#222 Addressing Anti-Black Racism in Medicine Utibe Essien MD, MPH

June 25, 2020 | By Matthew Watto, MD

Perspectives for Clinicians with Dr. Utibe Essien

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. 

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Credits

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

Sponsor

We are excited to announce that the Curbsiders are now partnering with VCU Health Continuing Education to offer continuing education credits for physicians and other healthcare professionals. Check out curbsiders.vcuhealth.org for more information.

Time Stamps

• 00:00 Intro, disclaimer, guest bio

• 02:40 Guest one-liner, Picks of the Week*: Just Mercy

• 09:20 Statement from the show; Importance of discussing racism in medicine

• 14:11 Definitions

• 18:06 Identifying how racism manifests in the clinical setting

• 37:46 Ideas for advocacy

• 49:50 Take points and Outro

Key Points on Addressing Anti-Black Racism in Medicine

1. Race is a social construct.
2. Be careful to understand that the pathology underlying some health disparities is racism, rather than race. Medical education often trains us to associate race as a risk factor for diseases when the underlying risk factor is the result of structural racism.
3. There are significant physical and mental health tolls experienced by Black Americans in response to racial discrimination and vicarious racism associated with hearing about incidents of police brutality. Dr. Essien recommends clinicians who wish to address these with patients should begin from a listening-based approach.
4. Race-based formulas are based on historical myths and worsen some care disparities; clinicians should be aware of and actively avoid using race-based formulas for GFR and PFTs.

Anti-Black Racism in Medicine Notes

Addressing Discomfort

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.

Terms and Basics Regarding Racism in Medicine

Key Terms and Concepts

Definitions

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)

Understanding Racism, not Race, as the Pathology

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)

The Importance of Specificity

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)

Identifying Manifestations of Racism in the Clinical Setting

Dr. Essien walks us through some ways that racism and historical legacies of racism in medicine may alter health outcomes or clinician judgment.

Health Effects of Vicarious Racism and Racial Discrimination

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)

Metrics Based on Race

GFR

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)

PFTs

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)

Racial Bias in Prescribing

Anticoagulation

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) 

Pain Treatment Disparities

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)

Trainee Clinics

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.

COVID-19

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.

Brief Ideas for Clinician Advocacy

Supporting Black Trainees and Colleagues

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”.

In Teaching Roles

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.

Links*

1. Just Mercy by Bryan Stevenson
2. Byran Stevenson TED Talk
3. Drive Like Jehu by Drive Like Jehu
4. Homegoing by Yaa Gyasi
5. Throughline Podcast by NPR
6. MedEdPORTAL “Anti-racism in Medicine Collection”
7. Bonus: Articles from Dr. Essien & Dr. Christle Nwora on USMLE Step 1

*The Curbsiders participates in the Amazon Services LLC Associates Program, an affiliate advertising program designed to provide a means for sites to earn advertising commissions by linking to Amazon. Simply put, if you click on our Amazon.com links and buy something we earn a (very) small commission, yet you don’t pay any extra.

Goal

Listeners will understand the way that structural racism pervades medicine and develop approaches for addressing the effects of racism within their clinics and communities.

Learning objectives

After listening to this episode listeners will…  

1. Define common terms: race, structural racism, white supremacy, health disparities 
2. Develop an approach to talking to patients about the effects of structural racism on health
3. Develop an approach for advocating to colleagues and within institutions on the effects of structural racism
4. Identify situations in which historical myths and structural racism in medicine may alter clinician judgment: race-based formulas, disparities in pain management, and disparities in screening and treatment of common conditions.

Disclosures

Drs. Essien and Ceasar report no relevant financial disclosures. The Curbsiders report no relevant financial disclosures.

