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With the shootings of Breonna Taylor, George Floyd, and other Black citizens setting off protests and unrest, race was at the forefront of national conversation in the United States – along with COVID-19 – over the past year.
“We’ve heard things like, ‘We’re in a post-racial society,’ but I think 2020 in particular has emphasized that we’re not,” said Gregory Johnson, MD, SFHM, chief medical officer of hospital medicine at Sound Physicians, a national physician practice. “Racism is very present in our lives, it’s very present in our world, and it is absolutely present in medicine.”
Yes, race is still an issue in the U.S. as we head into 2021, though this may have come as something of a surprise to people who do not live with racism daily.
“If you have a brain, you have bias, and that bias will likely apply to race as well,” Dr. Johnson said. “When we’re talking about institutional racism, the educational system and the media have led us to create presumptions and prejudices that we don’t necessarily recognize off the top because they’ve just been a part of the fabric of who we are as we’ve grown up.”
The term “racism” has extremely negative connotations because there’s character judgment attached to it, but to say someone is racist or racially insensitive does not equate them with being a Klansman, said Dr. Johnson. “I think we as people have to acknowledge that, yes, it’s possible for me to be racist and I might not be 100% aware of it. It’s being open to the possibility – or rather probability – that you are and then taking steps to figure out how you can address that, so you can limit it. And that requires constant self-evaluation and work,” he said.
Racism in the medical environment
Institutional racism is evident before students are even accepted into medical school, said Areeba Kara, MD, SFHM, associate professor of clinical medicine at Indiana University, Indianapolis, and a hospitalist at IU Health Physicians.
Mean MCAT scores are lower for applicants traditionally underrepresented in medicine (UIM) compared to the scores of well-represented groups.1 “Lower scores are associated with lower acceptance rates into medical school,” Dr. Kara said. “These differences reflect unequal educational opportunities rooted in centuries of legal discrimination.”
Racism is apparent in both the hidden medical education curriculum and in lessons implicitly taught to students, said Ndidi Unaka, MD, MEd, associate program director of the pediatric residency training program at Cincinnati Children’s Hospital.
“These lessons inform the way in which we as physicians see our patients, each other, and how we practice,” she said. “We reinforce race-based medicine and shape clinical decision making through flawed guidelines and practices, which exacerbates health inequities. We teach that race – rather than racism – is a risk factor for poor health outcomes. Our students and trainees watch as we assume the worst of our patients from marginalized communities of color.”
Terms describing patients of color, such as “difficult,” “non-compliant,” or “frequent flyer” are thrown around and sometimes, instead of finding out why, “we view these states of being as static, root causes for poor outcomes rather than symptoms of social conditions and obstacles that impact overall health and wellbeing,” Dr. Unaka said.
Leadership opportunities
Though hospital medicine is a growing field, Dr. Kara noted that the 2020 State of Hospital Medicine Report found that only 5.5% of hospital medical group leaders were Black, and just 2.2% were Hispanic/Latino.2 “I think these numbers speak for themselves,” she said.
Dr. Unaka said that the lack of UIM hospitalists and physician leaders creates fewer opportunities for “race-concordant mentorship relationships.” It also forces UIM physicians to shoulder more responsibilities – often obligations that do little to help them move forward in their careers – all in the name of diversity. And when UIM physicians are given leadership opportunities, Dr. Unaka said they are often unsure as to whether their appointments are genuine or just a hollow gesture made for the sake of diversity.
Dr. Johnson pointed out that Black and Latinx populations primarily get their care from hospital-based specialties, yet this is not reflected in the number of UIM practitioners in leadership roles. He said race and ethnicity, as well as gender, need to be factors when individuals are evaluated for leadership opportunities – for the individual’s sake, as well as for the community he or she is serving.
“When we can evaluate for unconscious bias and factor in that diverse groups tend to have better outcomes, whether it’s business or clinical outcomes, it’s one of the opportunities that we collectively have in the specialty to improve what we’re delivering for hospitals and, more importantly, for patients,” he said.
Relationships with colleagues and patients
Racism creeps into interactions and relationships with others as well, whether it’s between clinicians, clinician to patient, or patient to clinician. Sometimes it’s blatant; often it’s subtle.
