Deconstructing Racism and Bias in Clinical Medicine

Key Terms and Concepts

Throughout this chapter, several key terms will be used ( Table 5.1 ). An understanding of these terms and concepts is critical as they form the foundation for the clinical skills presented. The central concepts that support the clinical skills presented in this chapter are bias , racism, and anti-racist skills .

Bias is a tendency or inclination that results in judgment without question ²

2 Ross HJ. Everyday Bias: Identifying and Navigating Unconscious Judgments in Our Daily Lives. Lanham, MD: Rowman & Littlefield Publishers; .

; it is expressed as snap associations we make about an individual based on a past experience or because of limited information and exposure. Bias can be explicit (conscious) or implicit (unconscious) and exists within individuals and institutions ( Table 5.2 ).

Implicit bias is an automatic response or mental association that occurs without awareness, intention, or control. ² Implicit bias is a normal human function. Well-known examples of implicit bias have been described in the human resources literature. ³

3 Rowatt WC, Franklin LM, Cotton M. Patterns and personality correlates of implicit and explicit attitudes toward Christians and Muslims. J Sci Study Relig. ;44(1):29.

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4 Schwartz M, O'Neal Chambliss H, Brownell K, et al. Weight bias among health professionals specializing in obesity . Obes Res. ;11(9):1033.

More recently there has been a growing body of evidence demonstrating how implicit biases of clinicians negatively impact patient care. ^5–8

5 Blair I, Steinert J, Havranek E. Unconscious (implicit) bias and health disparities: where do we go from here? Perm J. ;15(2):71.

6 Chapman EN, Kaatz A, Carnes M. Physicians and implicit bias: how doctors may unwittingly perpetuate healthcare disparities. J Gen Intern Med . ;28(11):1504.

7 Green AR, Carney DR, Pallin DJ, et al. Implicit bias among physicians and its prediction of thrombolysisdecisions for black and white patients. J Gen Intern Med. ;22(9):1231.

8 Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and itsinfluence on health care outcomes: a systematic review. Am J Public Health. ;105(12):e60.

Implicit bias is often in conflict with our conscious attitudes, behaviors, and intentions and is deeply rooted in and supported by race, class, and power-based structural divisions. Although clinicians pledge to do no harm, the profession itself has historically denied, resisted, or avoided addressing the role of bias in clinical medicine. The Cycle of Implicit Bias in Clinical Medicine shown in Fig. 5.1 illustrates how our unconscious behaviors are triggered, developed, primed, and ultimately rooted in medical education training and perpetuates bias in patient care.

When a bias is due to race, is it known as a racial bias . Racial bias is a person's identification with their racial in-group, which leads to preference for those of the in-group and negative preconceived notions about those of an out-group. Race is a social construct as opposed to a biological fact. That is, race is defined and made real by political, social, economic, and historical values of a time/era and geographical location. For example, a person may be racially designated differently in a different location (United States vs. Brazil vs. South Africa) and time/social context (early 1900s vs. early 2000s). While racial bias is an automatic, neurally-mediated belief , racism is grounded firmly in the above power structure and is the overt and/or passive action of biased beliefs. The ideology of racism is borne in the idea that human beings are naturally subdivided into distinct groups based on their physical appearance (i.e., race), in order to create a hierarchy that promotes domination and oppression. The concept of hierarchy has been doubly supported by science and medicine and in sync with American law. Racism can be simply defined as privilege plus power. ⁹

9 Sivanandan A Communities of Resistance: Writings on Black Struggles for Socialism. New York: Verso; .

According to this definition, two elements are required in order for racism to exist: racial prejudice, and social power to codify and enforce this prejudice onto an entire society. ¹⁰

10 Barndt J. Dismantling Racism: The Continuing Challenge to White America. Minneapolis, MN: Augsburg Books; .

The societal and cultural norms that create and perpetuate this racial hierarchy are referred to as “white supremacy culture.” White supremacy culture is the organizing principle of our society, regardless of the conscious intentions of individuals within society. The features of white supremacy culture have been well described. Select examples appear in Table 5.3 , White Supremacy Culture and Anti-Racist Clinical Approaches. ¹¹

11 dRworks at www.dismantlingracism.org , https://resourcegeneration.org/wp-content/uploads/2018/01/2016-dRworks-workbook.pdf , accessed on 8/25/2019.

White supremacy culture has biological effects and very real consequences for people's health, wealth, social status, reputation, and opportunities in life, especially if they are nonwhite.

