Amelia Cogan (’19) is a student at Grinnell College majoring in Biological Chemistry. In the fall of 2018, she will begin pursuing her Masters of Public Health at the University of Iowa. She then plans to attend medical school and work with vulnerable populations as a physician, hoping to achieve health equity in her community.
In a recent episode of Grey’s Anatomy (Season 14, Episode 11: “(Don’t Fear) The Reaper”) [1], Dr. Miranda Bailey, the black female chief of surgery at Grey Sloan Memorial Hospital, walks in to the Emergency Room of Seattle Presbyterian Hospital, telling the desk nurse that she is having a heart attack. She is promptly admitted as a patient. After examining her electrocardiogram (EKG), an intern assures her that that she is not having a heart attack. After an additional EKG returns normal and the intern’s dismissive attitude, Dr. Bailey demands to speak with whomever is in charge. Dr. Larry Maxwell, the Chief of Surgery at Seattle Presbyterian Hospital, is paged and comes to Dr. Bailey’s bed to tell her that her EKG and rapid troponin test do not show that she’s having a heart attack; and although they are running a full cardiac enzyme panel, he does not expect abnormal test results. Dr. Bailey continues to tell Dr. Maxwell that she is not well–she is nauseous and has heartburn. Dr. Maxwell asks Dr. Bailey about the stress in her life, diet and exercise, and medications. Dr. Bailey explains that she is overall healthy, despite taking medications for obsessive compulsive disorder (OCD) and running a hospital – an obvious stressor for anyone in this position. Dr. Bailey continues to demand additional tests, but when her demands continue to be ignored, she asks for another opinion. Dr. Gregory, a psychiatrist, comes to Dr. Bailey’s bed to examine her a half an hour later, keeping in mind that heart attacks are extremely time sensitive. He, too, does not believe she is having a heart attack. He emphasizes her limited coping skills and lack of a support system, implying that she is crazy. At this point, Dr. Bailey states a startling statistic,
63% of women who die suddenly from coronary heart disease had no previous symptoms, and women of color are at a far greater risk. So, if I were consulting on the patient you just described, I would take into considerations statistics that would never even occur to people like you. [2]
In recent years, Shonda Rhimes, the creator, head director, and producer of ABC’s Grey’s Anatomy, has done an excellent job of keeping the show socially and culturally relevant. This episode was no different. As Dr. Bailey stated, women of color are in fact at a greater risk of dying from coronary heart disease than their white peers; and this health disparity extends beyond coronary heart disease. [3] Women of color are at a greater risk of dying from stroke, breast cancer, child birth, and cervical cancer than white women. There are numerous reasons why we see major health disparities: policy making, social factors, individual behavior, biology and genetics, and access to and quality of health services. The focus of this blog post is to discuss how physicians’ biases, throughout history, have negatively impacted black patients’ experience and quality of health care and how these differences have contributed to major health disparities among black patients.
The history of medicine is deeply rooted in blatant racist beliefs and prejudices, but bias in medical care has evolved from blatantly racist tactics to physicians’ implicit, or unconscious, biases. We will begin our discussion during the 17th and 18th centuries where beliefs in black inferiority, both intellectually and biologically, dominated white thought, especially in the antebellum South. These ethnocentric beliefs were also held by those in positions of power, such as physicians, natural scientists, and policy makers during these times.
These beliefs and feelings of white superiority justified giving slaves unequal medical treatment. It was in slave owners’ and slave traders’ best interests to keep their slaves healthy to optimize economic success, so they commonly admitted their sick or injured slaves to commercial hospitals and subsequently paid for their treatment. However, medical care of slaves was not simply the relationship between the patient and physician – it was the relationship between the slave, the physician, and the slave owner who was viewed as the physician’s client. Since the slaveholder was the paying client and slaves were viewed to be “medically incompetent,” ill or injured slaves had little say in treatment decisions regarding their bodies, rendering them vulnerable and helpless. [4]
Slaves were also the subjects of many experimental treatments, some of which were debilitating and fatal. Obstetrics and gynecology emerged at this time, and physicians in these new fields utilized black women to perfect new techniques and surgeries. Experimental surgeries, such as the cesarean section and an experimental surgery for women who suffered from vesico-vaginal fistulas, were never done on white middle- or upper-class women. These slave women, who never provided consent for these surgeries, developed addictions to opium for post-operative pain and underwent these procedures without anesthesia, which was justified by the white physician’s belief that black women were not as sensitive to pain as white women. [5] Black women would never benefit from these improved techniques and surgeries, perpetuating health disparities and inequitable health outcomes despite significant medical advancements for white patients.