A common, recurring example Dr. Unaka has experienced in the clinician to clinician relationship is being confused for other Black physicians, making her feel invisible. “The everyday verbal, nonverbal, and environmental slights, snubs, or insults from colleagues are frequent and contribute to feelings of exclusion, isolation, and exhaustion,” she said. Despite this, she is still expected to “address microaggressions and other forms of interpersonal racism and find ways to move through professional spaces in spite of the trauma, fear, and stress associated with my reality and lived experiences.” She said that clinicians who remain silent on the topic of racism participate in the violence and contribute to the disillusionment of UIM physicians.
Dr. Kara said that the discrimination from the health care team is the hardest to deal with. In the clinician to clinician relationship, there is a sense among UIM physicians that they’re being watched more closely and “have to prove themselves at every single turn.” Unfortunately, this comes from the environment, which tends to be adversarial rather than supportive and nurturing, she said.
“There are lots of opportunities for racism or racial insensitivity to crop up from clinician to clinician,” said Dr. Johnson. When he started his career as a physician after his training, Dr. Johnson was informed that his colleagues were watching him because they were not sure about his clinical skills. The fact that he was a former chief resident and board certified in two specialties did not seem to make any difference.
Patients refusing care from UIM physicians or expressing disapproval – both verbal and nonverbal – of such care, happens all too often. “It’s easier for me to excuse patients and their families as we often meet them on their worst days,” said Dr. Kara. Still, “understanding my oath to care for people and do no harm, but at the same time, recognizing that this is an individual that is rejecting my care without having any idea of who I am as a physician is frustrating,” Dr. Johnson acknowledged.
Then there’s the complex clinician to patient relationship, which research clearly shows contributes to health disparities.3 For one thing, the physician workforce does not reflect the patient population, Dr. Unaka said. “We cannot ignore the lack of race concordance between patients and clinicians, nor can the continued misplacement of blame for medical mistrust be at the feet of our patients,” she said.
Dr. Unaka feels that clinicians need to accept both that health inequities exist and that frontline physicians themselves contribute to the inequities. “Our diagnostic and therapeutic decisions are not immune to bias and are influenced by our deeply held beliefs about specific populations,” she said. “And the health care system that our patients navigate is no different than other systems, settings, and environments that are marred by racism in all its forms.”
Systemic racism greatly impacts patient care, said Dr. Kara. She pointed to several examples: Research showing that race concordance between patients and providers in an emergency department setting led to better pain control with fewer analgesics.4 The high maternal and infant mortality rates amongst Black women and children.5 Evidence of poorer outcomes in sepsis patients with limited English proficiency.6 “There are plenty more,” she said. “We need to be asking ourselves what we are going to do about it.”
Moving forward
That racial biases are steeped so thoroughly into our culture and consciousness means that moving beyond them is a continual, purposeful work in progress. But it is work that is critical for everyone, and certainly necessary for those who care for their fellow human beings when they are in a vulnerable state.
Health care systems need to move toward equity – giving everyone what they need to thrive – rather than focusing on equality – giving everyone the same thing, said Jenny Baenziger, MD, assistant professor of clinical medicine and pediatrics at Indiana University, Indianapolis, and associate director of education at IU Center for Global Health. “We know that minoritized patients are going to need more attention, more advocacy, more sensitivity, and more creative solutions in order to help them achieve health in a world that is often stacked against them,” she said.
“The unique needs of each patient, family unit, and/or population must be taken into consideration,” said Dr. Unaka. She said hospitalists need to embrace creative approaches that can better serve the specific needs of patients. Equitable practices should be the default, which means data transparency, thoroughly dissecting hospital processes to find existing inequities, giving stakeholders – especially patients and families of color – a voice, and tearing down oppressive systems that contribute to poor health outcomes and oppression, she said.
“It’s time for us to talk about racism openly,” said Dr. Kara. “Believe your colleagues when they share their fears and treat each other with respect. We should be actively learning about and celebrating our diversity.” She encourages finding out what your institution is doing on this front and getting involved.
Dr. Johnson believes that first and foremost, hospitalists need to be exposed to the data on health care disparities. “The next step is asking what we as hospitalists, or any other specialty, can do to intervene and improve in those areas,” he said. Focusing on unconscious bias training is important, he said, so clinicians can see what biases they might be bringing into the hospital and to the bedside. Maintaining a diverse workforce and bringing UIM physicians into leadership roles to encourage diversity of ideas and approaches are also critical to promoting equity, he said.
