicit bias has never impacted the care I delivered, however I'm sure it has. I appreciate Dr. Carroll raising an issue that all of us need to come to terms with.
It's hard to imagine how the Africian-American patients who were treated in the past by Gov. Northam must feel as they recognize his racist past.
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@Former Hoosier: And yet, the majority of African Americans in VA want the Governor to stay in office.
It's amazing how people can be completely different from one situation to another. A doctor may have a few too many over the week end, but is totally sober on Monday morning when it's time to see patients.
It's certainly possible that even as the Governor did something he shouldn't have when being silly with his friends in med school, that when it cam time to treat patients, he put on his white coat and became the doctor they needed.
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@Stephanie
These studies, as I understand it, are not about weekend behaviors or carefully scripted comments made to the public, but rather well-controlled evaluations of actual actions taken and real outcomes in medical treatments that differ statistically depending on the race of the patient. The decisions that you make in your nice, sterile office on Monday can still be affected by your implicit biases.
And let's not forget that the governor referred to human beings captured and transported across the ocean to be sold as property as "indentured." That's the kind of word choice, made in the moment in an interview, that really makes you wonder where this man has been living his whole life. And it reflects attitudes that go a lot deeper than any white coat he may put on on a Monday morning.
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@Stephanie
It is fake news to say the majority of blacks in Virginia want Northam to remain in office because the polls sampled fewer than 2,000 Virginians and had no objective way of determining that the respondents were actually black. Even if we presume all actually were black, they represent less than one percent of the total black population in Virginia (1.7 million). Contrary to popular belief, blacks are not a monolith.
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Dr. Carroll, what about including care provided by advanced practice providers (advanced practice registered nurses and physician assistants) in your otherwise excellent discussion? It seems the Times and its writers commonly forget that we are healthcare providers, too, in the same settings and with the same types of patients you discuss.
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How about redoing this story for a different set of patients - the elderly.
I remain appalled at the treatment my aging parents received when in hospital. Their FP knew them and treated them with respect. When they needed surgery or had emergencies however, the story was quite different.
Here are just two instances:
My Father was discharged after colon surgery one day earlier than his FP had told us to expect. In spite of protests, the hospital insisted. He was up fixing his breakfast the next morning and felt faint. Luckily I was there and caught him as he sagged to the floor, in and out of consciousness. I couldn't get a peripheral pulse, only a carotid one. He was hauled back to hospital by the EMTs who said his blood pressure was so low it was barely readable. He spent another 3 days in hospital, which of course ran up another bill.
When my Mom had arthroscopic knee surgery, I questioned the surgeon as why he had only smoothed out the cartilage rather than doing a replacement. He straight up told me what he did was 'good enough for a woman of her age'. She was 68. With swelling that wouldn't go away and intense pain, my Mom waited for 3 months before they would reschedule her for knee replacement.
Assuming that elderly patients are sedentary old folks who likely pass their time watching TV is demeaning. Neither of my parents fit that stereotype AND they were upper middle-class with excellent health insurance!
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the arrogance of much of the medical establishment is
Plain to see. The bean counters are pushing Doctors to get the patients out as fast as possible,I know I had a small stroke was mis diagnosed by one hospital,sent home
Fell again and taken to another hospital, tested for 24 hours and sent home in less then 48 HoursTo say it was
Chaotic is an understatement.Its Money, Money and how fast can they get it and get you out.
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@B Dawson
You bet. I'm 68. New doctor, I came in by myself. Same situation as your parents. Face to face interview. After the standard do you smoke, drink, vape questions - answer no/never. Did I use a cane? NO. Do you need to hold onto walls when you walk? NO. I actually jumped out the chair and twirled and danced for them. i asked - do I look unsteady on my feet? I still climb ladders, I can;t reach anything as I'm 5' even so I'm on a ladder on a regular basis. I move furniture that's taller than I am from room to room.
Don't even get me started on pharmacists that question me about prescriptions. And no, i'm not taking any controlled substances.
You get treated a lot different as you get older.
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@B Dawson Thank you for your post. I am the widow of a Medicare patient and you are correct. And Medicare patients and their survivors may find it impossible to find a lawyer, even when obvious malpractice and negligence have occurred, because the case wouldn't be lucrative enough.
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Dr's are Bayesian machines - especially given the time crunch of the average appointment.
When you make educated probabilistic assessments supported by - you know - empirical data - it is not racism - except is some bizarro University setting.
Take one of your examples - POC do exhibit real-life lack of Medication Adherence - it has been documented across many studies and across many countries.
I guess you can pretend it doesn't exist - you can ignore it and not set up safeguards so the patient has no protection - or you could accept it and save a few lives.