The United States made progress towards racial equality in the late nineteenth century. However, despite new laws giving African Americans legal rights, whites still held deeply rooted ethnocentric beliefs. The United States faced a time of “separate but equal” in which Jim Crow laws mandated the segregation of whites and blacks from 1876 to 1965. As we know, separate was not equal.
During the civil rights movement, the issue with health inequalities was not just a quality of care problem but also a lack of access to health care, resulting in black deaths and creating major health disparities. White doctors and nurses did not treat black patients fairly, and as Dr. Ranzy Weston, a highly regarded physician who practiced medicine during the civil rights movement, recalled, “[a white doctor] would see all of his white patients first and then he would see his black patients afterwards. In the meantime, some patients did sit up and die; black patients.” [6] Of course, not all white doctors treated their patients poorly, but Dr. Weston believed they likely they did not give equal service to their black patients.
With the passage of Title VI of the 1964 Civil Rights Act, it was against the law to discriminate based on race, color, or national origin for any program receiving federal funds. [7] Both public and private hospitals received federal funds, meaning patients could not be turned away for those reasons. The National Health Planning Act of 1974 required hospitals receiving federal funds to accept Medicare and Medicaid patients. This act supported people of color and many of those who were impoverished, and it helped ensure that hospitals complied with Title VI. In 1979, the Department of Health, Education, and Welfare adopted regulations that prohibited hospitals from denying admission based on insurance status, ability to pay, or professional privileges. [8]
Eventually, the United States achieved integrated hospitals through black activism and legislation. Physicians could no longer legally discriminate against patients based on their race, religion, and insurance status. However, legislation was not a cure for the health inequities black and minority patients faced. Health disparities continued to persist, and part of the problem can be attributed to physicians’ implicit biases.
Implicit bias is any attitude or belief that affects our actions or decisions unconsciously, commonly in disagreement with our personal beliefs. Physicians, like all people, are influenced by their experiences and environment. White Americans tend to have pro-white biases. Implicit bias is dangerous because it can impact a physician’s clinical decisions that can perpetuate health care disparities, as was depicted in the episode of Grey’s Anatomy cited above. [9]
Physicians’ beliefs and implicit biases can impact physician-patient interactions for blacks by affecting the quality of communication, verbal and nonverbal, with a patient. A physician’s style (e.g. asking open-ended questions, allowing patients to ask questions, etc.) and content (e.g. how much information is given based on a patient’s perceived health literacy skills) may differ between patients of different racial backgrounds because of preexisting assumptions about certain groups of patients. [10] Physicians may also spend more time with white patients and keep patients of color waiting longer for assessment or treatment. [11] These problems can lead to black patients feeling unsatisfied with their care, perpetuating their severe distrust in the health care system.
Numerous studies across almost all major specialties confirm that physicians’ beliefs and implicit biases also impact their decision making for diagnoses and treatment. This may perpetuate health disparities in minority groups further. Treatments for patients with the same presenting symptoms, disease, or illness may differ based on the patient’s color. For example, Green et al. found that physicians with pro-white bias were more likely to recommend thrombolysis to white patients than black patients. [12] Sabin and Greenwald found that pediatricians recommend the “ideal management of pain” at lower rates for black patients and higher rates for white patients. [13] Physicians may make these decisions based on a patient’s perceived ability to follow a specific treatment regimen, ability to pay for such treatment, insurance status, or other socioeconomic factors. [14] These differences can lead to very different health outcomes for patients of color.
In the case of Dr. Bailey, physicians without such prominent implicit biases against black women would have taken her complaints more seriously. She may not have required additional intervention in the end had these physicians given her the same standard of care she would have received if she were a white patient. If treatment and other medical decisions are not equitable for black patients, these implicit biases have major impacts on the health outcomes for poor and minority patients. Fortunately for medicine, progress to eliminate health disparities caused by implicit bias is possible. Physicians can mitigate their implicit biases and have a profound positive impact on minority patients and their health outcomes. The first step is for physicians to recognize their own implicit biases. Then, we need to improve training and education, such as cultural-competence training, to assist health care professionals in recognizing and mitigating the impacts of their own implicit biases and delivering culturally competent care to a growing diverse population. The next step would be to bring about systematic change to revamp Title VI to include implicit biases and more clearly define Title VI’s role in health care to extend legal protections for minority patients.