The creation of race is historically linked to medicine. Physicians supported the creation of race to sustain and justify social and political power via the creation of a racial hierarchy ( Fig. 5.2 ). Racial hierarchies were used to justify the genocide of Native Americans and the enslavement of black Americans, and to perpetuate inequities of black Americans through contemporary times. Scientific racism employs pseudoscientific empirical inquiry and data to define and support the idea of hierarchical racial categorization to justify racism. It is deeply rooted within medicine's history and culture (as medicine developed within particular historical moments), and is ubiquitous in contemporary medical practice.

Within this paradigm, clinicians are taught to pay attention to race, along with the outcomes of health inequities, without any acknowledgment of the historical and sociopolitical forces that yield inequitable outcomes. This is done explicitly, through guidelines and clinical prediction rules that employ race as a biological construct, and implicitly through observational studies that report on racial health inequities without providing a sociopolitical framework for these outcomes. Clinicians thus rely on their own assumptions and explanations, which include genetic and biological differences, as well as behavioral choices and innate abilities. Together, this has been shown to manifest clinically as false beliefs about biological differences between races ¹²

12 Roberts, Dorothy E. Fatal Invention: How Science, Politics, and Big Business Re-create Race in the Twenty-first Century. New York: New Press; .

and inequities in care management based on a patient's race. ^{13 ,}

13 Hoffman KM, Trawalter S, Axt JR, et al. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. ;113(16):4296.

¹⁴

14 Goyal MK, Kuppermann N, Cleary SD, et al: Racial disparities in pain management of children with appendicitis in emergency departments. JAMA Pediatr. ;169(11):996.

White supremacy culture is thus entangled with medicine: influencing medical practice and being perpetuated by scientific racism.

White supremacy culture is also interdependent with medical culture through dominant narratives. A dominant narrative refers to “an explanation or story that is told in service of the dominant social group's interests and ideologies.” ¹⁵

15 LSA Inclusive Teaching Initiative, University of Michigan https://sites.lsa.umich.edu/inclusive-teaching/2017/08/24/dominant-narratives/

The concept of a “dominant narrative” is a useful lens through which we can understand how stories are told and how medical knowledge is transmitted. These narratives serve to perpetuate power hoarding within the dominant social group and are most often incomplete or false representations of complex social histories. In order for that narrative to be perpetuated, it must be told without consideration for alternative explanations and in service of those in power. These stories shape our perception and by consequence our understanding of what should be done. Moreover, the repetition of these stories becomes pervasive, unquestioned, and seemingly objective. Common false messages that are often perpetuated are that:

• “Obese patients are noncompliant with their medication because they do not care about their health.”

• “Black patients do not take doctor's advice because they do not trust the health care system.”

• “Native American health is often so poor because of alcohol use.”

We can characterize the dominant narratives in these examples by asking a number of questions:

• 1

  Who or what is the problem being described?

• 2

  Are there other facts or stories that may complicate the singular story being told here?

• 3

  How is this narrative perpetuated?

• 4

  Who benefits from the way this narrative is being told and who is harmed?

• 5

  Is this narrative reflective or a larger set of values and beliefs?

The end result of this process is that the collection of dominant narratives, particularly those leveraged against marginalized people, contribute to how the medical establishment treats those communities ( Box 5.1 ).

Traditional cultural competency paradigms sought to reduce such inequities by improving clinicians’ knowledge of specific cultural beliefs, attitudes, and practices. ¹⁶

16 White-Means S, Zhiyong D, Hufstader M, et al. Cultural competency, race, and skin tone bias among pharmacy, nursing, and medical students: implications for addressing health disparities. Med Care Res Rev. ;66(4):436–55.

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17 Kumagai AK, Lypson ML. Beyond cultural competence: critical consciousness, social justice, and multicultural education. Acad Med. ;84(6):782.

An anti-racist-based approach, in contrast, is an active process for identifying and eliminating racism by changing systems, organizational structures, policies and practices, and attitudes, so that power and privilege are redistributed and shared equitably. ¹⁸

18 While distinct from “insurgent multiculturalism,” anti-racism shares many charactersitics with this new clinical and educational paradigm, described here: Wear D. Insurgent multiculturalism: rethinking how and why we teach culture in medical education. Acad Med. ;78(6):549.

In the context of clinical practice, anti-racism examines the power imbalances between racialized people and non-racialized/white people whether they are patients, trainees, medical educators, or physicians. This approach counters white supremacy culture and seeks to decenter whiteness in the clinical encounter.

Practice Exercises