On the relevance of race in modern healthcare.
When you're nearly incapacitated from debilitating agony thanks to an infected cyst near your spine, the last person you want diving into your back with a scalpel is a dusty, ice-hearted surgeon. That's exactly who greeted my friend, Sarah (who prefers not to use her last name), when she wound up in an operating room to have the mass removed. Beforehand, all she received was a flat warning that the applied anesthesia gel might not be strong enough.
It wasn't. Ignoring Sarah's screams, Dr. Apathy resolved with a huff that she couldn't help her if she insisted on crying. She covered Sarah's incision with tape and gauze, and sent her on her way, cyst and all, without pain medication or a referral to another surgeon. Sarah saw another doctor for stitches and pain medication the next day. Turned off by the straight-faced barbarism of the second doctor as well, she received what she describes as humane treatment from a staff of black doctors after she moved back to her Caribbean home
"The difference was like night and day," she says.
Sarah's experience, though thoroughly wack, is far from unusual. Disparities in the way white doctors assess the pain of their black patients versus their white patients are well documented. These disparities are why many patients of color prefer to go to a doctor of the same race or cultural background.
To wit: A 2015 study by the psychology and family medicine departments at the University of Virginia explored bias in pain perception and treatment, and "false beliefs about biological differences between blacks and whites."
White doctors rate their black patients' pain lower than that of their white patients.
The study recruited "white laypersons," white medical students, and white residents. The regular white folks were asked to judge, on a four-point scale, the level of pain they'd experience in eighteen different scenarios, like getting a paper cut or slamming your hand in the car door. They were then asked what level of pain a black or white person of the same sex in the same scenario would likely experience. Next, they responded to fifteen statements about biological differences between the races—like "Black people have thicker skin than white people" (false), "White people are less prone to strokes" (true), "Blacks have stronger immune systems" (false)—rating each on a six-point scale from one (definitely untrue) to six (definitely true). Meanwhile, the 222 first-, second-, and third-year students and residents read mock cases about a black and white patient, rated their pain from zero to ten, and made recommendations for pain treatment.
As the researchers anticipated, the "laypersons" who held false beliefs about biological differences rated the pain of the blacks lower than the whites. Half of the medical students and residents subscribed to at least one false belief. Twenty-five percent of the residents believed black people have thicker skin. Those with the inaccurate misconceptions then rated the pain of blacks lower than whites, and in turn made less appropriate treatment recommendations.
These biases also manifest in more subtle ways. According to Suzette Creighton, director of risk management and quality improvement for a busy east coast hospital, racial biases also reveal themselves in coded language used to describe patients and communities. As with elsewhere in society, "urban" may be used to describe a hospital or clinic with a lot of black people, regardless of location. Latinx people may be labeled "displaced" if they are undocumented.
On the other end of the healthcare spectrum, as white patients' pain is often perceived to be more severe than that of others, they are more frequently over-prescribed pain medications, which explains in part why opioid addiction is three times as common among white people than among Hispanics and non-Hispanic blacks. This might be the sole upside of being under-prescribed.
Another study from the University of Boston school of dental medicine showed that black patients are half as likely to receive opioid prescriptions during emergency room visits—specifically for so-called "non-definitive" conditions like back or abdominal pain or migraines that are harder to diagnose—often under the guise of caution against "drug-seekers." There were, however, no differences in treatment for definitive conditions like toothaches, kidney stones, or broken bones.
While denials of pain medication can indeed be attributed to rising concerns about overdoses and a spreading opioid epidemic, doctors were more likely to exercise that caution when the patient was non-white. Others did so because of a higher level of provider-patient mistrust when it came time to prescribe the good stuff upon discharge from the ER.
Yesteryear's depravities leave a residue of distrust between patients of color and their white doctors.
Even without knowledge of these studies, a long, messed-up history inevitably leads to a distrust of white doctors among people of color. Consider, for instance, that many of the earliest advances in modern gynecology were because of the heinous anesthesia-free experiments and surgeries that physician James Marion Sims performed on enslaved black women whose bodies served as sandboxes for the sadistic, privileged and curious.
And then of course, there is the Tennessee Tuskegee Experiment, a 40-year study during which the US Public Health Service studied untreated syphilis in 399 black men in Alabama (and actively denied them treatment) under the guise of free healthcare from the government, all for some precious data from their autopsied corpses.
These atrocities may have happened ages ago, but yesteryear's depravities leave a residue of distrust between patients of color and their white doctors.
Washington, DC-based school administrator Akela Stanfield is quite familiar with that distrust. She spent a year being stereotyped by and receiving few answers from a string of doctors while trying to get to the bottom of the discomfort she'd been experiencing.
"Being a black female who is overweight automatically puts you in a diabetic category," she says. "They kept telling me I was 'pre-diabetic,' and I took way too many glucose tests. They were hunting for diabetes. I used to hate it—they would focus on it so much when I simply did not have diabetes."
