When we go to the doctor, we would like to think that all patients have equal access to quality care—but that’s not always true.
Despite progress, discrimination—including ageism, racism, sexism and bias against homosexuals and those who are physically disabled or obese—is still a fact of American life. When it occurs in health care, it can mean the difference between life and death.
To get the facts on a potentially grave threat to our readers’ well-being, Bottom Line/Health spoke with Augustus A. White III, MD, PhD, professor of medical education at Harvard Medical School and a national leader in the fight to overcome bias in health care.
Growing up in “Jim Crow” Tennessee, Dr. White saw discrimination up close—and struggled against it in a long career that made him the first black physician to head a department at Harvard University’s teaching hospitals. What Dr. White has observed in his research on health-care bias and in his 50 years of medical practice…
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What has led you to believe that health-care bias is a problem in the US? Scientists from the National Academy of Sciences’ highly respected Institute of Medicine and various other credible institutions have done exhaustive research on health-care bias. The findings show that racial, gender and other types of disparities in treatment and death rates exist—independent of such factors as socioeconomic status and insurance coverage.
For example, blacks with heart disease are less likely than whites to undergo angioplasty or coronary bypass surgery. They also are more likely to have amputations and hysterectomies for various health problems that might be solved in less severe ways. Mortality from nine of the 10 leading causes of death is 1.5 times higher for blacks than whites.
Similar disparities affect Latinos, women, the elderly, gays and so forth. Women with heart disease have fewer corrective procedures than men and are prescribed fewer of the drugs recommended after a heart attack. In addition, orthopedists are less likely to recommend knee replacement in women who have severe osteoarthritis. Health problems in the elderly often are dismissed as “just old age.”
What role might cultural and/or racial factors be playing? It’s true that cultural and/or racial differences play an important role.
Latinos, for example, often tend to be particularly deferential toward health-care professionals—they’re reluctant to press for explanations or trouble the doctor when things bother them and may stop taking the drugs their doctors prescribe instead of complaining about side effects. Elderly adults are also often reluctant to trouble a doctor by asking “too many” questions.
People from certain Asian cultures may be fatalistic and accept the suffering inflicted by illness—unless the doctor makes a special effort to explain how treatment can help.
What do you believe is at the root of health-care bias? Probably the same assumptions, stereotypes and beliefs (often unconscious) that underlie bias in general. The fact that blacks and Latinos are prescribed less pain medication than whites for comparable fractures, for example, very likely reflects the deeply ingrained and inaccurate racial stereotype that they feel pain less intensely.
The belief that women are “emotional” and “fragile” could explain why some doctors are slower to diagnose heart attack when a woman has chest pain and less likely to recommend surgery. Some health-care professionals regard the lives of older adults as simply less important than those of the young and, as a result, treat an older person’s illness more casually.
Anecdotal evidence shows that some doctors also tend to provide substandard treatment to any patient they consider “difficult”—that is, whose needs demand extra effort. This could include anyone whose medical problems are complicated by obesity or who have difficulty communicating in English and patients whose anxieties are assumed to require soothing and time-consuming attention.
How do you think that bias affects one’s actual doctor visit? The effects of bias can be subtle. Without being aware, many people feel less empathy toward people different from themselves—on the doctor’s part, this can translate into less concern about your pain and treatment side effects, less attentive listening to your symptoms, overlooked complications and missed diagnoses.
If you, as a patient, feel poorly understood by, or mistrustful of, your doctor, you’re less likely to follow his/her recommendations…to ask for clarification when you don’t understand instructions…or to report new problems or changes in your condition.
How can a patient tell whether bias is compromising his health care? Intuition is a good guide. If you’re uneasy about your doctor’s behavior—for example, if you feel that your doctor isn’t spending adequate time with you or listening to your concerns—bias could be involved.
You may want to say, “I came here because I know you’re a good doctor, and I have reason to believe that you’ll provide good care for me. But I don’t feel we’re communicating as well as we might. No disrespect, but may I ask if you’ve taken care of many Asian [or black or Latino or gay or elderly] patients?” A constructive, concerned response is a good sign that you’ll be able to work together. A hostile or defensive reaction suggests that you should find another doctor.
How can patients increase their chances of receiving good, unbiased treatment? You can start by humanizing your doctor. Even if your doctor’s race, nationality or sexual orientation is different from yours, you still share a common humanity. Meet your doctor on a person-to-person level with small talk about your family, the weather, goings-on in your community. Simple interactions of this sort build rapport and establish the basis for mutual trust and connection.
It’s also wise to take a friend or relative with you—because another set of ears will help ensure that you understand everything the doctor says and also provides an objective observer who can correct or corroborate your judgment if you suspect bias.
Would some patients be better off seeing doctors of their own race, religion or sexual orientation? Maybe. For most patients, working with a good doctor who is also a reasonably enlightened human being, demographic and cultural differences won’t be an issue. But if you genuinely believe that you would be more comfortable and have more rapport with a doctor with whom you share a common background, make the effort to find one.
What if a patient thinks that he has been the subject of bias? Seriously consider reporting it to someone higher up in the doctor’s practice, hospital or medical association. Speak to the highest level official you can find. This could be a hospital’s or clinic’s chief executive officer, chief operating officer or even the head of nursing.
Mistreatment, indifference and lack of respect still do happen, and such problems won’t be resolved until they are addressed. You’ll be doing others—and yourself, and the whole health-care system—a favor.