A UK government investigation into disparities in social care support (rather than medical care) picked up on the kind of unreflective preconceptions that, without being ill-intentioned, can lead to such disparities: so much so that its report was entitled “They Take Care of Their Own, Don’t They?”.
Of course institutional racism can happen in any organisation; and is there really any argument that medicine, to be effective, needs to be sensitive to the patient’s social environment, culture and expectations? Not all dis-ease is about organic chemistry.
Although monstro that study does not quite address the possibility that Black physicians are as subject to implicit bias towards Black patients as are White ones. It would not shock me.
Yes.
WhyNot - None of us will actually see institutional/structural racism from our vantage points. We are too up close. The whole idea is that seeing it requires us to pan out, so to speak. Institution racism is not the bit of bark on the tree we are looking at, or even the tree, but a function of the forest, where the rivers, fences, roads, and waste dumps are located within the forest, and how what impacts those features have. Heck by definition none of us are even aware of our implicit racism … that decreased empathy for someone different than you? It is not a conscious choice or even within our conscious awareness unless we make special effort to recognize it and to do something about it. IMHO quite a few who think they are “race blind” and actually just more blind of their own implicit racial biases.
Thanks also. That would imply that black doctors are more sympathetic to blacks than white ones, and less sympathetic to whites. Since there are disproportionately fewer black doctors, the effects against whites are much outweighed by the effects against blacks.
I would still be interested in direct evidence that black doctors treat black patients better than white doctors do. I can imagine a general attitude in ERs that some groups complain too much spreading across medical personnel of all races.
DSeid’s cite says -
I find it interesting that it didn’t affect pain scoring. The doctors were able accurately to score the pain, even with less empathy. As well as diagnose, admit, and follow up as appropriate.
IIRC, black people harbor anti-black implicit bias, but it is far less than the anti-black implicit bias that white people have. Black people are also more likely to harbor “pro-black” bias than white people.
I don’t think implicit bias necessarily maps onto empathy. The latter seems more repitilian than the former. Like, I could see someone having a “positive” implicit bias for a certain group but still having reduced empathy for individuals in that group. Believing that Asians are smart doesn’t equate to feeling more sympathy for them, especially if you’re never encountered them before.
Pain scores are patient reports on a number scale - using numbers or frowning to smiling faces that correlate with numbers. No empathy required, just a standardized process. They got the scores fine. They then paid less attention to them and took longer to do it.
I see it. I see it a lot. My Black patients are bounced out of the hospital in 24-48 hours, for conditions that my White ones get 3-4 days for. My Black patients have a lot more ER visits than my White ones (which may be a learned cultural habit, not medical advice, but it still impacts quality of care and gets them branded “frequent flyers” and GOMERs.) My Black patients are prescribed older, cheaper drugs, while the White ones get drugs I have to look up because they’re new (I’m not sure who has the better end of that deal, actually.) I have a lot harder time getting the primary doc to give me referrals to pain specialists for my Black patients that I do my White ones.
I know for me personally, I’ve had to work a lot harder to learn how to assess Black skin, because I didn’t grow up with it. I am certain I miss more stage I pressure ulcers and cellulitis on dark skin than I do in White people. I’m working on getting better at that, but I know my care isn’t equal there, although I try. It has nothing to do with hating Black people, it has to do with Black skin being unfamiliar to me…but I’m sure if you ran my statistics, you’d see more skin problems with fewer early interventions in my Black patients, which is going to look like inequality of care.
On the first point what black people do probably varies based on individual background and class.
It does relate to the circumstance of police. Black cop may very well still identify more as cop against the them, than with the shared skin color group that they are policing, depending on the nature of the training and of institutional culture.
I think this applies to everyone, not just black people.
I’m guessing a white doctor who is a married to a black person and has a lot of black friends is less likely to have racial bias in his practice than a white doctor who doesn’t have any experience with black people.
I’m also guessing that white doctors who care for black patients that span a range of socioeconomics are less likely to show bias than white doctors who care for black people who are overwhelmingly poor.
Which is why I think diversity in the educational setting is important starting as early as kindegarten. I know racists all seem to have “best friends who are black”, but I can’t see how increasing positive interracial interactions and relationships wouldn’t chip away at some of this problem.