“You cannot fix what you cannot face,” said Dr. Unaka. Education on how racism impacts patients and colleagues is essential, she believes, as is advocacy for changing inequitable health system policies. She recommends expanding social and professional circles. “Diverse social groups allow us to consider the perspectives of others; diverse professional groups allow us to ask better research questions and practice better medicine.”
Start by developing the ability to question personal assumptions and pinpoint implicit biases, suggested Dr. Baenziger. “Asking for feedback can be scary and difficult, but we should take a deep breath and do it anyway,” she said. “Simply ask your team, ‘I’ve been thinking a lot about racial equity and disparities. How can I do better at my interactions with people of color? What are my blind spots?’” Dr. Baenziger said that “to help us remember how beautifully complicated and diverse people are,” all health care professionals need to watch Nigerian novelist Chimamanda Ngozi Adichie’s TED talk “The Danger of a Single Story.”
Dr. Baenziger also stressed the importance of conversations about “places where race is built into our clinical assessments, like eGFR,” as well as being aware that many of the research studies that are used to support everyday clinical decisions didn’t include people of color. She also encouraged clinicians to consider how and when they include race in their notes.7 “Is it really helpful to make sure people know right away that you are treating a ‘46-year-old Hispanic male’ or can the fact that he is Hispanic be saved for the social history section with other important details of his life such as being a father, veteran, and mechanic?” she asked.
“Racism is real and very much a part of our history. We can no longer be in denial regarding the racism that exists in medicine and the impact it has on our patients,” Dr. Unaka said. “As a profession, we cannot hide behind our espoused core values. We must live up to them.”
References
1. Lucey CR, Saguil, A. The Consequences of Structural Racism on MCAT Scores and Medical School Admissions: The Past Is Prologue. Acad Med. 2020 Mar;95(3):351-356. doi: 10.1097/ACM.0000000000002939.
2. Flores L. Increasing racial diversity in hospital medicine’s leadership ranks. The Hospitalist. 2020 Oct 21.
3. Smedley BD, et al, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington: National Academies Press; 2003.
4. Heins A, et al. Physician Race/Ethnicity Predicts Successful Emergency Department Analgesia. J Pain. 2010 July;11(7):692-697. doi: 10.1016/j.jpain.2009.10.017.
5. U.S. Department of Health and Human Serves, Office of Minority Health. Infant Mortality and African Americans. 2019 Nov 8. minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23.
6. Jacobs ZG, et al. The Association between Limited English Proficiency and Sepsis Mortality. J Hosp Med. 2020;3;140-146. Published Online First 2019 Nov 20. doi:10.12788/jhm.3334.
7. Finucane TE. Mention of a Patient’s “Race” in Clinical Presentations. Virtual Mentor. 2014;16(6):423-427. doi: 10.1001/virtualmentor.2014.16.6.ecas1-1406.
With the shootings of Breonna Taylor, George Floyd, and other Black citizens setting off protests and unrest, race was at the forefront of national conversation in the United States – along with COVID-19 – over the past year.
“We’ve heard things like, ‘We’re in a post-racial society,’ but I think 2020 in particular has emphasized that we’re not,” said Gregory Johnson, MD, SFHM, chief medical officer of hospital medicine at Sound Physicians, a national physician practice. “Racism is very present in our lives, it’s very present in our world, and it is absolutely present in medicine.”
Yes, race is still an issue in the U.S. as we head into 2021, though this may have come as something of a surprise to people who do not live with racism daily.
“If you have a brain, you have bias, and that bias will likely apply to race as well,” Dr. Johnson said. “When we’re talking about institutional racism, the educational system and the media have led us to create presumptions and prejudices that we don’t necessarily recognize off the top because they’ve just been a part of the fabric of who we are as we’ve grown up.”
The term “racism” has extremely negative connotations because there’s character judgment attached to it, but to say someone is racist or racially insensitive does not equate them with being a Klansman, said Dr. Johnson. “I think we as people have to acknowledge that, yes, it’s possible for me to be racist and I might not be 100% aware of it. It’s being open to the possibility – or rather probability – that you are and then taking steps to figure out how you can address that, so you can limit it. And that requires constant self-evaluation and work,” he said.
Racism in the medical environment
Institutional racism is evident before students are even accepted into medical school, said Areeba Kara, MD, SFHM, associate professor of clinical medicine at Indiana University, Indianapolis, and a hospitalist at IU Health Physicians.
