The Inadequacy of Thoughts and Prayers

(This was initially published in Connecticut Medicine, the Journal of the Connecticut State Medical Society, available here: https://ctmed.csms.org/publication/?m=52908&l=1) For a few minutes today, think about where we are as a profession. We have found ourselves in the middle of a novel viral pandemic concurrent with political unrest in a traditionally stable nation. You are a physician or other provider and you are facing concerns about exposure to COVID19, your children’s education, distance between you and family members, worries about your job or business, or the status of your patients’ needs. You may be wondering about your access to vaccination, a return to normalcy, or other home, health, or life concerns. While you’ve been trying to live your life, it’s possible you have missed something rather important, something life-changing, and something that has, for too long, gone underappreciated, especially in our profession. Though many of you may know it already, or perhaps have your own opinion on the matter, I find myself in a position to bring it to your attention.

Black lives matter.

In late 2002, Johns Hopkins University published interviews on the topic of “Black Lives Matter in Medicine: What Must Change?”1 Those influencers interviewed expressed a few important notions of their experiences. Some felt that investment in Black students’ STEM education was important; others, that a shift of medical education was required to train physicians with competency in understanding the disparities in the care we provide to our patients. These are each absolutely required. One comment, though, impressed upon me something uncomfortable to hear: certain types of practices in medicine exist that “are inherently racist.” Is it mine?

This may be an obvious statement to some, but to an unfortunate portion, it isn’t. To say that inherent racism exists in our practice of medicine is not necessarily an admission that patients of color are being boldly discriminated against in their endeavor to receive care (they are), but it is an alarm to note that each of us may render care that is inadequate (it has been). It may be that the racial diversity of one practice’s population does not reflect that of the community at large, resulting in implicitly disparate delivery of care (which, often, it does).

We are not as aware or informed as we can be with respect to the needs of our individual patients. We sometimes pretend to be aware; we sometimes cannot admit that we don’t relate to or understand the plight of the person before us. This may be true for any patient, but when we focus on patients of color, it matters. We may have compassion; we may approach medicine as humanists, emphasizing the value and agency of personhood, and we may care deeply, but it is that a situational awareness has been bred out of us by our treasured medical educations – it is wrong to believe only that every patient deserves the same care. Instead, we should be fully aware and ready to admit that every patient deserves the same outcomes.

As summarized by Sherita Hill Golden, MD, Chief Diversity Officer at Johns Hopkins, during her interview, we must reach the time “…where everyone is valued and everyone feels empowered to speak up...[we must] focus on outcomes and can miss important contributors to the problem…exposure to environmental pollutants, reduced access to healthy and affordable food, and access to green spaces for physical activity…”

An awareness campaign drew more and more attention after the death of George Floyd, and was further driven by many other names; too many to mention all of them, but important nonetheless. The lives of Rayshard Brooks, David McAtee, Tony McDade, Dion Johnson, Maurice Gordon Jr., Breonna Taylor, Ahmaud Arbery, and so many more, in fact, matter. 

 Systemic and structural racism exists in nearly every facet of life, from education, work, arts, entertainment, health, wealth, and politics. Within health care, outcomes are worse for people of color with nearly every disease state. Dr. Golden’s comments are prudent—patients aren’t always vocal advocates for their own health. We must ask the right questions and we must help navigate the very system built without their needs in mind.

Barriers also exist at every step for underrepresented candidates for medical school, residency, and attending jobs, not to mention leadership positions in health care. A wide-sweeping example includes Obermeyer and colleagues, who reported a problematic algorithm used in United States hospitals that systematically discriminates against people of color with a lower likelihood of referral to programs that aim to improve care for complex patients.2 Many of us have been involved in local attempts to right these wrongs and improve equity among those we serve, but it hasn’t been enough.3–6

Black lives matter. As health care providers, we must believe it to care. Black Lives Matter is not simply a movement, but an undeniable fact of life that we must hold as a basic tenet of our profession. Racism, it turns out, is a bigger killer than prostate cancer, breast cancer, or colon cancer.7 Physicians are personally engaged in institutions that contribute to the victimization of patients of color, without even knowing it. We are less likely to provide sufficient pain medication, direct patients toward cancer screening, and we give fewer chances for organ transplantation.8 We are unconsciously motivated by implicit biases. We are also influenced by structural racism within health care dollar distribution. We are paid less for patients who are uninsured or underinsured, which disproportionately affect people of color. As a result, people of color do not experience the same care as the rest of our practices.

