How Racial Bias and Healthcare Inequality Are Killing Black Patients

Dr. Robert Pearl on the Pandemic and the Long-Reaching Impact of Institutional Racism

In 2020, one of the most chaotic strings of events in US history occurred in just a matter of months. As the coronavirus pandemic ravaged homes and hospitals, and as communities and businesses began to feel unprecedented economic pressure, and as a contentious presidential election loomed, and as the push for racial justice in America intensified, the cracks in the country’s foundation grew wider and more visible.

As one online commentator put it, “Imagine living through the Spanish Flu, the Great Depression, and the Civil Rights Movement… all at once.”

During the mass demonstrations that followed the police killing of George Floyd, politicians and TV pundits voiced concerns that large gatherings of mostly unmasked people could lead to further outbreaks of the coronavirus. Health experts like Dr. Anthony Fauci, one of the nation’s leading immunologists, agreed: “When you get congregations like we saw with the demonstrations, that’s taking a risk.” Even the World Health Organization weighed in, supporting the protests while asking demonstrators to exercise caution by wearing masks.

There was, in that moment, a strange convergence of seemingly unrelated events: A global pandemic, which was affecting the health of millions of people, was suddenly sharing airtime with protests against the unequal treatment of African Americans. And as the two biggest storylines of 2020 briefly overlapped, one of the greatest medical threats to human life at the time was being ignored.

The connective tissue, which bound the pandemic with the protests, was institutional racism. Contrary to what commentators chose to discuss, marches against inequality did not threaten the African American community’s health nearly as much as the inequality that already existed in US medicine. Consider the disparities of the disease in question. African Americans comprise 13 percent of the US population but accounted for a quarter of the country’s COVID-19 deaths, according to the CDC. In fact, when corrected for discrepancies in age, the mortality rate for Black people was more than double that of their white counterparts.

Present this data to doctors, and their first response is to blame socioeconomic factors like income and education, elements that exist outside of their offices and medical practices. No doubt, social and economic undercurrents help explain higher rates of coronavirus deaths among African Americans. Racial minority groups are more likely to work essential (frontline) jobs, live in more congested neighborhoods, and have unequal health insurance coverage. Indeed, all of these factors contribute to poorer health outcomes.

Dive a level deeper, however, and it becomes clear that Black patients also suffer higher rates of prejudice and mistreatment in US hospitals, clinics, and physician offices, driving up their risk of death. As an example, billing data showed that African American patients who came to the emergency room with symptoms of COVID-19 (including cough and fever) were far less likely to be tested than white patients with similar symptoms. This doesn’t make any sense. With Black patients twice as likely to die from the disease, the logical response would be for doctors to test African American individuals more, not less. But when faced with a shortage of COVID-19 testing kits, a disproportionate number was used on white patients.

In the early days of the pandemic, when emergency rooms had to ration testing kits, doctors could perform only two or three tests per eight-hour shift. In the frenzy, and amid the fear of losing a truly sick patient, doctors saved those kits for the candidates they deemed most deserving. This quick-fire deciding process played out at a subconscious level and, more often than not, the patients who were chosen were the ones who looked most like the doctors.

In the culture of medicine, doctors believe they treat all patients the same. The data indicate otherwise. When presented with evidence of racial bias, physicians point to flaws in society as the reason Black patients experience the poorer health. They insist that social determinants (where people are born, raised, work, play, and socialize) along with social dynamics (such as racial segregation, poverty, and educational barriers) are to blame—not doctors. As in so much of American healthcare, the systemic and cultural issues are intertwined. In this century, expressions of racism in medicine have become less obvious and more statistical.

For example, one reason African Americans have died at twice the rate of white patients from COVID-19 is that Black people have statistically higher rates of diabetes, hypertension, and heart disease than other groups. When not properly controlled, these are three of the medical problems shown to worsen the severity of COVID-19 and increase a patient’s chances of dying. The prevalence of these chronic diseases can be attributed, in part, to diet and stress, but much of the problem results from poorer medical care provided by doctors. Overall, the average Black patient receives $1,800 less per year in total medical care than a white person with the same set of health problems.

As a consequence, African Americans experience 30 to 40 percent worse health outcomes than white Americans, according to a report by the Robert Wood Johnson Foundation, the nation’s largest philanthropy dedicated to health. And that’s a reflection of how doctors practice.

Childbirth is another example. Black mothers die at four times the rate of white mothers, according to the CDC, while the mortality rates for their unborn children are twice as high. Doctors view this as a systemic failure, but the research contradicts this conclusion. When the treating physician is African American, not white, this discrepancy evaporates.

In this century, expressions of racism in medicine have become less obvious and more statistical.