Mean MCAT scores are lower for applicants traditionally underrepresented in medicine (UIM) compared to the scores of well-represented groups.1 “Lower scores are associated with lower acceptance rates into medical school,” Dr. Kara said. “These differences reflect unequal educational opportunities rooted in centuries of legal discrimination.”
Racism is apparent in both the hidden medical education curriculum and in lessons implicitly taught to students, said Ndidi Unaka, MD, MEd, associate program director of the pediatric residency training program at Cincinnati Children’s Hospital.
“These lessons inform the way in which we as physicians see our patients, each other, and how we practice,” she said. “We reinforce race-based medicine and shape clinical decision making through flawed guidelines and practices, which exacerbates health inequities. We teach that race – rather than racism – is a risk factor for poor health outcomes. Our students and trainees watch as we assume the worst of our patients from marginalized communities of color.”
Terms describing patients of color, such as “difficult,” “non-compliant,” or “frequent flyer” are thrown around and sometimes, instead of finding out why, “we view these states of being as static, root causes for poor outcomes rather than symptoms of social conditions and obstacles that impact overall health and wellbeing,” Dr. Unaka said.
Leadership opportunities
Though hospital medicine is a growing field, Dr. Kara noted that the 2020 State of Hospital Medicine Report found that only 5.5% of hospital medical group leaders were Black, and just 2.2% were Hispanic/Latino.2 “I think these numbers speak for themselves,” she said.
Dr. Unaka said that the lack of UIM hospitalists and physician leaders creates fewer opportunities for “race-concordant mentorship relationships.” It also forces UIM physicians to shoulder more responsibilities – often obligations that do little to help them move forward in their careers – all in the name of diversity. And when UIM physicians are given leadership opportunities, Dr. Unaka said they are often unsure as to whether their appointments are genuine or just a hollow gesture made for the sake of diversity.
Dr. Johnson pointed out that Black and Latinx populations primarily get their care from hospital-based specialties, yet this is not reflected in the number of UIM practitioners in leadership roles. He said race and ethnicity, as well as gender, need to be factors when individuals are evaluated for leadership opportunities – for the individual’s sake, as well as for the community he or she is serving.
“When we can evaluate for unconscious bias and factor in that diverse groups tend to have better outcomes, whether it’s business or clinical outcomes, it’s one of the opportunities that we collectively have in the specialty to improve what we’re delivering for hospitals and, more importantly, for patients,” he said.
Relationships with colleagues and patients
Racism creeps into interactions and relationships with others as well, whether it’s between clinicians, clinician to patient, or patient to clinician. Sometimes it’s blatant; often it’s subtle.
A common, recurring example Dr. Unaka has experienced in the clinician to clinician relationship is being confused for other Black physicians, making her feel invisible. “The everyday verbal, nonverbal, and environmental slights, snubs, or insults from colleagues are frequent and contribute to feelings of exclusion, isolation, and exhaustion,” she said. Despite this, she is still expected to “address microaggressions and other forms of interpersonal racism and find ways to move through professional spaces in spite of the trauma, fear, and stress associated with my reality and lived experiences.” She said that clinicians who remain silent on the topic of racism participate in the violence and contribute to the disillusionment of UIM physicians.
Dr. Kara said that the discrimination from the health care team is the hardest to deal with. In the clinician to clinician relationship, there is a sense among UIM physicians that they’re being watched more closely and “have to prove themselves at every single turn.” Unfortunately, this comes from the environment, which tends to be adversarial rather than supportive and nurturing, she said.
“There are lots of opportunities for racism or racial insensitivity to crop up from clinician to clinician,” said Dr. Johnson. When he started his career as a physician after his training, Dr. Johnson was informed that his colleagues were watching him because they were not sure about his clinical skills. The fact that he was a former chief resident and board certified in two specialties did not seem to make any difference.
Patients refusing care from UIM physicians or expressing disapproval – both verbal and nonverbal – of such care, happens all too often. “It’s easier for me to excuse patients and their families as we often meet them on their worst days,” said Dr. Kara. Still, “understanding my oath to care for people and do no harm, but at the same time, recognizing that this is an individual that is rejecting my care without having any idea of who I am as a physician is frustrating,” Dr. Johnson acknowledged.
