Racism and discrimination in health care: Providers and patients

"People fail to get along because they fear each other; they fear each other because they don't know each other; they don't know each other because they have not communicated with each other."
— Martin Luther King, Jr.

A patient of mine recently shared a story with me about her visit to an area emergency room a few years ago.* She had a painful medical condition. The emergency room staff not only did not treat her pain, but she recounted: "They treated me like I was trying to play them, like I was just trying to get pain meds out of them. They didn't try to make any diagnosis or help me at all. They couldn't get rid of me fast enough."

There was nothing in her history to suggest that she was pain medication seeking. She is a middle-aged, churchgoing lady who has never had issues with substance abuse. Eventually, she received a diagnosis and appropriate care somewhere else. She is convinced that she was treated poorly by that emergency room because she is black.

And she was probably right. It is well-established that blacks and other minority groups in the U.S. experience more illness, worse outcomes, and premature death compared with whites.^1,2 These health disparities were first "officially" noted back in the 1980s, and though a concerted effort by government agencies resulted in some improvement, the most recent report shows ongoing differences by race and ethnicity for all measures.^1,2

Why are certain groups of patients getting different care?

Doctors take an oath to treat all patients equally, and yet not all patients are treated equally well. The answer to why is complicated.

Cases like my patient's above illustrate the negative assumptions and associations we can label racism, but "most physicians are not explicitly racist and are committed to treating all patients equally. However, they operate in an inherently racist system."³ In addition, we know that our own subconscious prejudices, also called implicit bias, can affect the way we treat patients.⁴ Basically, there are so many layers and levels to this issue, it's hard to wrap our heads around it. But, we'll try.

We now recognize that racism and discrimination are deeply ingrained in the social, political, and economic structures of our society.^3,4 For minorities, these differences result in unequal access to quality education, healthy food, livable wages, and affordable housing. In the wake of multiple highly publicized events, the Black Lives Matter movement has gained momentum, and with it have come more strident calls to address this ingrained, or structural, racism, as well as implicit bias.

Then, there was the 2016 presidential election. Explicitly expressed racism and religious intolerance has become commonplace. Last week, an older Muslim patient of mine* related that lately she has been harassed by strangers for wearing a headscarf. "I don't feel safe even walking around my neighborhood," she wept. "I used to love walking in the mornings or after work ... it's been months since I felt I could do that."

In response to the rhetoric of the election and this alarming increase in hate speech, a large group of physicians published an open letter seeking to reassure patients. The letter is a statement of commitment to health as a human right, women's health, mental health, LGBTQ health, evidence-based medicine, dismantling structural racism, and ending race-based violence.⁵ It's everything I want to tell my patients right now.

Why are doctors sometimes the targets of bias and racism?

A colleague of mine, Dr. Altaf Saadi, recently wrote about her experiences treating patients at our own hospital. She has been questioned, insulted, and even attacked by patients, because she is a Muslim woman who wears a headscarf.⁵ She is not alone. Recent published reports include overt bigotry expressed towards doctors of black, Indian and Jewish heritage.^6,7,8 Several medical journals have just published guidelines for doctors with titles like "Dealing with Racist Patients" and "The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees."^9,10 It's sad that we need these guides.

And can we fix this?

Articles addressing racism in medicine suggest many of the same things. To fight racism and discrimination, we all need to recognize, name, and understand these attitudes and actions. We need to be open to identifying and controlling our own implicit biases. We need to be able to manage overt bigotry safely, learn from it, and educate others. These themes need to be a part of medical education, as well as institutional policy. We need to practice and model tolerance, respect, open-mindedness, and peace for each other.

It is important to link all of these goals and actions together, as they are layers of the same huge problem. The insidious structural racism, subconscious implicit bias, and overt, external discrimination come from the same place. Dr. Saadi's words hold very true:

"We — as physicians and society more generally — must realize that the struggles of one marginalized community are struggles of all of us. My fight as a Muslim-American doctor to serve my patients without fear of racism, and the fight of an African-American patient to be treated with dignity and respect, should also be your fights."

To that end, the call to action to address racism and discrimination in medicine is for all of us, providers and patients.

*Details omitted or changed to protect the patients' privacy.

Sources

1. National Center for Health Statistics (US). Health, United States, 2015: With Special Feature on Racial and Ethnic Health Disparities. Hyattsville, MD: National Center for Health Statistics (US); 2016 May. Report No.: 2016-1232.
2. The Department of Health and Human Services, United States (HHS). National partnership for action to end health disparities: Offices of Minority Health (note: automatic download). Washington, DC, 2011.
3. Rachel R. Hardeman, Ph.D., M.P.H., Eduardo M. Medina, M.D., M.P.H., and Katy B. Kozhimannil, Ph.D., M.P.A. Structural Racism and Supporting Black Lives — The Role of Health Professionals. New England Journal of Medicine, October 12, 2016.
4. King CJ, Redwood Y. The Health Care Institution, Population Health and Black Lives. Journal of the National Medical Association, May 2016.
5. Sreshta, Nina, et al. The Social Justice Coalition of the Cambridge Health Alliance: An open letter to our patients in the Trump era.
6. Saadi, Altaf: A Muslim-American doctor on the racism in our hospitals.
7. Gupta, Renuka. Slaves. Annals of Internal Medicine, November 1, 2016.
8. Howard, Jaqueline. Racism in medicine: An 'open secret' CNN.
9. Okwerekwu, Jennifer Adaeze. The patient called me "colored girl." The senior doctor training me said nothing. STAT news.
10. Kimani Paul-Emile, J.D., Ph.D., Alexander K. Smith, M.D., M.P.H., Bernard Lo, M.D., and Alicia Fernández, M.D. Dealing with Racist Patients. New England Journal of Medicine February 25, 2016.
11. Whitgob EE, Blankenburg RL, Bogetz AL. The Discriminatory Patient and Family: Strategies to Address Discrimination Towards Trainees. Academic Medicine, 2016 Nov (11 Association of American Medical Colleges Learn Serve Lead: Proceedings of the 55th Annual Research in Medical Education Sessions):S64-S69.
12. Sharma M, Kuper A. The elephant in the room: talking race in medical education. Advances in Health Science Education: Theory and Practice, November 5, 2016. [E-pub ahead of print]