Dr. Ron Wyatt stopped into an award-winning hospital in the west Chicago suburbs last July after developing a concerning fever. He’d just returned from a week volunteering to spend time with orphaned children in Zambia, Africa, and his temperature had risen to nearly 104 degrees that day.
Wyatt is the patient safety officer and medical director in the Division of Healthcare Improvement at The Joint Commission, an organization that accredits and certifies health care providers throughout the country. The nonprofit, which is based in Oakbrook Terrace, Illinois, wields significant power in the health industry. But that day Wyatt was not on official business. He was a patient. And the treatment he received was substandard at best.
It began with a nurse telling his wife, who has power of attorney, that Wyatt would have to provide his own information, despite his wife's request that she be able to do so because he wasn't feeling well. "No, he will have to come sit right here," Wyatt recalls the nurse saying, ordering him to sit next to her, where she took his temperature. “Then she holds the thermometer really close to my face and says, ‘See! It’s only 99.6. OK?’” He’d just taken a Tylenol, so his fever had come down. The physician-now-patient would experience chills and see his temperature return above 100 degrees before the visit ended. But before that, the nurse placed a nametag on him after he gave her his information and let him know the doctor was ready to see him. “Then she walks off – not with me, but in front of me. … she never looked back.”
In the exam room, he meets another nurse who treats him well, but then a person comes in to get his insurance, and she pulls up another patient’s name on her computer. He tells her it’s not his name, and she says that – yes, in fact, it is, Wyatt laughs, incredulously. "No, that’s not me," he insisted. “So, she then asks me, ‘Can you show me your ID?’ So I show her my ID.” A physician comes in, and after a less-than-thorough exam and never looking Wyatt in the face, he orders IV fluids and tells Wyatt that his labs are "mostly normal," Wyatt says, noting that he had to press him for more information. “But what struck me most was he had one foot in, one foot out of the door."
Later, despite experiencing chills, his temperature rising, again, to above 100 and a nurse making it clear to the doctor that more should be done, Wyatt overhears the doctor say: "Tell him he can just take some Tylenol when he gets home," Wyatt recalls. "I never saw him again."
Having grown up in the segregated South in Alabama, Wyatt, 61 – who is African-American – has no doubt that what he encountered was more than simply lackluster care. Aside from an accommodating administrative staffer they encountered in the waiting room who was black – and who told Wyatt's wife in an aside, after the nurse curtly denied her request to provide Wyatt's information: "Don’t let it bother you," which Wyatt translated to mean, “We see this all the time” – all those he encountered at the hospital, which he declined to name, were white.
Mounting research finds that racial bias and discrimination in health care as well as outside of medicine contribute to poor health for African-American patients and other racial and ethnic minorities. “I believe that a racist system of health kills people. There is ample evidence to show that,” says Wyatt, who cowrote an opinion piece on racial bias in medicine for the Journal of the American Medical Association in August.
“Some people are just aware of it; they’re just racist, explicitly biased – prejudiced and biased. … Others aren’t,” Wyatt says; he and other experts say that today, health care provider biases are typically more subtle. “The problem with it is we continue to see bad outcomes for black folks, and at some point we’ve got to say, whether explicit bias, unconscious bias – whatever it is, we need to know it and intervene so people live longer and live healthier.”
Nor is it simply social determinants, like lower socioeconomic status, that disproportionately touch many minority populations, and which can also contribute to higher disease rates, shorter life spans and more limited access to health care and patient choice, that account for the disparities in care nonwhite patients receive, and result in poorer treatment and health. Even accounting for such differences, racial bias – in and of itself – whether in health care or experienced anywhere else in society, can have a negative drag on a person’s health, explains Tené T. Lewis, an associate professor of epidemiology at Emory University Rollins School of Public Health in Atlanta. Lewis led a review published last year in the Annual Review of Clinical Psychology that looked at research on self-reported experiences of discrimination, wherever it takes place, and health: “The overwhelming body of research on discrimination and health indicates that self-reported experiences of discrimination are an important risk factor for poor mental and physical health,” the researchers wrote.