Then there’s the complex clinician to patient relationship, which research clearly shows contributes to health disparities.3 For one thing, the physician workforce does not reflect the patient population, Dr. Unaka said. “We cannot ignore the lack of race concordance between patients and clinicians, nor can the continued misplacement of blame for medical mistrust be at the feet of our patients,” she said.
Dr. Unaka feels that clinicians need to accept both that health inequities exist and that frontline physicians themselves contribute to the inequities. “Our diagnostic and therapeutic decisions are not immune to bias and are influenced by our deeply held beliefs about specific populations,” she said. “And the health care system that our patients navigate is no different than other systems, settings, and environments that are marred by racism in all its forms.”
Systemic racism greatly impacts patient care, said Dr. Kara. She pointed to several examples: Research showing that race concordance between patients and providers in an emergency department setting led to better pain control with fewer analgesics.4 The high maternal and infant mortality rates amongst Black women and children.5 Evidence of poorer outcomes in sepsis patients with limited English proficiency.6 “There are plenty more,” she said. “We need to be asking ourselves what we are going to do about it.”
Moving forward
That racial biases are steeped so thoroughly into our culture and consciousness means that moving beyond them is a continual, purposeful work in progress. But it is work that is critical for everyone, and certainly necessary for those who care for their fellow human beings when they are in a vulnerable state.
Health care systems need to move toward equity – giving everyone what they need to thrive – rather than focusing on equality – giving everyone the same thing, said Jenny Baenziger, MD, assistant professor of clinical medicine and pediatrics at Indiana University, Indianapolis, and associate director of education at IU Center for Global Health. “We know that minoritized patients are going to need more attention, more advocacy, more sensitivity, and more creative solutions in order to help them achieve health in a world that is often stacked against them,” she said.
“The unique needs of each patient, family unit, and/or population must be taken into consideration,” said Dr. Unaka. She said hospitalists need to embrace creative approaches that can better serve the specific needs of patients. Equitable practices should be the default, which means data transparency, thoroughly dissecting hospital processes to find existing inequities, giving stakeholders – especially patients and families of color – a voice, and tearing down oppressive systems that contribute to poor health outcomes and oppression, she said.
“It’s time for us to talk about racism openly,” said Dr. Kara. “Believe your colleagues when they share their fears and treat each other with respect. We should be actively learning about and celebrating our diversity.” She encourages finding out what your institution is doing on this front and getting involved.
Dr. Johnson believes that first and foremost, hospitalists need to be exposed to the data on health care disparities. “The next step is asking what we as hospitalists, or any other specialty, can do to intervene and improve in those areas,” he said. Focusing on unconscious bias training is important, he said, so clinicians can see what biases they might be bringing into the hospital and to the bedside. Maintaining a diverse workforce and bringing UIM physicians into leadership roles to encourage diversity of ideas and approaches are also critical to promoting equity, he said.
“You cannot fix what you cannot face,” said Dr. Unaka. Education on how racism impacts patients and colleagues is essential, she believes, as is advocacy for changing inequitable health system policies. She recommends expanding social and professional circles. “Diverse social groups allow us to consider the perspectives of others; diverse professional groups allow us to ask better research questions and practice better medicine.”
Start by developing the ability to question personal assumptions and pinpoint implicit biases, suggested Dr. Baenziger. “Asking for feedback can be scary and difficult, but we should take a deep breath and do it anyway,” she said. “Simply ask your team, ‘I’ve been thinking a lot about racial equity and disparities. How can I do better at my interactions with people of color? What are my blind spots?’” Dr. Baenziger said that “to help us remember how beautifully complicated and diverse people are,” all health care professionals need to watch Nigerian novelist Chimamanda Ngozi Adichie’s TED talk “The Danger of a Single Story.”
Dr. Baenziger also stressed the importance of conversations about “places where race is built into our clinical assessments, like eGFR,” as well as being aware that many of the research studies that are used to support everyday clinical decisions didn’t include people of color. She also encouraged clinicians to consider how and when they include race in their notes.7 “Is it really helpful to make sure people know right away that you are treating a ‘46-year-old Hispanic male’ or can the fact that he is Hispanic be saved for the social history section with other important details of his life such as being a father, veteran, and mechanic?” she asked.