Citation

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

References 

1. Carter-Pokras O, Baquet C. What is a “health disparity”?. Public Health Rep. 2002. [https://pubmed.ncbi.nlm.nih.gov/12500958/] 
2. Project Change. The Power of Words. Racialequitytools.org 2019. [https://www.racialequitytools.org/resourcefiles/RET_Glossary_Updated_October_2019_.pdf]
3. Nardone A, Casey JA, Morello-Frosch R, Mujahid M, Balmes JR, Thakur N. Associations between historical residential redlining and current age-adjusted rates of emergency department visits due to asthma across eight cities in California: an ecological study. Lancet Planet Health. 2020. [https://pubmed.ncbi.nlm.nih.gov/31999951/]
4. Nieblas-Bedolla E, Christophers B, Nkinsi NT, Schumann PD, Stein E. Changing How Race Is Portrayed in Medical Education: Recommendations From Medical Students, 2020. [https://pubmed.ncbi.nlm.nih.gov/32379145/]
5. Jones CP. Toward the Science and Practice of Anti-Racism: Launching a National Campaign Against Racism. Ethn Dis. 2018. [https://pubmed.ncbi.nlm.nih.gov/30116091]
6. Bor J, Venkataramani AS, Williams DR, Tsai AC. Police killings and their spillover effects on the mental health of black Americans: a population-based, quasi-experimental study. Lancet. 2018. [https://pubmed.ncbi.nlm.nih.gov/29937193/]
7. Martz CD, Allen AM, Fuller-Rowell TE, et al. Vicarious Racism Stress and Disease Activity: the Black Women’s Experiences Living with Lupus (BeWELL) Study. J Racial Ethn Health Disparities. 2019. [https://pubmed.ncbi.nlm.nih.gov/31215018/]
8. Heard-Garris NJ, Cale M, Camaj L, Hamati MC, Dominguez TP. Transmitting Trauma: A systematic review of vicarious racism and child health. Soc Sci Med. 2018. [https://pubmed.ncbi.nlm.nih.gov/28456418/]
9. Michaels EK, Reeves AN, Thomas MD, et al. Everyday Racial Discrimination and Hypertension among Midlife African American Women: Disentangling the Role of Active Coping Dispositions versus Active Coping Behaviors. Int J Environ Res Public Health. 2019 [https://pubmed.ncbi.nlm.nih.gov/31783683/]
10. Bethea TN, Zhou ES, Schernhammer ES, Castro-Webb N, Cozier YC, Rosenberg L. Perceived racial discrimination and risk of insomnia among middle-aged and elderly Black women. Sleep. 2020. [https://pubmed.ncbi.nlm.nih.gov/31555803/]
11. Eneanya ND, Yang W, Reese PP. Reconsidering the Consequences of Using Race to Estimate Kidney Function. JAMA. 2019. [https://pubmed.ncbi.nlm.nih.gov/31169890/]
12. Braun L, Wolfgang M, Dickersin K. Defining race/ethnicity and explaining difference in research studies on lung function. Eur Respir J. 2013. [https://pubmed.ncbi.nlm.nih.gov/22878881/]
13. Essien UR, Holmes DN, Jackson LR 2nd, et al. Association of Race/Ethnicity With Oral Anticoagulant Use in Patients With Atrial Fibrillation: Findings From the Outcomes Registry for Better Informed Treatment of Atrial Fibrillation II. JAMA Cardiol. 2018 [https://pubmed.ncbi.nlm.nih.gov/30484833/]
14. Green CR, Anderson KO, Baker TA, et al. The unequal burden of pain: confronting racial and ethnic disparities in pain. Pain Med. 2003 [https://pubmed.ncbi.nlm.nih.gov/12974827/]
15. Pletcher MJ, Kertesz SG, Kohn MA, Gonzales R. Trends in opioid prescribing by race/ethnicity for patients seeking care in US emergency departments. JAMA. 2008. [https://pubmed.ncbi.nlm.nih.gov/18167408/]
16. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016. [https://pubmed.ncbi.nlm.nih.gov/27044069/]
17. Lagisetty PA, Ross R, Bohnert A, Clay M, Maust DT. Buprenorphine Treatment Divide by Race/Ethnicity and Payment. JAMA Psychiatry. 2019 [https://pubmed.ncbi.nlm.nih.gov/31066881/]
18. Essien UR, He W, Ray A, et al. Disparities in Quality of Primary Care by Resident and Staff Physicians: Is There a Conflict Between Training and Equity?. J Gen Intern Med. 2019 [https://pubmed.ncbi.nlm.nih.gov/30963439/]
19.  Yancy CW. COVID-19 and African Americans. JAMA. 2020 [https://pubmed.ncbi.nlm.nih.gov/32293639/]