Listen as our esteemed guest Dr. Utibe Essien MD, MPH @UREssien walks us through key terminology and evidence necessary to understand anti-Black racism in medicine. Dr. Essien provides insights into ways that racism impacts our work in the clinical and academic settings and offers approaches for addressing anti-Black racism in these settings.
Producer and Writer: Joniqua Ceasar MD, Hannah Abrams MD
Cover Art: Hannah Abrams MD
Infographic: Beth Garbitelli
Hosts: Matthew Watto MD, FACP; Paul Williams MD, FACP; Joniqua Ceasar MD
Editor: Paul Williams MD, Chris Chiu MD (written materials); Clair Morgan of nodderly.com
Guest: Utibe Essien MD, MPH
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Dr. Essien points out that we as clinicians are trained to talk to patients about so many topics that are “difficult” to discuss: bad news, sexual histories, domestic violence. In Dr. Essien’s opinion, there is no “best” way to address racism with patients, colleagues, or friends, but he suggests that the priority for non-Black clinicians should be listening.
Health disparities: the difference in health care received by or health status of one group relative to another. (Carter-Pokras 2002)
Race: A social and political construct that changes over time and is not rooted in biological fact. (Project Change 2019)
Racism: Racism is different from racial prejudice, hatred, or discrimination. Racism involves one group having the power to carry out systematic discrimination through the institutional policies and practices of the society and by shaping the cultural beliefs and values that support those racist policies and practices. (Project Change 2019)
Structural Racism: The normalization and legitimization of an array of dynamics – historical, cultural, institutional and interpersonal – that routinely advantage Whites while producing cumulative and chronic adverse outcomes for people of color. (Project Change 2019)
White Supremacy: The idea (ideology) that white people and the ideas, thoughts, beliefs, and actions of white people are superior to People of Color and their ideas, thoughts, beliefs, and actions. (Project Change 2019)
Dr. Caesar identifies an example from her medical education to explain how clinicians may be falsely taught to see race rather than racism as a risk factor for disease. A test question may identify a patient in a clinical vignette as Black in order to imply that they are at greater risk for asthma; however, this ignores the historical housing discrimination that might lead Black individuals to be more likely to live in more polluted areas. (Nardone 2020) Such biases may lead students to incorrectly believe that the underlying risk factor is race, rather than correctly understanding the pathology to be structural racism. (Edwin 2020)
Dr. Caesar notes that interventions aimed at raising clinician awareness of health disparities often focus on implicit bias, which is one contributing factor of many. However, in the context of addressing the deep historical legacies of racism in modern medical practice, experts from the American Public Health Association (APHA) recommend that a key step is to specifically name both individual and structural racism as causes of disparities. (Jones 2018)
Dr. Essien walks us through some ways that racism and historical legacies of racism in medicine may alter health outcomes or clinician judgment.
Hearing about anti-Black police brutality is associated with severe health burdens for Black individuals in the United States. The national mental health burden on Black Americans of hearing about these events is almost the same of those of diabetes (Bor 2018), and vicarious racism has documented effects on disease course for patients with lupus (Martz 2019) and child mental health (Heard Garris 2017). Perceptions of and coping with racial discrimination are associated with hypertension (Michaels 2019) and insomnia. (Bethea 2020)
GFR has historically had a correction factor for race based on the concept that Black individuals have a higher muscle mass; this can result in delays in eligibility for kidney transplant listing because of overestimation of GFR in Black individuals. (Eneanya 2019)
The tool for pulmonary function tests, spirometers, were designed with inherently racist assumptions that Black individuals had lower lung capacities. This results in inconsistent assessment of lung function and may contribute to disparities in pulmonary care. (Braun 2013)
Black patients, adjusting for insurance, education level, and income, were approximately 20% less likely to receive DOACs for atrial fibrillation.This difference persisted even controlling for factors including access to specialists and insurance. (Essien 2018)
Broad racial treatment disparities exist in analgesic prescribing for a variety of indications, including long bone fracture and nephrolithiasis. (Green 2003, Pletcher 2008) Clinician perception of patients’ pain is also affected by racial bias: half of a sample of medical students and residents thought that Black patients experienced less pain or had “thicker skin.” (Hoffman 2016) Unfortunately, this has been described as “protective” from the opioid crisis rather than understood as an epidemic of pain undertreatment in Black patients. (Frakt 2019, Mosley 2020) Dr. Essien notes that Black patients are also less likely to be prescribed buprenorphine for treatment of opioid use disorder. (Lagisetty 2019)
Dr. Essien points out that he, as a resident, was understandably busy moving back and forth between his duties in the hospital and clinic. He studied the outcomes between patients seen in resident clinics in terms of coronary artery disease screening, diabetes screening, and cancer screening and found that resident patients were less likely to achieve these process metrics and more likely to be uninsured or insured via Medicaid, to be living in poverty, to identify as a racial minority, and to not speak English as a primary language. (Essien 2019) Dr. Essien suggests that residency programs critically assess the patient populations that are seen in their residency clinic and how that may be a driver for disparities.
Structural racism underlies several potential etiologies of the vastly disproportionate impact of COVID-19 on Black Americans. (Yancy 2020) Dr. Essien points out some factors that may contribute to disparate risk due to structural racism, including employment type, health care access, where testing sites are built, and ability to safely socially distance.
Dr. Caesar points out that one way to support Black trainees is to simply acknowledge the toll of these events. Beyond that, however, ways that academic clinicians can support Black colleagues and trainees include supporting institutional initiatives such as the White Coats for Black Lives Racial Justice Report Card, recruitment and support of Black students and trainees, and advocating for institutional action to combat racism in medicine.
Dr. Essien recommends a “listen, learn, lead” approach. Listen to the experiences and needs that Black colleagues are voicing, learn from anti-racism resources, and then lead by promoting investment in offices for DEI or research missions in research on both racism and health equity. One resource for learning for medical educators is the MedEdPORTAL “Anti-racism in Medicine Collection”.
Dr. Essien’s advice for those in bedside teaching roles is to approach teaching on the topic of racism in medicine is similar to teaching on many other issues: by example. We should be attendant to historically used labels that have been used disproportionately to stigmatize Black patients, like “noncompliance,” and we should model consideration of racism as a risk factor for issues of access and health disparities, as well as modelling advocacy at the state, local, and national levels.
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Listeners will understand the way that structural racism pervades medicine and develop approaches for addressing the effects of racism within their clinics and communities.
After listening to this episode listeners will…
Drs. Essien and Ceasar report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.
Essien UR, Ceasar JN, Abrams HR, Williams PN, Watto MF. “#222 Addressing Anti-Black Racism in Medicine”. The Curbsiders Internal Medicine Podcast. http://thecurbsiders.com/episode-list June 25, 2020
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