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Akron Univ. School of Law

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Saturday, November 15, 2008

Confronting the Racial Barriers Between Doctors and Patients

The New York Times reports that the election of the nation’s first African-American president raises questions about racial disparities in health care.  Pauline W. Chen, M.D. provides an account of her experiences,

Stethescope4Last Tuesday, like most of the country, I stayed up too late watching the election results come in and then became emotional when it was clear that Barack Obama, an African-American, was going to be our next president. Wednesday morning’s New York Times captured the most salient part of the moment for me in its headlines: “Racial Barrier Falls in Decisive Victory.”

But a few days later, as I thought more about racial barriers, I started to question my election euphoria. In politics, the racial barriers might have fallen, I thought, but what about in health care?

There is no question that racial barriers still exist in many parts of this society. The first time I remember having a frank conversation about racial barriers in medicine was during my residency.

Of all the surgical residents I trained with, “Eric” was easily one of the smartest. He possessed a great bedside manner, brilliant clinical skills and plenty of that Obama cool. Eric was African-American, and one night, when we were both on call together, he told me something I have never forgotten.

“You know, Pauline,” he said, “there are a lot of times when I go to a patient’s room for the first time and they ask me, 'Are you transport? Are you here to wheel me to radiology?’” I can remember Eric shaking his head as he spoke. “They never assume I’m one of the doctors.”

Most of the research over the last 30 years has focused on the racial inequalities that affect patients; and the findings have been dismal. In 2002, the Institute of Medicine published a report that cited multiple examples of disparities across a wide range of health care and disease settings. African-Americans, for instance, were more likely to undergo less desirable procedures like amputation of all or part of a limb, while minorities with some forms of lung cancer had higher mortality rates because they were less likely to have surgery.

While there are probably multiple factors involved, researchers over the past decade have looked at how patients’ and doctors’ race and ethnicity might contribute to these disparities. One of the leading researchers in this area is Dr. Somnath Saha at the Oregon Health and Science University in Portland. Dr. Saha and his colleagues have shown that minority patients and white patients report better health care experiences when their doctors are of the same race or ethnicity .

But as my residency colleague, Eric, could attest, race and ethnicity can also influence the experiences of minority physicians. A recent study by Dr. Irena Stepanikova from the University of South Carolina notes that white patients who had non-white physicians were more likely to report a medical error than white patients with white doctors.

After reading through these study results, I decided to give Dr. Saha a call. I thought I would initially ask a couple of questions about his research, but I could not help starting with the election.

“On the one hand,” Dr. Saha said, “Obama’s election really provides some hope for people who thought it was impossible. But his election doesn’t automatically change what happens on the ground floor. Part of the downside of this historical event is that we may no longer believe that race can create a disadvantage. We may forget that we still do look at certain racial and ethnic minorities in a different way — not consciously but unconsciously.”

“I think the first step in addressing the disparities,“ Dr. Saha continued, “is really acknowledging that certain things affect the way we deliver care — our own stereotypes, our own cultural upbringing, our own ‘anxiety meters’ when we are interacting with people who aren’t like the people we grew up with.”

I never forgot my conversation with Eric because I, as an Asian-American woman, have had similar experiences. When working on consults with a white medical student or resident, I have watched physicians from other departments in the hospital look past me in order to speak to them. When preparing to operate on organ donor patients in other hospitals, I have had nurses and scrub technicians walk by me to help my assistants first, assuming that they were the lead surgeons.

But my own experiences were not the only reason I remembered Eric this past week. I remembered because our frank discussion was deeply unsettling. In order to empathize with my colleague and friend, I had to do the very thing Dr. Saha was talking about: I had to acknowledge my own biases and stereotypes first. And that was not easy.

I have prided myself on being as fair and as compassionate a doctor as I could be. But I am also very much the daughter of Taiwanese immigrants; and when, for example, I see patients or colleagues who come from a similar background, empathy comes almost automatically.

However, when I meet individuals whose race or ethnicity differs from mine — individuals who, for instance, are black, white, Hispanic or American Indian — there are fewer shared experiences. So I, like others, unconsciously tap into past experiences in order to bolster the connection and bring a greater sense of familiarity to the interaction. And it’s difficult to acknowledge that what I have tapped into may not always be fair.

“I think the key is getting to know each patient’s story and to treat each patient as an individual,” Dr. Saha said. “In doing so, you can really begin to understand where he or she is coming from. Empathy is really walking in their shoes, getting to know them, and putting your own biases aside.”

“It takes time to do that, Pauline,” Dr. Saha reflected. “But when it happens, it can really be a powerful thing.”

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