Yes of course. But the dynamic of being a minority in an institution dominated by a differing majority is not something the White physicians have been dealing with. I am not sure how that impacts one’s ability to identify with and have empathy for others who share your skin color. Maybe it doesn’t. But again, if someone showed me data it did it would not surprise me.
Funny side note; I had surgery in Virginia, everything was completely segregated. All of the doctors were middle aged white men, all of the physician assistants were younger white women, all of the receptionists were latino or black women. Each of these departments had at least 10 individuals.
After this experience it seems laughable to me that institutional bias could be dismissed out of hand.
Institutional racism is a reality that we know has an affect on laws and enforcement of laws. There is evidence that it has an affect on education. That it would have no affect on medicine would seem odd, under the circumstances.
On the other hand, it is not a blanket explanation for everything that occurs in which there is disparate outcome as measured by ethnicity. While it would be foolish for reasonable people to dismiss it, outright, it should not necessarily be the “go to” explanation for any phenomenon without actual investigation.
Sorry to be snarky here but no one in this thread has taken anything like a position that all disparities are the result of structural/institutional racism. Only that a) health disparities do exist and b) one contributor to those disparities is structural/institutional racism, a concept that is more than a buzzword in regards to healthcare and that awareness of it (and addressing it) is useful if one is interested in improving healthcare outcomes at population levels.
I see that the points I raised have been ignored or dismissed as irrelevant.
Then what can we say about behavior of a group of people that results in a disproportionately poor outcome for sickle cell anemia patients? Recall that earlier in this thread, sickle cell anemia was held up as an example of a genetic disease that white people are supposedly ignoring in favor of funding research into cystic fibrosis, thus constituting “institutional racism”.
As the link I provided earlier shows, there is a problem in providing adequate care to sickle cell patients, in that blacks aren’t donating enough blood (vital and life-saving for sickle cell treatment) and have a poorer record of blood donation than other ethnic groups. Should we label this as a form of “institutional racism”? Will that help spur more blood donation by blacks, or would it be counterproductive?
I also see that no one has accepted the concept that interest in and deep concern about one problem (i.e. cystic fibrosis) does not mean lack of concern and “racist” behavior in regards to another problem.
Coming back to the example of “alternative” medicine (sorry, but it is relevant), there are legitimate concerns about patient-physician communication and improving interactions between the two to improve patient satisfaction. DSeid (who I have incalculably huge and near-nuclear respect for) dislikes the idea that he needs to make his practice holistic and patient-centered and to discard the patriarchal aspects of the way he practices, as well as incorporating what he contemptuously dismisses as “woo” in order to please his patients. He finds these “buzzwords” annoying and unhelpful. But flinging charges of “institutional racism” and railing about the “power elite” in medicine supposedly is helpful.
I don’t buy it. It not only ignores reality but alienates people who are needed to help solve problems.
Quite true, but I certainly can do my part to address it. For instance, just recently I diagnosed a case of keloid (a form of hypertrophic scarring) in a skin excision from a black patient (yes, you can usually tell black v. white from a skin biopsy). I added a comment to my report suggesting that since this was a recurrent problem, there must be institutionally racist aspects to this patient’s care that should be addressed by her caregivers.
The physician feedback was discouragingly hostile in this instance, which indicates defensiveness and guilt. But I will keep trying to raise consciousness.
Although, as a White chick with a few lovely keloids (7? 8, I think? My body is really great at hypertrophic scar tissue), I wonder…do you see disproportionately more Black samples with keloid scarring? Is it, like my dreaded pressure ulcers, something to do with a difficulty in early diagnosis of whatever’s causing the keloid? Does greater melaninization have anything to do with hypertrophic scar tissue formation? (I’m covered in dark moles; do I form keloids because my skin, while White, has more patches of melanin than most White people?)
If we know the answer to that is, “no, no difference. Black people shouldn’t be having any more keloids than White people,” then I’m totally down with attributing that disparity to some impact of institutional racism, either in nutrition or job bias (more manual labor = more opportunity for injury) or preventative care or surgical technique or wound care…lots of reasons why Black people could be getting more hypertrophic scarring that are race based, both within and outside of health care.