My instinct is that Dr. Carroll uses Bayesian techniques all of the time - he just feels some of them are not socially acceptable.
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@SteveRR
"Educated probabilistic assessments supported by - you know- empirical data" IS racism when the data themselves are the products of systemic racism and inherent bias, as it has been shown repeatedly that much of our research is. The very idea of "adherence" is itself a product of that systemic racism. It goes far beyond the structure of a medication list. It is linked to the systemic oppression that disallows POC to participate in a workforce that supports their ability to afford to take their medications as prescribed. It is linked to practices such as redlining and then basing public-school funding on property taxes, so that in many areas of the country, POC are relegated to 5th grade reading levels, which physicians (more often than not) do not accommodate when writing discharge instructions. The fact that it has been documented across many studies and countries doesn't negate the fact that it STILL reflects systemic racism, oppression, and lack of equity. If anything, it is more evidence, empirical evidence, of how profound the lack of equity is.
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@Jude Bornstein-Chau, MD
Multi-factor multi-country independent studies that include random selection are only biased is so far as they don't fit within your agenda that all social, racial, gender sexual-orientation groups present as a uniform whole with no distinguishing characteristics.
Note I did not hypothesize any causal mechanisms because that is not what Bayesian modeling does - what other folks choose to do with their predictive models may be more irrational and sociologically based.
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@SteveRR
Except it really does matter because black women like me die as a result of this bias.
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Nothing new here and much of the worse bias is against women and black women, forget it!
Research dating back to the 1960's on bias against women by Physicians, used similar testing . women and men were sent to doctors with the same script using exactly the same words and men were respected, believed and treated whereas the majority of women were sent home without treatment but plenty of judgement.
How about the research showing that nurses treat new born babies differently if they are male or female or a baby of color.
That comment on African Americans mistrust of Doctors being part of the problem because they don't trust doctors is racist, why even have that in this article?
Sadly Homo Sapiens are programed for tribal bias and we aren't going to change that till we can change our DNA.
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The author sets the stage for his article by citing a 1984 yearbook photo of Virginia's Governor Northam in either blackface or a KKK outfit, then moves on to say that some elements of racial or ethnic bias continue to exist in 2019 US medical treatment.
This should hardly come as a surprise since all facets of US life in 2019 continue to display some elements of racism. However, I would be willing to bet that these racist elements were much more prevalent in 1984 than they are today. Unfortunately, the data the author relies on to support his argument do not extend anywhere near as far back at 1984.
Blackface and the KKK are indefensible, but, to put it another way, I am sure progress has been made in reducing racial bias in medical diagnosis and treatment since 1984. And, of course, there is still room for improvement, though surely not as much room as there was in 1984.
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Dr. Carroll is usually spot on. So much so that I own two of his books and quote him when I lecture. But in this instance, I do NOT believe this bias nearly so wide spread. My wife and I are both physicians, one in private practice, one university based. I can tell you without question that all patients in both our practices are treated the same. I can't speak for care in Indiana where Dr. Carroll practicies, but I would be quite surprised if any of the physicians in my circle carry bias into the exam room either. That said, the overwhelming majority of local patients are insured and so care here may be subject to that slant. 1984 and 2003 were a good while ago. John Post, MD
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@john
Me and my African American family have lived this. Every day of our existence.
My 8-year-old-daughter had an endocrinologist walk out of her appointment after he asked her if she drinks orange juice, and she replied, "yes."
My mother and I went to 6-7 physicians and specialists trying to find someone to help her with her extreme headaches and dizziness. Finally, she was told by neurologist at Cleveland Clinic that she had "old people's dizziness" and told her to deal with. (Not a single test was ordered.) She died of metastatic breast cancer 4 months later.
And, try being fat, black and female! No matter WHAT condition I present with, the only answer ever given is to lose weight. Well, familial hormone imbalance kind of makes that impossible. So, I self diagnose and try to treat herbally.
I could go on and on and on.
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@john I am sure you do your best to provide equal care and treatment to all of your patients.
But to say that this bias doesn't exist or isn't widespread flies in the face of clear evidence.
I suggest you find an implicit bias test online -- many universities and other sites offer them -- and take it (honestly and without trying to manipulate the results). Have your colleagues do the same. You may all be surprised.
Even for an educated and liberal-minded person, wanting to be colorblind, or wanting not to be sexist to give another example, often isn't enough to make it so.
Acknowledging that UNCONSCIOUS bias does exist and is widespread is a important first step. People can't try to address the problems until they become aware of them and admit that they are real. Pretending they don't exist doesn't help anyone (except maybe the ego of the pretender).
