(Originally published 04/21)

It seems so simple and yet, it is so deadly. But, it goes far beyond an equation.  The hard truth is that unconscious bias is baked into medicine.  I, who make up 2% of the American physician population, the EXACT same percentage of African American doctors that has existed in this country for 120 years, am treating bones, bruises, infection, and unconscious bias every single day of my life.  This has been tasked to me by my patients, though, in many cases, they don’t know how it has affected them in their medical outcomes.  What is even more perplexing and disturbing, is that my fellow colleagues who may treat my patients before they come back to me may also be under the same illusion- they simply don’t know that some of the decisions that they make in a medical interaction with patients of color is wrapped in unconscious bias, and, ofttimes contributes to a poorer outcome of said patient.

 

Now, my colleagues would ask me- in some case rightly, “Well doctor, where is your research?”  Data is the name of the game.  Even if I were to show them countless articles showing medical disparities and poor outcomes, they would attribute it to p-values, demographics, social determinants of health, genetics, we could go on for hours.  But what is all the more frightening to me is that I know that there is a switch that seems to be clicked when a Black patient walks into a room.  It is so subtle, you never hear it, it’s like a soft breeze, an in no time at all this said patient is sent down a rabbit hole of disaster, unbeknownst to the physician in some cases nor the patient as well.

 

So many times, I keep hearing about the stereotype of the belligerent and “aggressive” Black mother.  Everyone knows who she is.  She comes in, questioning everything that doctors are doing to her children and family.  They ask questions and demand explanations of care.  In some cases, this woman will have the audacity to ask names of medications, she will want to see copies of the bloodwork.  And, at all times, she will be difficult.  There is such disdain for this inflexible “character stereotype”.  The medical team never gets to know said woman.  In some cases, she may have security called on her.  Social services may need to get involved.  The medical team will pull away even further from the room so as not to engage or “upset” her.  All the while, in some cases, said family member, patient bears the brunt of this interaction.  

 

What my colleagues don’t seem to realize is that the other side of the coin in this stereotype is the doting Other mother, a woman who is caring and fiercely protective of her child.   This mother doesn’t need to ask questions about her family member’s health care because, in many cases, she is told.  The medical team keeps her up to speed because- well, they feel comfortable by her presence.  They will tell her about mechanisms in colloquial language, but, nothing that is a far derivation from the English that she speaks.  They will speak with her about the plan as if they are chatting with her over coffee and tell her how long that her child will be in the hospital,  what follow-up is needed and why, when to follow-up with her child’s physician.  It is an experience that empowers both the patient’s family and the medical staff- what every patients’ family  interaction should be… and yet, only reserved for some.

 

I have been a part of countless medical teams where I am both a participant and an observer in the treatment of Black families.  In some cases, even though the medical team does not speak to the families at all, nor inform them of the medical plan or have that “executive discussion”, I am asked to “translate” to these Black families.  These families speak English, look the same as the Other families that are treated, and yet, I am supposed to translate.   I remember one late night interaction,  I had a colleague who was tired and who was unable to fully explain the process that a patient was undergoing to a Black family.  However, rather than speaking to another attending, rather that rephrasing her words, she turned to me and told me to “talk to them.”  Now, mind you, I wasn’t the one in charge (big surprise), but, it was tasked to me as crew member to do a job that my colleague couldn’t.  What was so concerning to me is that this was an English speaking family- so, what the heck was I translating?  I knew, my colleague knew, and the family knew.  I was then forced to apologize in some way for the social slight, for the objectification of said family, for them simply being seen as a “problem”, and not as people who are interested and actively participating in their healthcare.  Of course, I didn’t directly apologize, tried to look at them with care and explain this invisible system in a nice way, to let them know that I saw them and I was able to give them some pointers so that they could navigate in the future without potentially offending this Other medical team which could potentially ruin the outcome of their family member.

 

For instance,  I advise many of my patients, regardless of who they are- to bring a family member.  Said family member is to observe, ask questions of the process, and raise concerns with anything that they feel may not be right.  I ask my patients to call me if they are in the ER or Urgent Care and they get that feeling that something may not be ok.  When patients are experienced with medical knowledge, I ask them to speak in a very conversational voice, very calm, and politely mention said medication, what the treatment plan has been in the past (if there is a chronic case) and to be as humble as possible- at first.  I advise my patients to ask questions at every turn.  This can be annoying for my medical colleague on the other end, but,  this colleague still probably doesn’t realize that these are the normal interactions that he or she routinely has with Other patients-  constantly answering questions, hopefully reminds them of this fact. 

 

I don’t know where we go from here.  I keep reading about this backlash to Critical Race Theory and I can’t help but wonder where this is taking us as a country.  The argument is that all Races are equal and that one isn’t superior- or treated as such.  That to believe that one is superior is racist…okay.   I still counter that with all of this, we must examine the root of the problem, specifically in medicine.  Our Medical teachings are based on Socrates and Aristotle, on medical practices that have largely been based on racist practices,  hypotheses, and we are indoctrinated as doctors.   We are taught to use stereotypes to help us diagnose and treat patients.  Algorithms that we learn from medical school and residency.  But, what happens when the pictures of the finding that you note in your textbook manifest in different ways- many times doctors are not able to see that they have missed things because of this unconscious bias.

 

I remember reading about a patient with a congenital genetic disorder who had gone eight to nine years being undiagnosed.  Instead, this Black girl had occupational therapy, physical therapy, speech therapy, was considered essentially “slow” and her mother, who struggled, had some encounters with Child Protective Services as the medical team couldn’t figure out if this girl suffered from neglect, whether her environment actually played a role in her current disability.  It wasn’t until the medical team “exhausted all efforts” that the physician just decided to have the patient go to a Geneticist, just to see if anything came up.  Lo and behold, the child had a well known and recognizable genetic disorder.  The problem, or issue with this was that the patient looked NOTHING like the hundred of pictures of the disorder- because the pictures that medical students are fed, the ones that are drummed in our brains, are Other- rarely, if ever Black.  So, how many children are out there, in the same situation, who are struggling and in this social determinants of health excuse nightmare?  How many children will miss out on proper interventions to help them be put in a proper medical context.  How many medical teams will miss out of the ability to identify said disorders because they are only trained to see a thing one way?

 

This is a constant battle that I fight. One for all of my patients and it is something that is so necessary. The book “Seeing Patients” by Augustus White, MD has become a true text to me, because it illuminates how physicians have been trained, it speaks about our biases, and how truly seeing patients can save and change lives for the better. And in this endeavor, I am still hopefully optimistic.