What part of her care is lacking that would prevent keloid formation? I’ve always been told that it’s just what my skin does, and that maybe going to a plastic surgeon instead of the dermatologist might minimize it, but there was nothing I could do about it. (The dermatologist sites scarred with even more hypertrophic tissue, so that didn’t work.)
And, just because I’ve always wondered this…can you tell Black skin from darker Middle Eastern or Asian or Hispanic skin, once it’s not attached to a body?
As you well know, there can be multiple factors explaining a phenomenon. Sickle-cell anemia patients are disadvantaged not just because there is less funding and research devoted to the condition and because the medical establishment does not treat their pain properly, but because they are members of a minority group that is also disproportionately poor. These individual factors are almost certainly interacting with each other, but that doesn’t mean they aren’t independently significant.
It should comfort you to know that there is a lot of outreach going on in black media to increase blood donation in the African American community. I’m bombarded by PSAs every time I listen to my local R&B radio station (I donate every 56 days like a good little O-negative). So addressing certain institutional problems does not prevent other problems to be addressed simultaneously.
Are you going to dismiss all the cites that have been offered up in this thread? You have a lot to say about the sickle cell stuff. You haven’t said a word about pain treatment.
Of course. Just like the Missing White Women phenomenon does not mean there’s a lack of concern for missing and murdered black people. But it does not hurt to stop and ask ourselves about how this bias frames our perceptions, and how it may be self-perpetuating. For instance, I don’t think it is unreasonable to wonder if all the awareness and fundraising campaigns for breast cancer diverts attention away from cancers that are far more deadlier and prevalent BECAUSE they don’t get ever any attention. I don’t think that makes me a “sex baiter”.
I have respect for DSeid too (though we disagree on a lot of things and sometimes he says stuff that makes me go WTF). I don’t know if he remembers the heated exchange we had last year. He took the position that patients should not select doctors based on gender or race, but rather on their credentials. I take the position that intangibles such as gender and racial background ARE credentials when it comes to physical and mental health, and that a patient is well within their right to use these variables when selecting someone to treat them.
I feel like my position has been vindicated based on the cites I’ve presented here. Why should a black person not feel the least bit wary about consulting a white doctor for pain treatment, when there’s good reason to believe the white doctor will not be as empathic as a black doctor? Not because the white doc is KKK racist. Not because he or she is malicious. But because their brains are not properly “attuned” due to lack of exposure. Now, I DON’T think a black patient should use race as the only screening metric. But if they have a choice between two doctors with very similar training and experience, but one is white and the other is black, and this patient only has a very limited amount of time and money, then they are not being racist by deciding to try out the black doc first. I haven’t screened practictioners racially (there just aren’t enough black doctors in my area so that this would make a whole lot of sense). But I have in terms of gender. If I’ve got pain in my hoo-hoo, I want someone who has a hoo-hoo to help me with it. I’m curious if DSeid still has a problem with this approach, given the research findings highlighted in this thread.
Of course, the problem with discriminating medical professionals in terms of race is that it only entrenches institutional bias. If white docs don’t have a chance to work with black patients because all the black patients are flocking to black docs, then white docs aren’t going to get the exposure they need to be more egalitarian in their practices. (And if black docs get all the black patients, they probably aren’t going to get a whole lot of white ones either).
But on an individual level, it makes perfect sense to get treatment from someone who looks like you and comes from the same cultural background as you. I don’t think PCness should complicate the life-and-death decisions a person makes for themselves. I don’t think patients should carry the brunt of being “unbiased” when the medical establishment clearly isn’t.
I really don’t appreciate the hostility in this post. You seem very defensive, as if someone is pointing a finger at you. It’s not clear to me why that’s the case. Can we just have a regular conversation, please? I’m tired of everything being a fight all the time.
This is probably where White Girl puts her foot in her mouth, but I’ve become accustomed to the taste of shoe leather, so here goes…
I *love *Black women doctors. Every single one I’ve worked with has been at the top of her game. I figure that anyone who overcame THAT much discrimination to make it through medical school and find a job is someone that I want fighting in my corner, because she’s got to be one tough, smart, badass woman who will not take no for an answer once she sets her mind on a goal.
