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Monday Apr 30, 2018

Acknowledging -- and Overcoming -- My Own Racial Bias

"What do white people know that we don't?"

[bias in black and white lettering]

"I'm sorry, what?"

I stared at the young woman sitting in front of me. Maybe I didn't understand what she was saying.

I thought she was just asking me about how vaccines work.

She was one of 10 community health workers in Harlem, all women of color, who worked to ensure good health among underserved patients in the area. I was there as a family medicine resident to learn about community medicine as a part of my medical training.

"What do white people know that we don't? Why are they choosing not to vaccinate their children? And why do doctors force us black folk to keep getting them?"

My jaw dropped.

Although I knew there was a contingency of individuals who, based on debunked studies and a distrust of the medical establishment, were against vaccinations, I had never thought about how race might impact the vaccine discussion. And I was sorely unprepared.

In medical school and residency, we discuss racial disparities in medicine as a public health problem. Most of us know about atrocities committed against people of color by our medical institutions. These include the unethical Tuskegee study,(www.cdc.gov) which withheld penicillin from black men who had syphilis. We're aware of Henrietta Lacks, a black woman who was never compensated for the now ubiquitous use of her cells in medical research. Perhaps you've heard of J. Marion Sims,(www.npr.org) the 19th-century gynecologist who performed experimental vaginal surgeries on black slaves without anesthesia. And countless women of color underwent forced sterilizations(www.reproductiveaccess.org) in the late 19th and early 20th century, which makes the topic of reproductive justice far more complicated and racially charged than I once thought.

In 2003, the Institute of Medicine (now the National Academy of Medicine) examined racial and ethnic disparities in the United States(www.ncbi.nlm.nih.gov) and identified them as a problem in health care. Medical literature has since been peppered with studies targeting how racial bias impacts quality of care, including whether minority patients receive appropriate discharge instructions(www.sciencedirect.com) or appropriate rehabilitation after traumatic brain injury,(www.ncbi.nlm.nih.gov) and whether a black woman is more likely to die in childbirth than a white woman.(www.wbur.org)  

We know that implicit biases,(ajph.aphapublications.org) where "health care providers appear … to have positive attitudes toward whites and negative attitudes toward people of color," exist. We also know that these biases still impact clinical decision-making. For example, studies show that blacks are often undertreated for pain, and that some pediatricians unconsciously administer less adequate pain treatment to children of color(www.ncbi.nlm.nih.gov) than white children. But other than highlighting the problem, we're not yet doing enough to solve it.

Racial bias within medicine is starting to receive attention in medical training.(www.medscape.com) But as a medical student four years ago, the only exposure I had to implicit racial bias, or unconscious attitudes toward people of color, was as a participant in the CHANGES (Cognitive Habits and Growth Evaluation Study) survey, a longitudinal study conducted by researchers at the Mayo Clinic that targeted non-black medical students to assess their bias and experience with race in medical school.(www.ncbi.nlm.nih.gov)  

For me, the act of the taking the Implicit Association Test,(implicit.harvard.edu) which was part of the research protocol, was eye-opening. I was shocked to find that, even as a brown woman of Indian heritage, I was more likely to associate positive words with Caucasian features and negative words with African features.

I now had information about my own racial biases without a way to unpack it. Did the results mean that I was more empathetic to white patients? Was I ignoring or minimizing the concerns of black patients? Was I perpetuating a brand of systemic racism through the medical care I provided? Was I risking their health in the process?

I didn't have specific mentors or guidance, so I attempted to grapple with my new knowledge on my own. I overcompensated for my biases by becoming stricter around white patients, while being more lenient (and trying too hard to relate) with patients of color. One day, after admonishing a white patient for not taking blood pressure medication, but joking with a black patient about how taking diabetes medication was a challenge, I realized my attempt to address my own biases still risked my patients' health, as well as my relationships with them.

I wish I had been actively encouraged, by professors and mentors, to explore the issue of race in medical school. I wish discussions on racism and racial bias within medicine were couched into my admittedly overwhelming medical training -- in the classroom and during clinical rotations. More importantly, I wish I had space to discuss and evaluate my unconscious racial biases, to allow myself forgiveness for them, and to actively dialogue about racial experiences with patient-educators, patients who volunteer to work with medical students, without shame or stigma.

It's hard to talk about race, but the earlier and more openly we discuss our own societal conditioning, the better equipped we are to develop a trusting relationship with our patients, regardless of their background. At the nonprofit in Harlem, I missed an opportunity to educate a curious community health worker about an important public health issue. I could have asked how her own experiences informed her understanding of how the medical community addressed race. I could have engaged in an open conversation with her about how the decreases in vaccinations for measles, mumps and rubella led to a resurgence in measles outbreaks throughout the country.

Instead, I was so uncomfortable with my own unprocessed racial biases that I became defensive. I threw around facts about how the polio vaccine saved thousands of lives. I may have said a few cringe-worthy words about how distrusting medical evidence was the reason people died. The woman whom I hoped to convince dug her heels in further, and the conversation didn't go well.

Since then, I've adjusted my approach. I'm not confident that I've transcended my racial biases, but I'm working on it. A few months ago, I met a patient who was in my office for a quick follow-up visit. She was a woman of color, of Caribbean and Mexican heritage, a Ph.D. who studied racial disparities. Keeping to my task as a primary care physician, I encouraged her to get a flu shot.

"I wonder if you would be cornering me in the same way about vaccines if I was white," she said.

Her body language challenged me, her language sharpened, her willingness to participate in the conversation vanished. Her reaction surprised me. However, this time I was prepared.

"I would. Absolutely." I smiled. "But I'm curious. Share your experience with me -- about being a woman of color, about your view on vaccines. I'm interested, and I want to know what you think."

Lalita Abhyankar, M.D., M.H.S., is a family physician practicing in New York City. You can follow her on Twitter @L_Abhyankar.(twitter.com)

Posted at 02:21PM Apr 30, 2018 by Lalita Abhyankar, MD, MHS

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