ER Goddess

COVID-19 Lays Bare Racial Bias in Health Care

Figure: coronavirus, COVID-19, racism, bias

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Warning: This article may make you feel uncomfortable, perhaps even defensive. Talking about racism will do that, but we don't have the luxury of ignoring the topic.

COVID-19 is disproportionately killing people of color. A recent Associated Press analysis of the available race and ethnicity data for COVID-19 found that nearly a third of those who have died are African American, even though they represent only 14 percent of the population. (April 18, 2020; https://bit.ly/3boybKl.) We physicians are doing our minority patients a disservice if we don't heed the virus's warning to address widespread health disparities.

The majority of physicians in this country (56%) are white. (Association of American Medical Colleges. July 1, 2019; https://bit.ly/3cx5e08.) Many of us may believe we're living in a post-racial, enlightened society, but I believe that comes from not having to experience discrimination based on the color of our skin.

Physicians mean well. If asked whether the race of their patients makes a difference beyond the epidemiological impact on disease probability, most doctors will earnestly say of course not. Most doctors' consciously held values are racially unbiased. Our thought process is similar to the majority of white Americans, more than 95 percent of whom said they were racially unbiased. And only six percent said they think about race at all. (Pew Research Center. Aug. 22, 2013; https://pewrsr.ch/2WsH7u3.) Despite those numbers, 35 percent of blacks and 20 percent of Hispanics said they have been discriminated against or treated unfairly because of their race in the past year. This dichotomy unfortunately plays out everywhere, including in health care.

What accounts for this discrepancy between our lofty ideals of equality and the reality of pervasive racism? We could blame the generations before us by pointing to our history of discrimination and marginalization of blacks, but we should not discuss inequality without acknowledging our unconscious racial bias.

Stored knowledge of social groups comes from the messages we receive from our environment—media images, political commentary, and song lyrics, to name a few. Doctors are not insulated from the pervasive negative imagery of minorities in our culture or the negative stereotypes that creates. Implicit bias is the unintentional application of stored social knowledge that occurs outside our conscious awareness, and it often contradicts our intentionally held racial views and values.

Implicit Bias

No physician thinks he is contributing to health disparities, but we are deluding ourselves if we think we are above the implicit bias that colors everyone's—even doctors'—perceptions of the people around them. The sad reality is that health inequality is often not the result of what we physicians are consciously thinking. Without meaning to, even those with the most egalitarian views subconsciously make instant assumptions about the patient in front of us that ultimately influences the doctor-patient interaction and medical decision-making.

How do unconscious racial biases infiltrate the clinical encounter and result in discriminatory care? Studies show that a physician's body language, eye contact, conversational pace, and verbal tone are different when the patient is a minority. (Am J Public Health. 2004;94[12]:2084; https://bit.ly/2LrJwPf.) Physicians spent more time with white patients than minority ones. In contrast, they were more verbally dominant and less patient-centered with minority patients than white patients. (Am J Public Health. 2012;102[5]:979; https://bit.ly/2Wua48M.) Physicians in these studies were not outwardly racist; on the contrary, they were often compassionate caregivers who were wholly unaware that their conduct changed. Let that sink in: Even well-intentioned, altruistic caregivers are affected by implicit bias.

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The fact that our behavioral changes aren't intentional doesn't mean they aren't harmful. Patients pick up on subtle behavior, and they respond in their own subtle ways, unintentionally returning signals that subconsciously confirm our implicit bias. It too easily becomes a feedback loop. Communication miscues can become cumulative, fueling distrust, especially in racially discordant physician-patient pairings.

Rather than take ownership of our inadvertent contributions to health disparity, it's easier for physicians to attribute disparities solely to differing access to health care. The uncomfortable truth is that despite having access, some patients fear physicians' attitudes to the point that they don't seek care. Even when minority patients initially pursue medical services at the same rate as white patients, interactions during the clinical encounter may change the relative rates at which they continue to access the health care system. (J Gen Intern Med. 2003;18[2]:146; https://bit.ly/2WvtMBo.)

Minority patients also report more often that medical professionals take their ailments less seriously. They are less likely to participate in shared medical decision-making, to experience satisfaction from their clinical encounters, or to comply with physician recommendations. (Fam Med. 2002;34[5]:353; https://bit.ly/3cGbzqt.) Dissatisfied and disenfranchised patients are less likely to come back. Minorities will often struggle with discontinuity in care as a result.

Power to Change

As we discuss why minorities disproportionately suffer and die from COVID-19, we must resist the temptation to consider only factors outside our behavior as physicians, such as lack of insurance, lack of sick leave, crowded living conditions that impede social distancing, greater likelihood of working essential jobs that put them on the front line, overrepresentation among those who are homeless and incarcerated, and a higher rate of comorbid conditions.

We must look inward and acknowledge our own unconscious racial bias as a factor too. Even though our implicit biases occur without our conscious volition, they still affect care. Our attitudes and behaviors as health care professionals are independently associated with poor minority health outcomes, even after controlling for wealth, income, education, and socioeconomic status measures. (Matthew DB. [2015]. Just Medicine: A Cure for Racial Inequality in American Health Care. New York, NY: New York University Press.) The good news is that our attitude is the one we have the most power to change.

I don't think a blonde-haired, blue-eyed person like me, no matter how well-intentioned, could presume to understand how unconscious racial bias affects people of color. I can only imagine what racial bias must be like from my experience with implicit gender bias. I can appreciate that subtle slights and microaggressions add up over time. I know feminist anger is deep-rooted frustration from being scarred by a thousand paper cuts. I cannot imagine the compounded discrimination for those facing racial and gender bias.

I will never truly understand the hardships that racial biases create for my patients of color, but it's my responsibility to try. It's the responsibility of all of us. We are not as impartial as we think we are. Implicit bias about age, race, gender—you name it—affects everyone. Acknowledging our own unconscious racial bias and wanting to change for the better is half the battle.

Get a sense of your own implicit bias by taking Harvard University's Project Implicit test at https://bit.ly/2LvqM1f. Next month: What we can do in our practice to neutralize implicit racial bias.

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Dr. Simonsis a full-time night emergency physician in Richmond, VA, and a mother of two. Follow her on Twitter@ERGoddessMD, and read her past columns athttp://bit.ly/EMN-ERGoddess.