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Anecdotes do not trump data. Better yet, I can match your anecdotes with my own. I am a Asian-American MD who has attended multiple appointments with relatives. My relatives are educated and speak English but often slower, with an accent. They've had some excellent doctors but also MDs who condescend to them and do not suggest treatments/ tests that are standard of care. They sometimes make assumptions that my relatives aren't interested, will not comply, cannot afford things, etc. when the opposite is true. Most are doctors who are not outright racist and are even nice people. Of course, things change when they find out I am an MD and my cousins are also. The same story repeats with my colleagues who come from Latino and Black families.
The first comments in this column related to aging. I also am a geriatrician so I see the same issues with elderly people denied certain procedures/ treatments when they are otherwise healthy and independent.
Implicit bias is the same beast in both cases.
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There’s a lot to reconcile and come to terms with here!
“Physicians sometimes had a harder time making accurate diagnoses because they seemed to be worse at reading the signals from minority patients, perhaps because of cultural or language barriers. Then there were beliefs that physicians already held about the behavior of minorities. You could call these stereotypes, like believing that minority patients wouldn’t comply with recommended changes.
"Of course, there’s the issue of mistrust on the patient side. African-American patients have good reason to mistrust the health care system; the infamous Tuskegee Study is just one example.”
Also, who is white? In my experience, I have had just as many if, not more, Arab, Iranian, Indian, other Asian, European doctors as white American ones.
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This was around 1990. A janitor who was black and I would exchange greetings and a few friendly words when he came for emptying my trash bin toward the day's end. One day he looked very sad. I asked what might have happened. He narrated the story of the night before of a car accident which killed his 18 year old son. He said his son was injured but was conscious and talking when he was taken to hospital by ambulance but the physician did not admit him in the emergency ward. He eventually did. But it was too late.
He thought it was physician-caused delay. It was hard for me to believe but his emotions overpowered my ability to ask questions.
If it were a white person, the thought of suing the hospital is the first that will come to such a victim's father. When I began to suggest that he do that, he cut me off saying this was not an option as he had no money for a lawyer. I would see him everyday after that day but he seemed changed. A few months later I did not see him; perhaps he had quit his job.
Nothing can be concluded from this that a physician treated his son differently than he would a white person. The father seemed convinced of this though.
It opened me to the possibility of physician bias in treating patients. This is more a instinctual or cultural bias. It is is some sense opposite of the higher attention (bias) which a wealthy person receives than an average one because of the latter's ability to afford.
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You have to be careful here. There is a difference between discrimination and "playing" the racial card.
Pre 1960s, this type of thing was legal and widespread, now all of that has changed.
Can discrimination still occur? Yes, however so can scapegoating, finger pointing, cherry picking, rationalizing, intellectualizing, aiding, abetting, figures don't lie but liars figure, playing the card etc.
It looks like you are straddling the line here.
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@Paul I'm sorry, but your comment is truly baseless. If anything is straddling "the line", it is your comment. This is an article that describes scientific studies. It provides facts. Is it somehow dubious to provide facts? I suspect these facts bother yo,u so you wish to suggest there is something wrong with them. But they are facts. In suggesting there is something wrong with stating facts, you've only revealed yourself to be the one "playing a card" and "finger-pointing".
Yes, discrimination occurs. That is a fact. And it is the point of this article. It is not playing the race card to point this fact out, and suggest we can maybe do better in healthcare treatment. If you have a problem with this discussion, ask yourself why you are so uncomfortable with the mere telling of the fact that discrimination is a reality for some.
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@marie-thank you for your reply. As the old saying goes there are three sides to every story, yours, mine and the truth.
Studies can be shown to disapprove everything Mr Carroll has said here. They would be as wrong as he is. Figures don't lie but liars figure.
Instead of playing the card, we should look at this issue re income not race. All poorer people not just blacks have poorer health because they cannot afford insurance.
If you play the card like Hillary (ie she played the feminiss card) you end up electing an ego maniac demagogue like Trump and hurt all people, black, white, poor etc.
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@Paul - thank you for clarifying, in your second comment (response to marie), the view only semi-expressed in your first comment.
Until the physicians are informed that the ATS Constitution-Dependent Inherited Real Risk exists, bedside diagnosed from birth with a common stethoscope, and removed by inexpensive Reconstructing Mitochondrial Quantum Therapy, we all are are treated as African-Ameican patients, i.e., in non-updated manner. What accounts for the reason that even outstanding and free newspapers do not disclose these advances in Medicine, which are efficient to stop the epidemic of AMI in the world. Let's remember the distressing event, Neil Armstrong died for AMI, after walking on the moon, after receiving certificates of helathy constitution, as President Donald Trump.