While our usual patient-provider relationship may be governed by a professional rapport, the relationship isn’t based on formal contract; it’s based on trust, and we each need to work on it. A confidante once told me, “no one cares how much you know until they know how much you care.”

Showing how much you care is not the hard part. Bias exists in systematic and organizational structures, resulting in worse health care outcomes.9 Personal implicit biases contribute to heath disparities by influencing how we, as providers, make decisions within our practices. They sit deep within our unconscious minds, and despite our best of intentions, exert their influence.10,11 Every provider of health care should endeavor a self-awareness activity with the Implicit Association Test (available at the Harvard University website).12 Being aware of our attitudes and beliefs can be shocking, but also enlightening. The goal of this test – and this column – is not the elimination of implicit bias. Instead, I aim to have you recognize it. From the website, the IAT “measures attitudes and beliefs that people may be unwilling or unable to report. The IAT may be especially interesting if it shows that you have an implicit attitude that you did not know about. For example, you may believe that women and men should be equally associated with science, but your automatic associations could show that you (like many others) associate men with science more than you associate women with science.” However uncomfortable the discovery of this bias may be, it is a first step along the path of understanding the importance of inclusivity and diversity, and the avoidance of bias in your professional interactions.

As empiricists, we have an obligation to care for our patients based upon the evidence available. The evidence shows us that patients who face inequity and discrimination have worse outcomes. When we provide measures and means to elevate their experiences, we can provide equity in outcome, and improve their health. Black lives will always matter; their movement, from the website itself, describe s itself: “We are working for a world where Black lives are no longer systematically targeted for demise.” As physicians who swear the oath commit to keeping their patients protected from harm and injustice. Black Lives Matter because they must. When you realize this fact, you will only then move our profession forward.

David S. Shapiro, MD, MHCM, FACS, FCCM, Editor, Connecticut Medicine

REFERENCES

1. https://www.hopkinsmedicine.org/news/articles/black-lives-matter-in-medicine-what-must-change (accessed 1/11/2021). . https://www.hopkinsmedicine.org/news/articles/black-lives-matter-in-medicine-what-must-change (accessed 1/11/2021).

2. Obermeyer, Z., Powers, B., Vogeli, C. & Mullainathan, S. Dissecting racial bias in an algorithm used to manage the health of populations. Science 336, populations. Science 336, 447–453 (2019). 47–453 (2019).

 3. Wouk K, et al. A systematic review of patient-provider and health system level predictors of postpartum health car use by people of color and low income people of color and low income and/or uninsured populations in the United States. J Women’s Health, 2020; accessed online, https://doi.org/10.1089/jwh.2020.8738, 1/11/2021.

 4. Bullock JL, et al. They don’t see a lot of people my color. Acad Med, 2020; 95(11S):S58-S66.

5. Laster Pirtle WN. Racial capitalism: a fundamental cause of novel coronavirus (COVID-19) pandemic inequities in the United States, Health Educ Behav, States, Health Educ Behav, 2020. 47(4):504-8. 020. 47(4):504-8.

 6. Martinez JH, et. Al. The role of experimental avoidance in the relation between racial discrimination and negative mental health outcomes, J Am College Health 2020; 21:1-8. ealth, 2020; 21:1-8.

 7. Walters FP, et al. The not-so silent killer missing in medical training curricula: racism. Nature Medicine, 2020; 26:1160-1 7. https://www.nature.com/articles/s41591-020-0984-3 41591-020-0984-3.

8. https://journalofethics.ama-assn.org/article/blacklivesmatter-physicians-must-stand-racial-justice/2015-10 accessed 1/11/202.

9. van Ryn M, Hardeman R, Phelan SM, et al. Medical school experiences associated with change in implicit racial bias among 3547 students: A medical student CHANGES study report. J Gen Intern Med. 2015;30(12):1748-1756.

10. Teal CR, Shada RE, Gill AC, et al. When best intentions aren’t enough: Helping medical students develop strategies for managing bias about patients. J Gen Intern Med. 2010;25 Suppl 2:S115-118.

11. Hofmeister S, Soprych A. Teaching resident physicians the power of implicit bias and how it impacts patient care utilizing patients who have experienced patients who have experienced incarceration as a model. Int J Psychiatry Med. 2017;52(4-6):345-354.

12. https://implicit.harvard.edu/implicit/takeatest.html