Weston de Lomba
Oct 12, 2020
Understanding and recognizing racial biases in clinical scenarios through dialogue.
You work in the emergency department. Your patient is a 77-year-old white male with a pretty serious cardiac history, including a prior heart attack and a coronary artery bypass graft. His presentation today is certainly concerning: he’s got crushing central chest pain, ECG changes that indicate an “ischemic event,” or a potential cardiac problem, and a lab called a troponin that tells you his heart is under an abnormal amount of stress. In short, you believe he’s having another heart attack now.
You’ve told him he needs to be admitted to the cardiology service. He’ll likely undergo a special diagnostic procedure that can make his pain go away and protect his heart. You know the situation is critical- in fact, time is of the essence. If the blockage in his heart isn’t cleared soon, the damage to his heart will accumulate, and he could die. He seems to understand the situation is serious; after all, he’s been through this at least once before. As you leave the room, he says a remark to you that stops you in your tracks: “I’ll come in, on one condition. I don’t want an Indian doctor! They messed me up good last time. I don’t trust Indians.”
What’s your initial reaction to this scenario? What would you do? And what’s the correct way to act in a situation like this? This discussion was of particular interest to my colleagues and I in the medical scribe program at Brown Emergency Medicine (BEM) as we gathered for our inaugural diversity, equity and inclusion summit. Formed in the wake of the murders of Ahmaud Arbery, Breonna Taylor, George Floyd and others, the Medical Scribe Committee for Diversity and Inclusion is focused on promoting safe spaces for discussions of racism and equitable advocacy for all of the members of our community. This initiative dovetailed nicely with the existing Diversity and Inclusion Committee at BEM, which had until then focused on the experiences of only our physicians, advanced practice providers, and administrators. Until only recently, a similar space had not formally existed within our scribe program.
Our August 18th meeting, hosting the better half of the company, was coordinated (like many things these days) via Zoom, and professionally guided by Dr. Taneisha Wilson and Dr. Hannah Barber-Ducet. It was one of the first truly concrete steps in our action plan, and represented, to the greatest of our abilities, a nuanced examination of racial issues and a lesson in the fundamentals of anti-racism and active advocacy.
At the outset, there was an internal dialogue at our company about what role anti-racism had, and how racial bias played out in the environment of our own workplace. Unfortunately, studies have thoroughly demonstrated that racial concordance (or when the race of the patient matches that of their provider) is correlated with more effective patient-physician communication. Inversely, when racial discordance is present, a Black patient will experience less effective communication when interfacing with a white physician. It is thought that this is the result of a confluence of factors, including: physicians’ explicit or implicit biases, cultural barriers, such as expectation of responsibility in shared decision-making, and patients’ attitudes and perceptions of their physicians. It is still the subject of much debate whether racial concordance can affect quality of medicine or outcomes. Overall, evidence strongly suggests that significant disparities in healthcare exist along lines of race.
On the end of the healthcare worker, it is within the power of the provider to be aware of racial dynamics, and to control or adjust for their behavior accordingly in a thoughtful and equitable way. Less within our control are the beliefs and attitudes of our patients. To this end, the boundaries of acceptable behavior are somewhat hazier and confounded by our own professionalism and our sense of cultural competency- in which we attempt to be aware of the differences between our worldview and others’, without stereotyping those differences. Of relevance is the oft-cited prototypical situation in which an observant Muslim woman requests a physician who is not male for her physical exam. Such a request is founded much more in religious observance than a harmful or discriminatory attitude.
This being said, blunt racism is never above reproach. In the first scenario, it may be met heartily with self-advocacy, it may be deftly dismissed, or it may even be ignored. Ultimately, the response is the decision of the responder, and we were told that there is no correct answer. In the year 2020, there is little room left for intolerance, and anecdotally I can say that such behavior is not taken lightly in the emergency department. As a general guideline, the response is correct so long as it does not compromise the delivery of patient care. Furthermore, if a patient’s request is found not to be rooted in discriminatory attitude, it should be taken into consideration in the patient’s course of care.
Yet the first scenario mentioned above is one in which a healthcare worker is confronted by abject and unmistakable racism. It is fictitious, but- high and far- not at all improbable. There is no single correct response. One physician may choose to brush off the interaction and admit this patient to cardiology regardless of their conditions, and another may openly confront their discriminatory bias. It can, however, be said that there would likely be no concession to the patient’s demands.
The scenario takes on many new dimensions as you consider how your own emotional reaction, decision-making and behavioral response alter as you roleplay. Are you the doctor or the nurse? Or are you a medical student, clinical scribe or volunteer? And most germane to us medical scribes and pre-medical students, how does our perceived placement in the professional power structure of medicine affect our ability to advocate for ourselves? How disempowering should we allow the pecking order to be when it comes to our own sense of comfort and safety? Do we believe our level of responsibility should shift from one provider level to the next? How does this impact our educational course as students of medicine?
For those of us also involved Sprout and S.T.E.M., the crux of this conversation–antiracism–was topical. The barriers Providence area students face are inextricably linked with the hurdles governing disparities in healthcare. 87% of Providence public students are economically disadvantaged. And despite ELL students and Latino students comprising 30% and 65% of the student body, a 2019 review from the Johns Hopkins Institute for Educational Policy condemningly found that racial equity is a low priority for the Providence public school district. Among other things, this study resulted in the inauguration of an action plan to address racial and ethnic inequity. Whether the conversation is occurring in the hallways of the hospital or the hallways of a school, this discussion is central to our mission to provide additional support for educationally disadvantaged students.