art by Angela Ryu
The Intricacies of Race in Medicine
by Krithika Pennathur
The Hippocratic Oath is at the heart of medical practice, followed faithfully by generations of physicians since its origins in Ancient Greece. Among its many venerable facets of guidance, the oath proclaims that patient care should not be hindered by discriminatory practices, serving to provide a platform of equal justice for all persons in need. In today’s world, would physicians be able to truthfully admit that they are delivering their skills with the utmost consideration of racial equality? In a society where racism, ableism, sexism, homophobia and various other forms of discrimination are crucial issues, giving “equal” care may take on a quite different connotation.
Given that many individuals argue we live in a post-racial society, racism in medicine is a taboo topic and naturally debated. In order to get a complete picture of how racism fits into the larger medical field, it might be beneficial to take a look at where we started and how far we have come over the years in terms of patient care. In other words, how does the past stand in view of the present?
Let us start by taking a brief look at the bygone years of human history, when the scenario was much different than it is today. A famous example that provides a stark remembrance is the Tuskegee Syphilis Experiment, which involved 600 black males who were recruited with the enticing benefits of free health care and meals, among other things, in order to study the progression of syphilis in black populations. The program went on for 40 years despite an early loss of funding for treatments. Even with the discovery and approved use of penicillin, the lifesaving therapy was hidden from study participants, showcasing a notable disregard for the subjects on multiple grounds.
Although the Tuskegee study is known to be an extreme case of racial bias, it may be worth investigating whether this is a common occurrence in the current era. Just within the past decade, there have been numerous investigations presenting evidence on the presence of scientific racism, which is a concept that refers to ideas and scientific techniques that further racial discrimination and biases. Scientific racism not only affects the way in which doctors might care for minority patients, but also the preconceived notions of how patients feel about the care they are receiving.
Looking at one of the most recent conversations on this issue, a directly applicable discussion was presented in a 2007 review article by Ahmed et al., titled “Racial discrimination and health: Pathways and evidence,” where the authors presented an interesting point with the concept of “perceived discrimination.” As “negative stereotypes and images of non-dominant racial groups are pervasive in a racialized society,” individuals are subject to experiences of discrimination. These manifestations may also explain the higher incidence of anxiety that minorities experience, especially in the realm of receiving health care. If minority patients are allegedly apprehensive, what does it say about the influence of racial ideologies in medicine? An argument states that as there is no “verbal,” obvious form of racism, it is hard to make a case proving discriminatory practices in medicine. But what about internalized racism?
This particular form of conceptualization is reflected in patients’ inherent distrust in their health care providers. Assuming that black and white populations are provided the same services, the 2007 review article (mentioned above) analyzed the responses of both groups in relation to trust, where participants were asked a series of questions regarding equal health treatment. One of the biggest findings indicated, “Blacks significantly reported a higher level of racism than did whites.” With this perception of racism, there is also data suggesting that there is a lack of trust in health care providers and their commitment to providing equal care to minorities. The study also noted, “In the absence of racism in health care, Black and White respondents in this study would have had the same level of health care trust.” Even though it seems that minorities actively experience racism, do we listen to their testimonies? And just how justifiable are these feelings of anxiety and mistrust?
In a recent University of Pittsburgh study published by Barnato et al. in January 2016 in the Journal of Pain and Symptom Management, investigating “Differences in Physicians' Verbal and Nonverbal Communication With Black and White Patients at the End of Life,” distinctions in on-task performance of physicians were analyzed with black and white patients. The rationale behind this research was to collect evidence on racial disparities from the provider’s perspective. According to the results, blacks were usually 1.5 times more likely to say that they wanted more life-sustaining measures than were white patients. However, they were also three times more likely to instead receive end-of-life care.
While verbal instances are often the primary form of data in this field, what about nonverbal gestures? In the same University of Pittsburgh study, a total of 33 physicians were given a standard script to read for a model patient who suffered from cancer. While the speech was the same throughout, the physicians were found to give body cues more frequently to white patients than black patients, and these cues were notably different as well. "With the white patients, they were more likely to stand right at the patient's bedside and touch them in a sympathetic manner than when it was a black patient," says Dr. Amber Barnato, lead author of the study. "If body language is a significant tool for building trust or rapport, then if they're standing further away, that could lead to this cascading misunderstanding that could result in the patient and their family not trusting their doctor." Considering these findings in the context of the Tuskegee study, it would be interesting to conduct a comparison and consider where we have actually come over the years.
In addition to an overarching internalized racial disparity from the patient and provider’s perspective that exacerbates an interaction bias in medical care, there have also been specific studies that have looked into particular differences in delivered care based on a racial factor. Evidence supporting that breast and ovarian cancer are likely detected differently in black and white women has been documented. According to a study led by Dr. Katrina Armstrong in 2005, titled “Racial Differences in the Use of BRCA1/2 Testing Among Women With a Family History of Breast or Ovarian Cancer,” it was noted, “Among women with a family history of breast or ovarian cancer, women who underwent BRCA1/2 counseling (cases) were significantly less likely to be African American than women who did not undergo BRCA1/2 counseling (7.4% of cases vs 28.8% of controls).” Furthermore, the black women were tested less frequently, which could have proffered a significant contribution to later detection in this group.
From the alleged anxiety and mistrust faced by minorities to differences in delivery of care, do we really live in a post-racial society? Given our turbulent history and cloudy present on the topic, it is often difficult to determine the best approach towards establishing a sense of racial equality in the medical field. From increasing awareness about the existence of an issue in the first place to implementing a systematic approach in order to consider the potential sources of discrimination, there is a wide range of avenues to achieve substantial progress.
The primary step is to recognize that racism in medicine is a prominent issue, one that has caused a significant mistrust among minorities. Medical care is one of the few equalizers in our society that allows every individual to be treated fairly. By changing the perspective of patient care from one defined by certain ideologies to a view of equitable regard, medicine may one day become the noble practice that we treasure it to be. At the end of the day, we can all strive and hope that the Hippocratic Oath will once again be upheld as it should be and allow society to recognize that we are all human, despite the differences in the shades of our skin.