Medicine has a race problem. Doctors consistently provide worse care to people of color, particularly African-Americans and Latinos. In studies that control for socioeconomic status and access to care, researchers have found racial disparities in the quality of care across a wide range of diseases: asthma, heart attack, diabetes and prenatal care, to name a few. Two studies performed in emergency rooms showed that doctors were far more likely to fail to order pain medication for black and Hispanic patients who came in with bone fractures. Doctors are less likely to diagnose black patients with depression yet more likely to diagnose psychotic disorders such as schizophrenia. Hispanic HIV patients are twice as likely to die as white HIV patients, and black HIV patients are less likely to get antibiotics to prevent pneumonia. There is, however, one procedure that doctors are more likely to perform on black patients: amputation.
As a medical humanities M.D./Ph.D. student, I set out to understand how my profession, which prides itself on objectivity, could be influenced by something so subjective and harmful as racial bias. I found part of the answer in the kind of objectivity that doctors value. As trainees, we aspire to be like scientists, who see the self as a potential source of error and therefore try to suppress it. But medicine is not a science—it is a moral practice that uses science. When problematic parts of ourselves, such as racial bias, intrude, we find it hard to recognize the problem.
In studying memoirs of medical students and residents, I found that many trainees feel an acute anxiety about the self. When we react emotionally to intense situations, we worry that we are not being good doctors. When we do not react—when we coolly watch a patient die or approach a critically ill child with clinical detachment—we worry that we are becoming monsters. We are unsure of the role emotions should play in clinical care. Interestingly, one specific emotion—discomfort—is thought to underlie disparities in care. Feeling uncomfortable, we rush out of encounters with patients of other races.
I was surprised to find that white trainees rarely mentioned race in their memoirs, even though we are disproportionately likely to care for patients of color in the free clinics and public hospitals where we learn. In medical school, we come to see race as a biological fact: something that predisposes certain patients to certain diseases. Medical students and residents of color perceive race differently—as a social experience. Former U.S. surgeon general Joycelyn Elders recounts being barred from the cafeteria when she was in medical school, and internist Rameck Hunt relates being unjustly arrested when he was a first-year med student. Navajo surgeon Lori Arviso Alvord writes about how touching a dead body in an anatomy lab course violates a Navajo taboo. Students of color also report feeling profoundly supported by their communities, and many are inspired by their own experiences of prejudice to provide excellent care to patients of color.
If white medical trainees avoid talking about race except as a biological fact, how can we explore racial bias? We might begin by revising our model of objectivity. Doctors are always themselves—emotional, particular and sometimes biased—in the hospital. We should accept this fact and learn to work with it. We should train ourselves, for example, to notice our own discomfort and respond by slowing down instead of rushing out of patient encounters. (Some medical schools are now training students to do just that.)
Other commonsense measures to tackle bias in care include aggressively recruiting and retaining medical students who reflect the diversity of the nation, explicitly training physicians to recognize unconscious bias and fairly promoting physicians of color within academic medicine. Ultimately, however, I hope that revising our understanding of objectivity in medicine can do more than just address bias. Medicine could be—it should be—a tool for ensuring that all people's lives are cherished. If we doctors begin to earn our authority as science-using moral leaders, then both medicine and society have much to gain.