“Racism is real and very much a part of our history. We can no longer be in denial regarding the racism that exists in medicine and the impact it has on our patients,” Dr. Unaka said. “As a profession, we cannot hide behind our espoused core values. We must live up to them.”
References
1. Lucey CR, Saguil, A. The Consequences of Structural Racism on MCAT Scores and Medical School Admissions: The Past Is Prologue. Acad Med. 2020 Mar;95(3):351-356. doi: 10.1097/ACM.0000000000002939.
2. Flores L. Increasing racial diversity in hospital medicine’s leadership ranks. The Hospitalist. 2020 Oct 21.
3. Smedley BD, et al, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington: National Academies Press; 2003.
4. Heins A, et al. Physician Race/Ethnicity Predicts Successful Emergency Department Analgesia. J Pain. 2010 July;11(7):692-697. doi: 10.1016/j.jpain.2009.10.017.
5. U.S. Department of Health and Human Serves, Office of Minority Health. Infant Mortality and African Americans. 2019 Nov 8. minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23.
6. Jacobs ZG, et al. The Association between Limited English Proficiency and Sepsis Mortality. J Hosp Med. 2020;3;140-146. Published Online First 2019 Nov 20. doi:10.12788/jhm.3334.
7. Finucane TE. Mention of a Patient’s “Race” in Clinical Presentations. Virtual Mentor. 2014;16(6):423-427. doi: 10.1001/virtualmentor.2014.16.6.ecas1-1406.
With the shootings of Breonna Taylor, George Floyd, and other Black citizens setting off protests and unrest, race was at the forefront of national conversation in the United States – along with COVID-19 – over the past year.
“We’ve heard things like, ‘We’re in a post-racial society,’ but I think 2020 in particular has emphasized that we’re not,” said Gregory Johnson, MD, SFHM, chief medical officer of hospital medicine at Sound Physicians, a national physician practice. “Racism is very present in our lives, it’s very present in our world, and it is absolutely present in medicine.”
Yes, race is still an issue in the U.S. as we head into 2021, though this may have come as something of a surprise to people who do not live with racism daily.
“If you have a brain, you have bias, and that bias will likely apply to race as well,” Dr. Johnson said. “When we’re talking about institutional racism, the educational system and the media have led us to create presumptions and prejudices that we don’t necessarily recognize off the top because they’ve just been a part of the fabric of who we are as we’ve grown up.”
The term “racism” has extremely negative connotations because there’s character judgment attached to it, but to say someone is racist or racially insensitive does not equate them with being a Klansman, said Dr. Johnson. “I think we as people have to acknowledge that, yes, it’s possible for me to be racist and I might not be 100% aware of it. It’s being open to the possibility – or rather probability – that you are and then taking steps to figure out how you can address that, so you can limit it. And that requires constant self-evaluation and work,” he said.
Racism in the medical environment
Institutional racism is evident before students are even accepted into medical school, said Areeba Kara, MD, SFHM, associate professor of clinical medicine at Indiana University, Indianapolis, and a hospitalist at IU Health Physicians.
Mean MCAT scores are lower for applicants traditionally underrepresented in medicine (UIM) compared to the scores of well-represented groups.1 “Lower scores are associated with lower acceptance rates into medical school,” Dr. Kara said. “These differences reflect unequal educational opportunities rooted in centuries of legal discrimination.”
Racism is apparent in both the hidden medical education curriculum and in lessons implicitly taught to students, said Ndidi Unaka, MD, MEd, associate program director of the pediatric residency training program at Cincinnati Children’s Hospital.
“These lessons inform the way in which we as physicians see our patients, each other, and how we practice,” she said. “We reinforce race-based medicine and shape clinical decision making through flawed guidelines and practices, which exacerbates health inequities. We teach that race – rather than racism – is a risk factor for poor health outcomes. Our students and trainees watch as we assume the worst of our patients from marginalized communities of color.”
Terms describing patients of color, such as “difficult,” “non-compliant,” or “frequent flyer” are thrown around and sometimes, instead of finding out why, “we view these states of being as static, root causes for poor outcomes rather than symptoms of social conditions and obstacles that impact overall health and wellbeing,” Dr. Unaka said.
Leadership opportunities
Though hospital medicine is a growing field, Dr. Kara noted that the 2020 State of Hospital Medicine Report found that only 5.5% of hospital medical group leaders were Black, and just 2.2% were Hispanic/Latino.2 “I think these numbers speak for themselves,” she said.