Consider, also, the death rate from breast cancer for Black women is 50 percent higher than for white women. One reason is that only 60 percent of low-income women are screened for breast cancer versus 80 percent of high-income women. But even within the same economic stratum, white women have higher screening rates than African Americans. What’s more, Black women are less likely to be offered breast reconstruction after mastectomy, something that is directly under the physician’s control.

Heart attack and stroke data are equally concerning. Not only do 25 percent of African Americans have elevated blood pressure, compared to ten percent of white Americans, but Black patients are also ten percent less likely to be screened for elevated cholesterol than white people. The result is a higher rate of heart failure and of stroke for African Americans. Doctors are aware that Black individuals may be genetically more prone to elevated blood pressure. Knowing that, physicians should pay added attention to various risk factors for cardiovascular disease like elevated cholesterol. Instead, as the data show, they tend to skip over these life-saving practices when the patient they are treating is Black.

In a culture that believes all patients are treated as equals, white physicians fail to recognize how often Black patients are treated as other. A powerful example occurs when Black patients go to the doctor in pain. Research shows that, compared to white patients, Black patients are 40 percent less likely to receive medication to ease their discomfort after surgery.

As Dr. Uché Blackstock, the founder of Advancing Health Equity, explained in a conversation with Forbes contributor Maryann Reid: “Black patients’ pain is routinely underrated and undertreated by clinicians. The undertreatment of pain has significant deleterious consequences, such as lost wages, decline in mental and emotional health, self-medication with counterfeit medications and chronic stress. One of the promises in the Hippocratic Oath is ‘do no harm,’ however, clinicians have routinely caused Black patients more harm by undertreating their pain.”

The most flattering explanation for this discrepancy is ignorance. And there’s evidence to suggest that it is part of the reason Black patients receive less pain medication. Another explanation emerged from a 2016 survey, which found that half of white medical students and residents held false beliefs about the biological differences between Black and white people. Among those misperceptions: Black people have thicker skin and less sensitive nerve endings. Knowing this, we might also blame our nation’s educational system for this failure. However, I believe there’s a far likelier reason that white doctors underprescribe pain medication to Black patients. That reason is cultural.

In a profession of mostly white men, physicians often fail to empathize with the suffering of those they see as other. Put plainly, white doctors literally don’t feel the pain of their Black patients—at least not as strongly as for patients with similar skin color and overall appearance. No one wants to see themselves as biased. But attributing these problems to external factors or biological falsehoods alone is a clear-cut expression of prejudice. And it prevents doctors from confronting the basic psychological and cultural patterns that lead to poorer outcomes.

Taken together, the data confirm that the color of people’s skin determines both the quantity and the quality of healthcare doctors provide. Black patients get fewer pain medications, less screening, and inequitable attention from doctors—even when the data are adjusted for systemic barriers like underinsurance, educational inequities, and the geographic placement of hospitals and clinics.

Dr. Darrell Gray, a gastroenterologist at the Ohio State University and medical director for the National African American Male Wellness Initiative, thinks doctors need to come to grips with the prejudices they may not even know they have.

“I think there are patients who experience the detrimental impacts of implicit bias, meaning those unconscious kind of stereotypes that influence someone’s care,” he said in a news interview from 2020. “If a patient comes in and looks a certain way or talks a certain way, there may be bias and that could impact their treatment.”

Dr. Gray’s reference to “implicit bias” is a crucial component to understand the incongruity between doctors’ words and actions. Decades of psychological and neurological testing show that even when we are certain that we’re being fair to everyone, our decisions often reveal hidden preconceptions. Implicit bias connects our societal realities with medicine’s cultural norms, leading to disparities in clinical care.

In a profession of mostly white men, physicians often fail to empathize with the suffering of those they see as other.

In one notable study called the Implicit Association Test, participants are asked to look at a combination of facial expressions and words on a computer screen, rating each as either good or bad with the touch of a key. The self-administered test, which you can take online, is capable of identifying even a millisecond’s delay when assigning positive or negative attributes to people of different races. Consistently, white test takers associate white faces with “good” attributes and Black faces with “bad” ones. Although doctors are certain they treat all patients the same, regardless of race, the data indicate something different. Harvard researchers found that two out of three clinicians have an implicit bias against African Americans, despite the majority of doctors in the study denying any racial prejudices during the self-evaluation phase of the test.

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The healthcare profession has, for centuries, tilted toward white men. The homogeneity of American physician culture has, therefore, made doctors oblivious to their own biases. But the problems extend beyond the exam room. When white clinicians interview medical school applicants, their implicit biases lead them to prefer students who look like them, talk like them, share the same interests, and come from similar backgrounds. But that alone does not explain the insufficient number of Black doctors in healthcare today compared to the patient population served.