“If you are African-American or Latino and you present to the emergency room with a broken leg or a kidney stone, for example, you’re less likely to be given analgesics at the recommended level,” Lewis says, regarding the administration of medicines that relieve pain. “It doesn’t matter what part of the country you’re in, it doesn’t matter what type of place you’d present to, that we’ve seen fairly consistently.” In addition, she says, there have been similar racial differences found in cardiac care and some studies showing delays in kidney transplantation rates.
In general, being regularly subjected to racial bias and discrimination, whether in health care, retail stores or restaurants, contributes to everything from high blood pressure to worse sleep, research finds. “We know that people who report more discrimination have higher rates of incident stroke and heart disease, we know that they have more asthma, we know that they have more of the bad type of fat that’s around your internal organs – visceral fat, more inflammation,” Lewis says. “So we conceptualize it as a form of psychological stress.”
Still, some doubt that such biases continue to persist despite evidence showing that to be the case not only in certain regions, or the U.S. as a whole, but throughout the world. “This is an area of research that is often met with a lot of suspicion, and people don’t quite buy the evidence. People think, well, it must be something else; people think, well, the world has changed, this isn’t 1956 Mississippi or 1961 Alabama,” Lewis says. “I think everyone has this general feeling that, sure, there are racists out there, but they’re not in the medical care profession, and they’re not intelligent, enlightened human beings. And what we find is people are biased. Period.”
Far from advocating doctors and patients throw up their hands, though, experts emphasize that health organizations as well as individual health providers and professionals should seek to raise awareness of unconscious biases, embrace diversity and work to be more sensitive to patients of different races. Although it’s still not clear how mindfulness training and other efforts will ultimately affect care, medical schools, health organizations and associations, nonprofits and governmental organizations, like the Centers for Medicare and Medicaid Services, are starting to take a harder look at the issue, Wyatt notes hopefully, and what can be done to address it.
Even subtle cues – like body language – can differ in patient-doctor interactions, depending on a doctor’s biases and whether a patient is white or black. Dr. Amber Barnato, an associate professor of medicine and clinical and translational science at the University of Pittsburgh School of Medicine, recently led research evaluating these interactions by having actors play caregivers and patients receiving end-of-life care.
“We found that doctors, when they went in to see the black versus white patients, they made the same treatment decisions, they said the same things with their voices – in terms of talking about the treatment choices, the risks and the outcomes to be expected from each treatment choice,” she says. But nonverbally they communicated something else entirely and were less likely to do little things that display empathy or built rapport. “For example, they would use more closed posture and they had their arms crossed, or had their hands in their pockets. They would stand further away from the bed,” Barnato says. “They would spend more time looking at the nurse or the monitor and less time touching the patient.”
The majority of the physicians studied for the research published in the Journal of Pain and Symptom Management in January were white men, so the research team couldn’t come to any statistically significant conclusions about whether the doctor's race had an impact on his or her actions. But Barnato speculates such cold interactions could breed distrust that makes it harder to have already difficult end-of-life discussions. She thinks that may contribute to African-Americans choosing more aggressive life-sustaining measures, including more intensive care, at higher rates. "Now, of course, it’s not clear that getting more – or less – intensive care is good or bad," she says. But even as African-Americans are slightly more likely to say they'd prefer to exhaust life support options if terminally ill, they're disproportionately much more likely to receive such care, although the majority of black and white patients say they'd prefer instead only comfort measures at the end, like medication to manage pain.
The roots of blacks' mistreatment in medicine run deep – from segregated waiting rooms to experimentation on African-Americans patients without their permission – so “off” interactions strike a chord of distrust that has history behind it. “It’s entirely reasonable that a black family might be primed to be suspicious of the motives of a physician, and then that gets reinforced, in some way, implicitly to them by the doctor standing further away and not making great eye contact,” Barnato says. “Whereas if the doctor had come up close to the bed and patted their husband’s hand, and looked them in the eye and expressed that kind of nonverbal compassion, then it’s entirely possible that it might help shift the patient or family member’s sense of distrust.”
Wyatt, for one, hopes that growing recognition in health care and throughout society of even subtle biases – as well as more overt ones – and efforts to overcome those biases, in addition to other social determinants that affect health, will make a significant difference. "I'm optimistic. I think we're further down the road on this than we've ever been," Wyatt says, but he adds it's going to take a collective effort to overcome such issues. "There has to be systematic change."