This blog post has discussed the impact of implicit bias based on black patients’ health. It’s important to remember that implicit bias impacts people of all different identities – educational level, employment status, and even weight or mental illness status. Mental illness and implicit bias is severely understudied, but may have profound impacts on their physical and mental health based on unconscious stereotyping of the mentally ill. Implicit bias also impacts people in a much broader context than just healthcare. Encounters with law enforcement, the courts, and other everyday interactions can be shaped by peoples’ implicit biases. It’s important for people, including physicians, to recognize their biases to mitigate any unwitting and potentially negative consequences.
Endnotes
[1] Rhimes, Shonda. “(Don’t Fear) the Reaper,” Grey’s Anatomy, ABC, Feb 1, 2018.
[2] Ibid.
[3] “Women and Heart Disease Fact Sheet,” The Centers for Disease Control and Prevention, last modified August 23, 2017, https://www.cdc.gov/dhdsp/data_statistics/fact_sheets_fs_women_heart.htm
[4] Fett, Sharla M. “Danger and Distrust.” In Working Cures: Healing, Health, and Power on Southern Slave Plantations. The University of North Carolina Press, 2002.
[5] Ibid.
[6] Ward, Thomas J. Jr. “Health Care.” In The Jim Crow Encyclopedia. 1 vols. Westport: Greenwood Press, 2008.
[7] Gordon, Colin. “Health Care in Black and White: Race, Region, and Health Politics.” In Dead on Arrival: The Politics of Health Care in the 20th-Century America. Princeton: Princeton University Press, 2003.
[8] Ibid.
[9] Chapman, Elizabeth, Kaatz, Anna, and Carnes, Molly. “Physicians and Implicit Bias: How Doctors May Unwittingly Perpetuate Health Care Disparities.” Journal of General Internal Medicine 28, no. 11 (2013): 1504-1510. doi: 10.1007/s11606-013-2441-1
[10] Matthew, Dayna B. Just Medicine: A Cure for Racial Inequality in American Health Care. New York: NYU Press, 2015.
[11] Hall, William J., Chapman, Mimi V., Lee, Kent M., Merino, Yesenia M., Thomas, Tainayah W., Payne, B. Keith, Eng, Eugenia, Day, Steven H., and Coyne-Beasley, Tamera. “Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review.” American Journal of Public Health 105, no. 12 (2015): 60-76. doi: 10.2105/AJPH.2015.302903
[12] Green, Alexander R., Carney, Dana R., Pallin, Daniel J., Ngo, Long H., Raymond, Kristal L., Iezzoni, Lisa I. and Banaji, Mahzarin R. “Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients.” Journal of General Internal Medicine 22, no. 9 (2007): 1231-1238. doi: 10.1007/s11606-007-0258-5
[13] Sabin, Janice A., and Greenwald, Anthony G. “The Influence of Implicit Bias on Treatment Recommendations for 4 Common Pediatric Conditions: Pain, Urinary Tract Infection, Attention Deficit Hyperactivity Disorder, and Asthma.” American Journal of Public Health 102, no. 5 (2012): 988-995. doi: 10.2105/AJPH.2011.300621
[14] Matthew, Dayna B. Just Medicine: A Cure for Racial Inequality in American Health Care. New York: NYU Press, 2015.
Further Readings
Betancourt, Joseph R., Green, Alexander R., and Carrillo, J. Emilio. “Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches.” The Common Wealth Fund. October 2002.
Byrd, Michael W., and Clayton, Linda A. “Race, Medicine, and Health Care in the United States: A Historical Survey.” Journal of the National Medical Association 93, no. 3 (2001): 115-345. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2593958/
Smith, David B. “Racial and Ethnic Health Disparities and the Unfinished Civil Rights Agenda.” Health Affairs 24, no. 2 (2005): 317-324. https://doi.org/10.1377/hlthaff.24.2.317
