In the wake of the #WhiteCoats4BlackLives "die-ins" by students at 70 United States medical schools in December 2014, public health officials and medical center faculty and students have started to discuss the possible contribution institutional racism has on well-documented disparities in health outcomes. Adding to that discussion, are two new perspective articles, published in the February 19 issue of the New England Journal of Medicine, that raise questions about disparities in health outcomes and institutional bias at academic medical centers.
In one article, Mary T. Bassett, MD, MPH, commissioner of the New York City Department of Health and Mental Hygiene, asks whether physicians have a role in fighting racism in and out of their clinic. "Should health professionals be accountable not only for caring for individual black patients but also for fighting the racism — both institutional and interpersonal — that contributes to poor health in the first place? Should we work harder to ensure that black lives matter?"
She notes that patterns of disease distribution and mortality have been affected not only by bad past policies but also by ongoing discrimination against people of African descent.
With the premature death rate 50% higher among black men than among white men in New York City, violence alone cannot account for all the lives cut short, Dr Bassett notes. Other factors contributing to this difference include disparate outcomes in cardiovascular disease, cancer, and HIV. According to Dr Bassett, certain population groups have higher rates of premature, preventable death and worse health throughout their lives.
Dr Bassett proposed three types of action to address this problem: critical research, internal reform, and public advocacy. Critical research on racism would be directed at identifying barriers to health equity. Institutional structures would be reexamined with a view toward hiring, promoting, training, and retaining staff of color.
"As a mother of black children, I feel a personal urgency for society to acknowledge racism's impact on the everyday lives of millions of people in the United States and elsewhere and to act to end discrimination. As a doctor and New York City's health commissioner, I believe that health professionals have much to contribute to that debate and process. Let's not sit on the sidelines," Dr Bassett writes.
In a second article, David A. Ansell, MD, MPH, and Edwin K. McDonald, MD, both from the Department of Internal Medicine at Rush University Medical Center, Chicago, Illinois cite evidence that racial stereotypes held by physicians can influence clinical decisions and that, despite physicians' and medical centers' best intentions, black–white disparities in outcomes, medical education, and faculty recruitment persist. They highlight the role of "implicit bias," unconscious racial stereotypes that grow from personal and cultural experiences or from lack of day-to-day interactions.
Referring to the Institute of Medicine's 2002 report Unequal Treatment , Dr Ansell and Dr McDonald write, "The [Institute of Medicine's] conclusion was that for almost every disease studied, black Americans received less effective care than white Americans." They suggest that implicit bias might contribute to mistrust on the part of black patients and might influence administrative decisions such as what services to provide or which insurance plans to accept.
Dr Ansell and Dr McDonald also suggest that implicit racial bias might contribute to the relatively low proportion of black medical students (about 7% of all medical students in 2012, whereas 13% of the US population is black). Within that group, the authors were particularly concerned about the low numbers of black men in medical school, with just 411 in 1980 and 517 in 2012. In contrast, there were 286 black women in medical school in 1980 and 880 in 2012.
"Our inability to recruit black men into medicine is alarming, given the urgency of racial health care disparities in the United States," Dr Ansell and Dr McDonald write.
They suggest that the low numbers of black faculty members at US medical schools (2.9%) might contribute to this problem. In addition, they note, black faculty members were "less likely than their white counterparts to be promoted, to hold senior faculty or administrative positions, and to receive research awards from the National Institutes of Health," as well as to be full professors.
Dr Ansell and Dr McDonald recommended assessing how bias might contribute to healthcare disparities, medical school recruitment, and faculty retention and auditing care to ensure best treatments and outcomes regardless of race, class, or sex.
"We can assess the climate within our centers and strive to ensure that our recruitment processes, classrooms, clinics, administrations, and boardrooms are inclusive to all," they conclude.
Dr Bassett, Dr Ansell, and Dr McDonald have disclosed no relevant financial relationships.
N Engl J Med. Published online February 18, 2015. Basset full text, Ansell and McDonald full text
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Cite this: #WhiteCoats4BlackLives Spurs Talk of Racial Bias in Medicine - Medscape - Feb 20, 2015.
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