In 2003 the IOM report Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare
brought together research that had surfaced in many hundreds of studies, but had been sufficiently scattered so that it hadn’t galvanized attention or created a call for action. The report documented in detail the fact that African Americans and Hispanic Americans received healthcare far inferior to that provided to their white fellow Americans.
Seventeen years later we know that it’s not just African Americans and Hispanics who suffer from disparate care and inferior outcomes, it’s women, the elderly, gays and lesbians, the Appalachian poor and others—thirteen groups in all have been documented. In plain language that means that in terms of relieving suffering, curing disease and saving lives, physicians are for some reason or reasons simply not living up to the standards of care we set for ourselves. That includes orthopedists and other musculoskeletal specialists. Studies, for example, have shown that African Americans and Hispanic Americans received far less pain medication for long bone fractures than white patients. How strange that is, when almost all physicians consider themselves and strive to be humane, compassionate, egalitarian caregivers.
We know that some of this disparate care is due to income inequality, the neighborhoods patients live in, the lack of insurance, and other inequities built into the social, political, and economic structure of our society. But the statistics reveal distressing discrepancies in outcomes even when insurance coverage and socioeconomic factors are accounted for. Why then does this happen?
That’s the question my collaborator, David Chanoff, and I attempt to answer in our book Seeing Patients
. We assume that even with physicians there’s at least some degree of overt racism, sexism, ageism, etc. involved, but we were far more interested in looking at unconscious bias, feelings about patients hidden deep in the brain’s processes for cognition and emotion.
In this regard we focused on two major elements that figure in unconscious bias. In his seminal book, Descartes’ Error
, neuroscientist Antonio Damasio spells out how the mind with its cognitive functions has evolved from the older limbic system for emotional response. Our thinking mechanism he tells us, is nested in our organs for feeling. Jerome Groopman, my colleague at Harvard, has written on the same subject. Most errors in diagnosis, he says, are mistakes in thinking. What causes these cognitive errors is our inner feelings, which we often simply do not recognize.
Could our diagnoses and treatments, then, be molded by our unrecognized feelings of like and/or dislike for our patients? David Schneider, a professor of cognitive science at Rice, gives us at least one explanation for why this could be. Stereotyping, he says, leads us all to make discriminatory judgements. “It happens with race,” he says. “It happens with disability. It happens with gender, age and physical appearance. It happens because that’s the way it is. Our mental apparatus was designed to facilitate quick decisions based on category membership.”
So, if we are designed such that our judgements are pervaded unseen by our emotions, and our feelings stem from stereotyping that we can’t really avoid, is there any way to counteract the unconscious bias that is in large part responsible for the glaring disparities evident in the statistics?
The answer, we think, is in two parts. One is awareness. If we are aware that we do harbor biases, and we all do, despite how we like to think of ourselves as models of egalitarianism, then we can take measures to counter their influence on us. We can practice mindfulness, culturally competent care, and conscious commitment to the individuality of each of our patients. Second, and this is perhaps more difficult, we can embrace the personal side of our interaction with patients, with all their diversity of color, gender, age, ethnicity and other uniquenesses. We should understand that empathy lifts up the spirit. It reduces stress and strengthens resilience. Empathetic care enhances the well-being of the doctor as well as the patient. It brings a level of satisfaction and enjoyment that gives a richer dimension to the practice of medicine. Is this or isn’t it crucial to us in the way we measure our lives? We would argue that it most certainly is.
We respectfully refer the reader to the following article:
White, A.A. and Chanoff, D. Medical Professionalism and Humanitarian Health Care in the American Age of “-isms.”, Journal of Racial and Ethnic Health Disparities, (2020). https://doi.org/10.1007/s40615-020-00725-7
Available at this link https://rdcu.be/b3IyK
This cited article presents some of these thoughts with a discussion of their relevance to issues of medical professionalism and burnout.