Racism in Health Care Isn’t Always Obvious

Editor’s Note (12/21/21): This article is being showcased in a special collection about equity in health care that was made possible by the support of Takeda Pharmaceuticals. The article was published independently and without sponsorship.

As physicians from three distinct racial minorities, our lives are defined by an innate tension. On one hand, we experience the privilege of being highly educated professionals, often with power dynamics and societal respect on our side. On the other hand, we are part of a system that provides unequal treatment to people of our same skin color. We also recognize the many manifestations of racism in health care, and today we call on all our colleagues to stand with us in denouncing and fixing one critical problem: racial bias.

Health care workers are constantly thinking about how to improve the quality of care being delivered to our patients. However, we rarely talk about our own biases toward our patients—let alone racial bias. We usually aren’t even aware of them. But they exist, and in fact, when it comes to our patients, evidence suggests that us doctors have the same level of bias as the wider population. Hence, it’s time we address them head on.

Let us paint a picture for you. Imagine two individuals come to a doctor’s office to determine if they need a procedure. All of the presenting signs and symptoms are the same and overall demographics are similar—but one person is white, and the other is Black. Studies show that, more often than not, the white patient is offered the necessary treatment, while the Black patient is not. Why? Doctors are sworn to “do no harm,” but the numbers are clear: we aren’t treating all of our patients equally.

In a 1999 New England Journal of Medicine study, researchers found that doctors were less likely to refer women and Black patients for necessary heart treatment. Nearly 20 years later, another study found persistent sex and race-based disparities with respect to heart treatment, with Black patients statistically less likely to have a heart specialist assigned to them or an intervention performed to evaluate the blood supply to their hearts. As it stands, Black people have higher death rates for eight of the 13 leading causes of death. Once again, we ask: why?

While we know there are many social determinants of health, we suggest starting with a variable within our own control as physicians: implicit bias. Defined as the unconscious attribution of particular qualities to a member of a social group or class of people, implicit bias is a term that has been making its way around the health care sector without ample consideration or integration to date. It is a particularly nefarious challenge given most of us are literally unconscious of it—not to mention being defensive about it when we’re called out.

But once again, the numbers are clear on its impact on health care for Black Americans: a study at four academic medical centers across the country evaluated physicians who self-reported no explicit preference for white versus Black patients. However, after completion of an implicit bias test, those same health care workers demonstrated a significant preference favoring white Americans, while their perception of Black Americans was negative relative to cooperation with medical procedures. The study also found that the more physicians were implicitly biased towards white people, the more likely they were to perform certain treatments on white patients in comparison to Black patients.

The times we live in would cause even the most optimistic person to see the glass as half empty. This idea of a two-tier system being intricately woven into the foundation of America is evident in analysis of education, law and health outcomes. The reality of this stark contrast that often falls along the lines of race, has been amplified in the recent occurrence of the COVID-19 pandemic. As of the end of May, COVID-19 had claimed the lives of 32 in every 100,000 Americans, compared to 1 in 2,000 African Americans. 

As we look at systemic racial injustice that permeates throughout America, it’s important to be clear that while the most recent public example happens to be centered around police brutality, there are numerous other George Floyds that exist throughout the system, including health care. And they exist along a spectrum from someone who might give you a dirty glance because of the color of your skin to an officer who kneels on your neck in broad daylight, taking your last breath away. Racism bleeds into every sector: law enforcement, journalism, education and health care.

How can we as a medical community address this issue? We believe it begins with understanding our own privilege and biases, and we believe it is critical that all our colleagues—regardless of race—join us without delay. We call on medical institutions and associations to require implicit bias training for all health care workers, including as part of initial and ongoing medical certification. States such as California have already passed legislation mandating implicit bias training for some physicians; hence there is no reason why we can’t expand this to all doctors and health care providers across the country.

Racial injustice will only change if each and every one of us take on a shared responsibility. For us health care workers, this must begin with conversations we have with our loved ones, speaking up for random strangers where we witness injustice, and boosting the advancement of brown and Black people within the workplace. Changing culture is hard. It does not happen overnight, and it requires all of us.

While the world’s attention is focused on racism within law enforcement, we must not lose sight of the fact that racism permeates every level of society—and the health care system is far from immune. This American uprising is a culmination of generations that have faced racism and injustice. Breaking that cycle requires us to dig deep and change our own behavior—unconscious and otherwise.