The movement to change what a doctor looks like is a daily, incremental effort
During my internship year of residency, I took care of an older African American woman, Mrs L*, whose x-rays were clinically ambiguous, prompting us to consider a CT scan. “Mrs L—we may need to do some more imaging if you do not improve,” I informed her as I finished my physical exam. To this, she looked bewildered, almost upset. “Why do you doctors do so many tests on me? I don’t want you doing all these tests.”
I discuss diagnostic and treatment decisions with patients every single day, and this is not the first time the recommendations I’ve given have been questioned. Navigating these conversations, and understanding a patient’s concerns, often means juggling many different considerations. But reading a new paper in the National Bureau of Economic Research has made me wonder if I have missed a critical aspect of caring for patients of colour, specifically.
This new study explored the relationship between a patient’s race, their physician’s race, and their healthcare decision making. The study found that black male patients (the study was only conducted with men) were significantly more likely to undergo preventative screening tests, such as diabetes and cholesterol measurements, and agree to the flu shot if they were offered by black male physicians rather than white male physicians. The effects were more pronounced among those patients who mistrusted or had minimal prior interaction with the health system. Furthermore, they found that patients were more likely to speak about their health issues with black doctors, and those doctors were more likely to write additional notes about the patients. The authors calculate that an increase in the diversity of the medical workforce could lead to a 19% reduction in the black-white gap in male cardiovascular mortality and an 8% reduction in the black-white gap in male life expectancy.
So what do we make of these findings? Should black patients be allowed to request black physicians? Some may point out that white patients requesting white physicians would not sit well in today’s social context. Yet I’d argue that increasing diversity in medicine is not only critical for equity (having more physicians of colour is in itself necessary regardless of additional benefits to patients), but that the absence of diversity may be actively harming patients. We know that African American patients are far less likely to trust their healthcare providers, and for good reason.
Historically, medical racism has been one of our profession’s most deplorable legacies: medical experimentation on black slaves, “Mississippi appendectomies,” the infamous Tuskegee Study, and the recent worrying finding that many white medical students and residents falsely believe that black patients have a higher tolerance to pain. This is not to mention the continued modern day differences black and white patients experience in standards of care, with a recent study showing that black patients do not receive standard of care treatments for heart attacks as often as white patients do. Accordingly, African American and Latino patients who perceived racism in the healthcare system are significantly more likely to prefer physicians of their own race.
I have to wonder if Mrs L would have felt more comfortable with my suggestion of further tests if I was female, or black? Importantly, as physicians, are we asking ourselves these questions often enough? As much as we have a sense of if a patient is clinically “sick” or “not sick,” do we also have a sense of how racial, social, and political factors influence our relationships with patients?
Recently, the Brigham and Women’s Hospital where I work made the historic decision to remove the portraits of previous department chairs from the hospital auditorium. The portraits were all men and, with the exception of one Asian American, white. A similar decision had been made at the Harvard T.H. Chan School of Public Health, where I completed an MPH the previous year. There, some of the portraits were instead replaced by portraits of important figures in public health that were in some way affiliated with the school, including Native American, African American, and other minority group leaders.
Exterior changes such as these are important because they symbolise a greater consciousness of inequity, and create physical space for celebrating diversity. But racism and sexism exist more subtly today than they did in the past; they now often manifest in the form of micro-aggressions and in the decisions that happen behind closed doors, many of which are still made by white males.
Ultimately, we need more minority physicians—period. We know that minority physicians are more likely to return to work in their communities, and more likely to treat underserved populations in general. Beyond this, empowering minority groups to become doctors is a matter of equity: everyone deserves an opportunity to succeed. This includes not only racial minorities, but also the economically disenfranchised of all races.
While cultural competency training for all physicians is important, there is currently poor evidence to suggest improved patient outcomes with existing training programmes—meaning we have much work to do on this front as well.
The movement to change what a “doctor” looks like today is a daily, incremental effort, requiring mentorship and outreach to low income and minority students. Strategies to reduce medical debt and increase financial aid are also especially important in this endeavour. (Take NYU’s recent announcement that tuition would be free for all its medical students—although many have pointed out that the funds would have been better distributed to those from lower socioeconomic backgrounds.)
All patients should feel safe when they see their doctors. For patients of colour, many of whom are still experiencing the echoes of medicine’s racist legacy, the medical system owes them much. One of these debts is a future in which the medical workforce looks less like me, and more like Mrs L.
*This patient’s initials have been changed.
Abraar Karan is a medical resident at the Brigham and Women’s Hospital. Twitter @AbraarKaran
Competing interests: None declared.