Dr. Unaka said that the lack of UIM hospitalists and physician leaders creates fewer opportunities for “race-concordant mentorship relationships.” It also forces UIM physicians to shoulder more responsibilities – often obligations that do little to help them move forward in their careers – all in the name of diversity. And when UIM physicians are given leadership opportunities, Dr. Unaka said they are often unsure as to whether their appointments are genuine or just a hollow gesture made for the sake of diversity.
Dr. Johnson pointed out that Black and Latinx populations primarily get their care from hospital-based specialties, yet this is not reflected in the number of UIM practitioners in leadership roles. He said race and ethnicity, as well as gender, need to be factors when individuals are evaluated for leadership opportunities – for the individual’s sake, as well as for the community he or she is serving.
“When we can evaluate for unconscious bias and factor in that diverse groups tend to have better outcomes, whether it’s business or clinical outcomes, it’s one of the opportunities that we collectively have in the specialty to improve what we’re delivering for hospitals and, more importantly, for patients,” he said.
Relationships with colleagues and patients
Racism creeps into interactions and relationships with others as well, whether it’s between clinicians, clinician to patient, or patient to clinician. Sometimes it’s blatant; often it’s subtle.
A common, recurring example Dr. Unaka has experienced in the clinician to clinician relationship is being confused for other Black physicians, making her feel invisible. “The everyday verbal, nonverbal, and environmental slights, snubs, or insults from colleagues are frequent and contribute to feelings of exclusion, isolation, and exhaustion,” she said. Despite this, she is still expected to “address microaggressions and other forms of interpersonal racism and find ways to move through professional spaces in spite of the trauma, fear, and stress associated with my reality and lived experiences.” She said that clinicians who remain silent on the topic of racism participate in the violence and contribute to the disillusionment of UIM physicians.
Dr. Kara said that the discrimination from the health care team is the hardest to deal with. In the clinician to clinician relationship, there is a sense among UIM physicians that they’re being watched more closely and “have to prove themselves at every single turn.” Unfortunately, this comes from the environment, which tends to be adversarial rather than supportive and nurturing, she said.
“There are lots of opportunities for racism or racial insensitivity to crop up from clinician to clinician,” said Dr. Johnson. When he started his career as a physician after his training, Dr. Johnson was informed that his colleagues were watching him because they were not sure about his clinical skills. The fact that he was a former chief resident and board certified in two specialties did not seem to make any difference.
Patients refusing care from UIM physicians or expressing disapproval – both verbal and nonverbal – of such care, happens all too often. “It’s easier for me to excuse patients and their families as we often meet them on their worst days,” said Dr. Kara. Still, “understanding my oath to care for people and do no harm, but at the same time, recognizing that this is an individual that is rejecting my care without having any idea of who I am as a physician is frustrating,” Dr. Johnson acknowledged.
Then there’s the complex clinician to patient relationship, which research clearly shows contributes to health disparities.3 For one thing, the physician workforce does not reflect the patient population, Dr. Unaka said. “We cannot ignore the lack of race concordance between patients and clinicians, nor can the continued misplacement of blame for medical mistrust be at the feet of our patients,” she said.
Dr. Unaka feels that clinicians need to accept both that health inequities exist and that frontline physicians themselves contribute to the inequities. “Our diagnostic and therapeutic decisions are not immune to bias and are influenced by our deeply held beliefs about specific populations,” she said. “And the health care system that our patients navigate is no different than other systems, settings, and environments that are marred by racism in all its forms.”
Systemic racism greatly impacts patient care, said Dr. Kara. She pointed to several examples: Research showing that race concordance between patients and providers in an emergency department setting led to better pain control with fewer analgesics.4 The high maternal and infant mortality rates amongst Black women and children.5 Evidence of poorer outcomes in sepsis patients with limited English proficiency.6 “There are plenty more,” she said. “We need to be asking ourselves what we are going to do about it.”
Moving forward
That racial biases are steeped so thoroughly into our culture and consciousness means that moving beyond them is a continual, purposeful work in progress. But it is work that is critical for everyone, and certainly necessary for those who care for their fellow human beings when they are in a vulnerable state.
