Chapter 2 – Race and Ethnicity
Leon McDougle MD MPH and Camilla Curren MD
Overview of racial and ethnic bias in patient-healthcare provider relationships
Racial and ethnic bias held by patients and healthcare providers may lead to unequal treatment outcomes.1-4 Establishing a therapeutic relationship between patients and healthcare providers requires mutual respect and a willingness to overcome bias and cultural barriers to effective communication. More commonly in recent years, healthcare providers are participating in self-reflective exercises such as taking the Implicit Association Test (IAT) and completing implicit bias awareness and mitigation classes. The goal of this approach includes becoming self-aware of unconscious bias and consciously adjusting attitudes to allow for receptiveness to providing patient-centered and culturally competent care.5-7
Whereas most of the focus has been on providing tools for healthcare providers, the growing use of patient – healthcare provider electronic communication platforms via the electronic medical record may provide future opportunities for implicit bias awareness and mitigation training for patients.8-9 This is critical since bias of patients toward healthcare providers may result in negative healthcare outcomes including inadequate patient compliance and decreased healthcare provider job satisfaction.10-13
It’s not uncommon for healthcare providers who are from groups underrepresented in the health professions to observe the differences between European American male privilege and themselves when providing cross-cultural care.14 Examples include how an underrepresented healthcare provider may be overlooked by a patient in favor of a more junior European American male healthcare provider or trainee when entering a hospital room or clinical office. To illustrate this point, Dr. Darrell Gray has observed a relatively high frequency of being asked to provide an extensive listing of details about where he went to college, medical school, and residency when providing cross-cultural care.
Prejudice and bias in the medical community based on race and ethnicity among professionals?
Microaggression, also known as microinequity is a term developed in 1970 by a psychologist named Dr. Chester M. Pierce. These repetitive manifestations of bias may be unintentional but the impact can accumulate over time. These subtle, stunning and often automatic and non-verbal exchanges which are ‘put-downs’, whether intentional or unintentional, communicate hostile, derogatory, or negative racial slights and insults toward people of color.15-16
Dr. Darrell Gray, who is board certified in both internal medicine and gastroenterology, reported how a hospital nurse sought approval of his evidence-based orders by an accompanying European American male who was a trainee with less experience and expertise.
Dr. Alejandro Diez, who is board certified in both internal medicine and nephrology, reported how other healthcare professionals can make misguided comments that question his Latino ethnicity based on stereotypes and lack of awareness about the diversity of the Hispanic and Latino populations. “He doesn’t look Latino.” “How am I supposed to know you’re Hispanic.”
Prejudice and bias in provider/patient relationships can be based on race and ethnicity
Unconscious bias may also result in healthcare provider acceptance of unsubstantiated beliefs about differences in patients based on race and ethnicity. For example, an African American female patient complained that she had experienced racism during her hospitalization. When the registered nurse (RN) caring for her tried to administer an abdominal heparin injection, the needle did not go in on the first attempt. The second attempt was successful and the patient said “ouch.” The RN “explained” that pigmented skin is more difficult to inject. The patient remembers the comment as “It is this dark skin that is keeping the needle from going in.” The patient was very disturbed by the comment and told the RN, who was likewise upset by the patient’s reaction. The charge RN was made aware and went to see the patient. The patient says that the charge RN confirmed to the patient that it has been her experience as well that this is true.
This important quality of care issue also appears to be related to a somewhat common, but false belief and has implications for pain management. A survey study from the Proceedings of the National Academy of Medicine reported that 25% of the 28 participant European American medical residents polled falsely believed that Black skin is thicker than White skin.3
This may also be a case of personally mediated racism whereby differential assumptions about race led to differential action. Such racism can be unintentional or intentional and was manifested by a perceived difference in skin thickness that may have caused the RN to stick the African American patient twice instead of once.17
This patient complaint led to additional education for the nurses involved and provided an opportunity for continuous quality improvement across the hospital to help maintain compliance with the Joint Commission pain management statement.
Techniques to reduce the severity of racial and ethnic bias in healthcare
Providing micro-affirmations by communicating how someone from a cross-cultural background has been an asset to the achievement of goals may counteract and provide protection against microaggressions and microinequities. Whereas microaggressions and microinequities diminish opportunities for therapeutic relationship building, micro-affirmations build confidence, resilience, and relationships.16
Dr. Gray observed that acknowledging bias is the first step and that racial and ethnic bias may be impacting patient-healthcare provider relationships. Identifying commonalities of values or interests may serve as a method to repair or build an effective therapeutic relationship between the patient and healthcare provider. Dr. Gray notes that identifying personal values and commonalities shared by patients and healthcare providers may place them on a more even playing ground and improve interpersonal relationships.
Dr. Diez states that the common thread is recognition of bias. Healthcare providers should take the opportunity to explain how the biased statement was offensive. However, there is a fine line between being confrontational and informative. For instance, if a person uses the term “Oriental” a response could be to explain how the inappropriate term may make others feel. This could include a statement similar to “I think you meant to say Asian” to facilitate an informative and respectful discussion.
Negative effects of unidentified or unaddressed bias and discrimination
Research has shown that increased levels of healthcare provider bias towards a patient lead to less “team-ness” in decision making and decreases the likelihood that the therapeutic plan will be followed.18 Dr. Gray states that unrecognized bias may lead to fewer options for care being offered including a decreased likelihood of affected patients being asked to participate in clinical trials. This may create disparate healthcare outcomes and lead to negative interactions between the healthcare community and discordant racial, ethnic, and cultural groups.
Dr. Diez states that unrecognized bias and discrimination may reflect poorly on the institution and healthcare provider. The opportunity cost may be reflected in persons from that community seeking care elsewhere. In addition, the poor experience may lead to avoidance of healthcare providers and result in higher morbidity, mortality, and healthcare expenditures for emergency care.
An example from Dr. Diez involves how the provider’s tone and lack of explanation prior to removing family members from a Latino patient’s room to perform a procedure may be off-putting to the patient and family. Allowing the patient to be more involved in the decision and to take ownership of the disease treatment may result in a better relationship with patient and family.