If you want to understand the origins of racial discrimination in American physician culture, a good place to start is with the largest physician membership organization in the United States. Since the early 1900s, the American Medical Association has served as an accrediting body for more than 100 of the nation’s medical schools and has therefore played a decisive role in who gets trained to be a doctor and who is eligible for state licensure. Historical records show that for most of the 20th century, the AMA used its tremendous power to deny membership to African American physicians. The depth of racism within the medical profession can best be understood against the backdrop of our nation’s most significant integration milestones.

Consider that it wasn’t until 1964 that the American Medical Association forced its state chapters to integrate and to stop excluding Black physicians from membership. That was ten years after the US Supreme Court ruled in Brown v. Board of Education of Topeka that racial segregation in public schools was unconstitutional. It was 16 years after an executive order desegregated the US armed forces. And it was 17 years after Jackie Robinson famously broke the color barrier in Major League Baseball by joining the Brooklyn Dodgers.

Fast forward to 2008. Forty-four years after it repealed its discriminatory rules against Black doctors, the AMA finally acknowledged “its past history of racial inequality toward African American physicians” and publicly apologized for decades of racist policies and actions. Medicine’s troubling history, in which it lagged the nation’s path toward integration, helps explain why nearly 90 percent of graduates from US medical schools were either white or Asian from 1978 to 2008. Combined, Black and Hispanic people make up less than ten percent of current practicing physicians.

Ask white doctors whether they think this is a problem, and most will assert that you don’t need to be Black to effectively treat Black patients. Research on clinical outcomes suggests otherwise. A study published in the Proceedings of the National Academy of Sciences found that Black babies were three times more likely to die in the hospital than white newborns when cared for by white doctors. When Black doctors cared for Black babies, the mortality rate was cut in half.

Similar findings came from a study out of Stanford in which researchers randomly assigned Black and non-Black male doctors to a group of over 1,300 Black men in Oakland, California. They found that patients treated by Black doctors were more likely to seek preventive services than those treated by non-Black doctors. The effect was particularly pronounced for invasive tests. Black patients with Black doctors were 47 percent more likely to get diabetes screening and 72 percent more likely to get cholesterol tests than ones with white physicians. They were also more likely to discuss personal health issues with doctors of the same race. The study concluded that increasing the number of Black doctors “could help reduce cardiovascular mortality by 16 deaths per 100,000 per year” among Black men.

Months of protests following the killing of George Floyd, combined with the rise of the Black Lives Matter movement across the country, have pushed the issue of race into the doctor’s office. It’s something physicians can’t ignore anymore. It wasn’t that racial disparities were completely unknown in healthcare before. It was that physicians didn’t see themselves as contributing to the problem. With all the pressures weighing on doctors today, the thought of addressing institutional racism seems like too great a burden. Therefore, rather than acknowledging their implicit biases or double-checking their decisions when caring for Black patients, doctors continue to tell themselves they treat all patients the same, despite growing data to the contrary.

When Black doctors cared for Black babies, the mortality rate was cut in half.

The long-hidden problem of racism in healthcare won’t be seen, let alone addressed, until the US trains and hires a more diverse physician workforce. Individuals from different backgrounds see problems and opportunities differently. In general, they are more likely to notice problems that affect people similar to themselves. Consider who would be the first to notice higher rates of COVID-19 mortality among Black patients, a white doctor or an African American physician? Who would be the first to hear about the issue of doctors underprescribing pain medications to Black patients? Who would be more concerned about omissions in prevention, doctors whose friends and families are given superior medical care or ones whose communities experience excessive chronic illnesses?

To be clear, white physicians do not consciously decide to give Black patients substandard care. Yet it is also true that solving institutional racism is not their highest priority—especially not when they feel overwhelmed by other workplace demands and systemic pressures. If you doubt that these facts present obstacles toward racial inequality in American medicine, just ask yourself this question: Who would be more likely to challenge the biases embedded in physician culture, the doctors who benefit from those biases or the doctors who are discriminated against?

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uncaring, robert pearl

Excerpted from Uncaring: How the Culture of Medicine Kills Doctors and Patients. Used with the permission of the publisher, PublicAffairs, an imprint of Hachette Book Group, Inc. Copyright © 2021 by Robert Pearl, MD.

Robert Pearl, MD
Robert Pearl, MD
Dr. Robert Pearl is the former CEO of The Permanente Medical Group. Named one of Modern Healthcare‘s 50 most influential physician leaders, Pearl is a clinical professor of plastic surgery at Stanford University School of Medicine and is on the faculty of the Stanford Graduate School of Business, where he teaches courses on strategy and leadership, and lectures on information technology and health care policy. He is the author of the Washington Post bestseller Mistreated, hosts the popular podcast Fixing Healthcare, publishes a newsletter with over 10,000 subscribers, and is a regular contributor to Forbes. He has been featured on CBS This Morning, CNBC, NPR, and in TIME, USA Today and Bloomberg News, and is a frequent keynote speaker at healthcare and medical technology conferences.





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