The racist photo in the medical school yearbook page of Gov. Ralph Northam of Virginia has probably caused many physicians to re-examine their past.
We hope we are better today, but the research is not as encouraging as you might think: There is still a long way to go in how the medical field treats minority patients, especially African-Americans.
A systematic review published in Academic Emergency Medicine gathered all the research on physicians that measured implicit bias with the Implicit Association Test and included some assessment of clinical decision making. Most of the nine studies used vignettes to test what physicians would do in certain situations.
The majority of studies found an implicit preference for white patients, especially among white physicians. Two found a relationship between this bias and clinical decision making. One found that this bias was associated with a greater chance that whites would be treated for myocardial infarction than African-Americans.
This study was published in 2017.
The Implicit Association Test has its flaws. Although its authors maintain that it measures external influences, it’s not clear how well it predicts individual behavior. Another, bigger systematic review of implicit bias in health care professionals was published in BMC Ethics, also in 2017. The researchers gathered 42 studies, only 15 of which used the Implicit Association Test, and concluded that physicians are just like everyone else. Their biases are consistent with those of the general population.
The researchers also cautioned that these biases are likely to affect diagnosis and care.
A study published three years earlier in the Journal of the American Board of Family Medicine surveyed 543 internal medicine and family physicians who had been presented with vignettes of patients with severe osteoarthritis. The survey asked the doctors about the medical cooperativeness of the patients, and whether they would recommend a total knee replacement.
Even though the descriptions of the cases were identical except for the race of the patients (African-Americans and whites), participants reported that they believed the white patients were being more medically cooperative than the African-American ones. These beliefs did not translate into different treatment recommendations in this study, but they were clearly there.
In 2003, the Institute of Medicine released a landmark report on disparities in health care. The evidence for their existence was enormous. The research available at that time showed that even after controlling for socioeconomic factors, disparities remained.
There’s a significant literature documenting that African-American patients are treated differently than white patients when it comes to cardiovascular procedures. There were differences in whether they received optimal care with respect to a cancer diagnosis and treatment. African-Americans were less likely to receive appropriate care when they were infected with H.I.V. They were also more likely to die from these illnesses even after adjusting for age, sex, insurance, education and the severity of the disease.
Disparities existed for patients with diabetes, kidney disease, mental health problems, and for those who were pregnant or were children.
The report cited some systems-level factors that contributed to this problem. Good care may be unavailable in some poor neighborhoods, and easily obtained in others. Differences in insurance access and coverage can also vary by race.
But the report’s authors spent much more time on issues at the level of care, in which some physicians treated patients differently based on their race.
Physicians sometimes had a harder time making accurate diagnoses because they seemed to be worse at reading the signals from minority patients, perhaps because of cultural or language barriers. Then there were beliefs that physicians already held about the behavior of minorities. You could call these stereotypes, like believing that minority patients wouldn’t comply with recommended changes.
Of course, there’s the issue of mistrust on the patient side. African-American patients have good reason to mistrust the health care system; the infamous Tuskegee Study is just one example.
In its report, the Institute of Medicine recommended strengthening health plans so that minorities were not disproportionately denied access. It urged that more underrepresented minorities be trained as health care professionals, and that more resources be directed toward enforcing civil rights laws.
In practice, it endorsed more evidence-based care across the board. It noted the importance of interpreters, community health workers, patient education programs and cross-cultural education for those who care for patients.
All of this has met with limited success.
In 2017, the Agency for Healthcare Research and Quality issued its 15th yearly report on health care quality and disparities, as called for by the medical institute in 2002. It found that while some disparities had gotten better, many remained. The most recent data available showed that 40 percent of the quality measures were still worse for blacks than whites. Other groups fared worse as well. Measures were worse for 20 percent of Asian-Americans, 30 percent of Native Americans, and one third of Pacific Islanders and Hispanics.
Of the 21 access measures tracked from 2000 to 2016, nine were improving. Nine were unchanged. Three were worsening.
It would be easy to look at a racist photo from the 1980s and conclude that it was a different time and that things have changed. Many things have not. We know that racism, explicit and implicit, was pervasive in medical care back then. Many studies show that it’s still pervasive today. The recommendations from the medical institute in 2003 still hold. Any fair assessment of the evidence suggests much work remains to be done.