Health care systems need to move toward equity – giving everyone what they need to thrive – rather than focusing on equality – giving everyone the same thing, said Jenny Baenziger, MD, assistant professor of clinical medicine and pediatrics at Indiana University, Indianapolis, and associate director of education at IU Center for Global Health. “We know that minoritized patients are going to need more attention, more advocacy, more sensitivity, and more creative solutions in order to help them achieve health in a world that is often stacked against them,” she said.
“The unique needs of each patient, family unit, and/or population must be taken into consideration,” said Dr. Unaka. She said hospitalists need to embrace creative approaches that can better serve the specific needs of patients. Equitable practices should be the default, which means data transparency, thoroughly dissecting hospital processes to find existing inequities, giving stakeholders – especially patients and families of color – a voice, and tearing down oppressive systems that contribute to poor health outcomes and oppression, she said.
“It’s time for us to talk about racism openly,” said Dr. Kara. “Believe your colleagues when they share their fears and treat each other with respect. We should be actively learning about and celebrating our diversity.” She encourages finding out what your institution is doing on this front and getting involved.
Dr. Johnson believes that first and foremost, hospitalists need to be exposed to the data on health care disparities. “The next step is asking what we as hospitalists, or any other specialty, can do to intervene and improve in those areas,” he said. Focusing on unconscious bias training is important, he said, so clinicians can see what biases they might be bringing into the hospital and to the bedside. Maintaining a diverse workforce and bringing UIM physicians into leadership roles to encourage diversity of ideas and approaches are also critical to promoting equity, he said.
“You cannot fix what you cannot face,” said Dr. Unaka. Education on how racism impacts patients and colleagues is essential, she believes, as is advocacy for changing inequitable health system policies. She recommends expanding social and professional circles. “Diverse social groups allow us to consider the perspectives of others; diverse professional groups allow us to ask better research questions and practice better medicine.”
Start by developing the ability to question personal assumptions and pinpoint implicit biases, suggested Dr. Baenziger. “Asking for feedback can be scary and difficult, but we should take a deep breath and do it anyway,” she said. “Simply ask your team, ‘I’ve been thinking a lot about racial equity and disparities. How can I do better at my interactions with people of color? What are my blind spots?’” Dr. Baenziger said that “to help us remember how beautifully complicated and diverse people are,” all health care professionals need to watch Nigerian novelist Chimamanda Ngozi Adichie’s TED talk “The Danger of a Single Story.”
Dr. Baenziger also stressed the importance of conversations about “places where race is built into our clinical assessments, like eGFR,” as well as being aware that many of the research studies that are used to support everyday clinical decisions didn’t include people of color. She also encouraged clinicians to consider how and when they include race in their notes.7 “Is it really helpful to make sure people know right away that you are treating a ‘46-year-old Hispanic male’ or can the fact that he is Hispanic be saved for the social history section with other important details of his life such as being a father, veteran, and mechanic?” she asked.
“Racism is real and very much a part of our history. We can no longer be in denial regarding the racism that exists in medicine and the impact it has on our patients,” Dr. Unaka said. “As a profession, we cannot hide behind our espoused core values. We must live up to them.”
References
1. Lucey CR, Saguil, A. The Consequences of Structural Racism on MCAT Scores and Medical School Admissions: The Past Is Prologue. Acad Med. 2020 Mar;95(3):351-356. doi: 10.1097/ACM.0000000000002939.
2. Flores L. Increasing racial diversity in hospital medicine’s leadership ranks. The Hospitalist. 2020 Oct 21.
3. Smedley BD, et al, eds. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Institute of Medicine Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington: National Academies Press; 2003.
4. Heins A, et al. Physician Race/Ethnicity Predicts Successful Emergency Department Analgesia. J Pain. 2010 July;11(7):692-697. doi: 10.1016/j.jpain.2009.10.017.
5. U.S. Department of Health and Human Serves, Office of Minority Health. Infant Mortality and African Americans. 2019 Nov 8. minorityhealth.hhs.gov/omh/browse.aspx?lvl=4&lvlid=23.
6. Jacobs ZG, et al. The Association between Limited English Proficiency and Sepsis Mortality. J Hosp Med. 2020;3;140-146. Published Online First 2019 Nov 20. doi:10.12788/jhm.3334.
7. Finucane TE. Mention of a Patient’s “Race” in Clinical Presentations. Virtual Mentor. 2014;16(6):423-427. doi: 10.1001/virtualmentor.2014.16.6.ecas1-1406.