Personally, I love my white Jewish psychotherapist. We’re as different as two people can get, at least in superficially. But she’s “down” just enough so that I feel she gets me and where I’m coming from. Her favorite book right now is “Her Eyes Were Watching God”. I don’t care what you look like, if you can get down with Zora Neale Hurston, I’m gonna like you.
But I’m been friends with white Jewish women my whole life, so in retrospect, it really isn’t surprising we connected so well. If I had had different life experiences, it may not have worked out.
monstro would you be okay with a White person wanting to avoid the Black doctor and waiting for a White one because of the possibility that a White doctor might be more empathic in some subconscious way?
I appreciate your point but I still believe that on the individual interaction level prejudging people is wrong even if something is statistically more likely given a White or Black or female or male individual. That is the same argument used to justify a lot of biased actions against young Black males.
Jackmanni, “there is a problem in providing adequate care to sickle cell patients, in that blacks aren’t donating enough blood”? Indeed higher SES and higher education and student status levels are associated with greater blood donation as is ease of opportunity.
In fact the low amount of blood donation from Black donors is EXACTLY an issue that an awareness of some principles of sociology and psychology should be applied to. It is a structual problem with a racial disparity impact. Can structures be altered to address it? Yes. Coupling education about the need for donors from Blacks in Black churches with ease of opportunity to donate by having drives in those churches, is an effective strategy. Facing the historic mistrust from things like Tuskagee that creates a barrier for increased donation head on helps.
One might wonder if the fact that there is not more of that sort of outreach going on is the result of structural factors as well …
And I am officially giving up on trying to explain the difference between individual explicit racist beliefs and how structures have racist impacts. Either you do not want to understand the concepts or I have insufficient ability to explain it clearly but either way I am done banging my head against that wall.
Would I want them to get a bullhorn and announce their preference from the rooftops? No.
But like I said, if they have to make a choice with limited information and they’ve got good reason for feeling the way they do, I would be okay with it. It’s their bodies. It’s their personal comfort. Why would I want to interject “shoulds” into the very private relationship that is between doctor and patient?
Of course, sometimes it makes sense to be “picky” and sometimes it doesn’t. Being picky over a dentist doesn’t make a whole lot of sense. But if I’m looking for a GP and I know I’ve got a health issue that has a pronounced nexus with culture and race, I’m going to look for someone who has first-hand experience with where I’m coming from. Barring that, I’ll find someone who is specifically trained in “where I’m coming from”. For instance, I know a white female doctor who was trained at Morehouse School of Medicine and did her internship at Grady Memorial (in Atlanta, where I hail from). I’d probably look at her more favorably than someone who lacked that experience, if I was looking for someone to treat something like my sickle-cell anemia.
It’s not the same thing at all. A cop’s snap judgment about a young black male can result in that young black male losing his life–either by gunshot or by prison industrial complex. But a patient’s thoughtful consideration over their healthcare provider only results in one doctor getting their business and another doctor having to find someone else to fill that appointment. I don’t think there’s a lot of white doctors going out of business because black patients are afraid to be treated by them.
I would not expect black doctors to have serious problems with empathy for white patients, since they will usually have a lot of exposure to white people, both in their personal lives and in their practice. Most black people are educated in majority-white institutions and have a long positive history of interacting, befriending, and even marrying whites. Black people in general are well-versed in the ways of white folk, because white faces and white bodies bombard us on a daily basis. I’m open to discussing the possibility that black doctors provide inferior treatment to whites, if you’ve got cites to share. But I’m not going to assume that’s true simply because there’s evidence of the reverse.
Since you acknowledge that there’s institutional racism in health care, do you think it’s fair for patients to act as if it’s NOT there? Do you think it makes sense for a patient to be “color-blind” with respect to their own health care providers, when health care providers are not color blind? Why should someone who is suffering have to “play fair” when the medical establishment is full of Jackmannii’s who can’t see there’s a problem? A person shouldn’t have to wait for an institution to fix itself when it comes to acquiring the best for themselves (or their children).