Medicine and Racial Bias: The Patient Experience

“Yolanda’s biggest problem is she needs to stop doing drugs,” exclaimed one of the doctors as he was talking to a nurse about Yolanda’s pain, implying that Yolanda was an addict to street drugs. In the early stages of my private practice career, I was shocked as I heard him utter these words, as she was my patient and I knew her medical history, and totally disagreed with his assessment. Yolanda, an African American female in her 40’s, had been treated with high intensity radiation for cervical cancer. This treatment left her vagina, bladder, pelvis and rectum with horrible radiation damage, which created intense pain, requiring her to be hospitalized repetitively for pain control. Yolanda’s pain was real and not concocted to solicit drugs, as this doctor had implied. What had prompted him to make such a sweeping indictment?

Now in NY for the last 15 years, I can tell you Yolanda’s story is not unique, as I have seen countless examples of doctors, nurses and other medical personnel implying drug use or abuse directed at lower to middle class minorities, mainly Blacks and Hispanics, with no evidence to support such claims.  The surprise from a young doctor’s perspective has left, but the outrage remains.

The reality is that racial bias permeates throughout medicine and has done so for a long time (think Tuskegee experiment where black men with syphilis were purposely untreated to explore the natural history syphilis in the mid 1900’s, paid for by U.S. government). While in many circumstances it implies only an attitude, often it has implications for adverse medical care. As a resident in Virginia I had seen gross examples of racial bias in medicine. I once had a young black man come into the hospital writhing in pain after being kicked, discharged home with concerns he was seeking drugs, only to return via ambulance with a large perforation in his bladder that required immediate surgery. Studies have shown that Black and Hispanic patients have their pain undertreated for painful conditions like kidney stones and broken bones, a trend that persists in every geographical region in the U.S., not just in the South.

The results go beyond just acute care for pain, this effect is also seen with life-saving cardiac procedures.  A study from Duke University looked at nearly 13,000 patients across the country, and found black patients were 13% less likely to undergo angioplasty and 32% less likely to undergo cardiac bypass surgery than their white counterparts. (https://www.nejm.org/doi/full/10.1056/NEJM199702133360706)

A landmark study from 2002, “Unequal Treatment: Confronting Racial and ethnic Disparities in Health Care”, highlighted disparities in care between white and minority patients: minority patients were less likely to receive appropriate cardiac medications, less likely to receive kidney transplant and remain on dialysis, and more likely to undergo amputation for vascular disease.

Black women are 3-4 times more likely to die at childbirth than white women (12 per 100,000 for whites, 40 per 100,000 for blacks, CDC statistics), even when corrected for education and socioeconomic status. Serena Williams, the great African American tennis player, recounts her traumatic childbirth experience, where upon developing a cough post C-section and being concerned about developing a pulmonary embolism (PE), she was dismissed by a nurse telling her she was probably just hallucinating. Only after demanding a CT scan and confirming that she developed a PE did she get the proper treatment (Listen to Dr. Williams, she wrote).

I am not suggesting that healthcare providers are racist but there are implicit biases that operate subconsciously in dealing with minority communities. A study out of the University Chicago looked at over 160 healthcare givers from the U.S. and France, asked identical clinical questions for a given scenario, and only changed the race from white to black. They found that the American clinicians were more likely to feel that the white patients would improve and follow clinical recommendations than blacks. However, the clinicians in France, with the same experiment conducted, showed no bias as to which race would improve and follow clinical recommendations.

I would like to expect more from institutions such as medicine, but the reality is that they are reflective of society at large. I don’t have all the solutions, but awareness is always the first step. True change will have to come through opening all fields of medicine to men and women from all racial, ethnic and religious backgrounds.

 

 

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