These stressful dealings with white male doctors made appointments—none of which resulted in a successful diagnosis—a source of dread. But her outlook on healthcare changed during an appointment for the same ongoing issues when her primary doctor was unavailable, causing a life-changing encounter with a black female doctor who was filling in.
"That was the most enlightening 60 minutes of my life," Stanfield says.
While a stream of white doctors minimized her concerns, treated her like a type, and struggled to find answers to the issues she'd been having for over a year, this doctor changed the game. "She was able to look at me and find the issue—which was PCOS, polycystic ovarian syndrome—in that first session," Stanfield says. "She helped get me where I needed to go. It was the first time I felt treated like a human being, not a demographic."
Recognizing that Stanfield was clearly not diabetic, this new doctor had another answer: Binge Eating Disorder. There's an understudied but established link between PCOS and eating disorders—women with PCOS have turned to binge eating to cope with the altered self image caused by symptoms like weight gain and acne. None of her previous doctors had ever explored mental or emotional factors in their fruitless examinations.
With the new diagnosis came practical lifestyle changes. With her newfound support, she lost weight and despite the chance of PCOS-related infertility, she was ecstatic to be able to get pregnant.
Doctors aren't immune to the same conscious and unconscious biases that reside within the rest of us humans. But Creighton believes those preconceptions can be reinforced in medical school, where doctors often work in communities where they don't live, surrounded by people that don't look like them.
The white male doctor told Long he'd have to "bring her in so he could get her up on that table and manhandle her a bit to see what's wrong."
Imani J. Walker, psychiatrist and full-time black woman, recalls shadowing an Egyptian-American doctor at Temple Hospital in North Philadelphia. The doctor asked a group of residents visiting a black patient, "What do you do at Temple if you forget a patient's name?"
"Look at her chart?" they wondered.
"Look at her arm. It's usually tattooed on her somewhere," he replied.
"That kind of thing was commonplace," Walker says, adding that the discrimination is not limited to white healthcare providers. "They treat people like statistics."
Jennifer Braun, a white staff psychologist who provides treatment for patients deemed incompetent to stand trial at Napa State Hospital in California, ensures that she, for one, treats patients like people, not demographics, when trying to differentiate between severe mental illnesses. At the same time, she sees how patients of color can thrive when treated by a physician they are comfortable with.
"This is my professional and personal belief, but the cornerstone of meaningful therapy is allowing someone to bear witness to your life from a place of understanding, free from judgement," she says. "To be able to see yourself reflected in the other can lead to profound healing."
Julian Long, a branding and marketing consultant, calls it a "compassion gap." When he accompanied his 71-year-old mother to a doctor's appointment, he witnessed the infantilizing, pacifying, and ignoring of his mother by doctors and nurses. They didn't acknowledge her concerns when she mentioned having a drooping face and slurred speech. Doctors considered it a blood sugar issue and told her she'd be fine. An overconfident cardiologist misdiagnosed her with Bell's palsy and treated her with the steroid prednisone, sending her blood pressure through the roof.
All the while, nurses and specialists talked across and around her as if she weren't in the room, or with limited information, as if she wouldn't understand, though she could clearly articulate her symptoms and concerns. It took three MRIs and five days to properly recognize these as signs of a stroke—after she had had several smaller strokes at some point beforehand.
On another visit, while scheduling an appointment for his mother with a urologist, the white male doctor told Long he'd have to "bring her in so he could get her up on that table and manhandle her a bit to see what's wrong."
Long, who wonders if the doctor would have used that language with someone he regarded as being like his grandmother or daughter, tempered his rage with crossed arms and deep breaths.
Even with extensive studies on racial bias and America's troubled past with black folks and medical treatment, the difference often boils down to the comfort of knowing your doctor understands the uniqueness, importance, and nuances of your culture and lived experiences.
"Any time you don't have to explain the subtleties of your world, your comfort increases. It doesn't seem as strange to explain to your fellow black American doctor why it's hard to stick to your new cardiac diet when Big Mama is inviting you to Sunday dinner," Creighton says of the comfort that comes with familiarity. "And the micro-aggressions that can occur are deadly to building rapport and trust, the same way it is in any working relationship."
Patients of color can thrive when treated by a physician they are comfortable with.
Walker echoes those sentiments. She recalls a suicidal patient of Chinese descent in her facility recently. The young woman was highly paranoid and talked of death constantly. After two weeks of treatment with little insight to the source of her trauma, she revealed that she was afraid she had brought shame to her family and would be viewed as a disappointment. If she had a doctor of her own ethnicity, it may have been easier for her to convey those nuances and the significance of familial shame in Chinese culture.
Though cultural competency is taught in medical school, Walker says that you can't teach empathy. "I grew up in Harlem. I'm used to people in wheelchairs, doing crack outside, whatever. So if you're [a doctor] in an inner city hospital and can't see the human in these patients and aren't comfortable interacting intimately with people who don't look like you, they won't get the care they need," she says.
Furthermore, because of interactions with police, she adds, patients view everybody in positions of authority as "the cops." "I let them know that I'm not that person and they can trust me," Walker says. "It helps to be able to speak the same language."