In 2015, President Obama announced the “Precision Medicine Initiative”, a program designed to improve the health of Americans by emphasizing individuals’ genetic, environmental, and lifestyle differences. While this initiative paved the way for today’s concept of personalized medicine, which focuses heavily on genetics, Obama was spot-on in noting the importance of approaching each patient as their own individual person.
It’s well-known that Black Americans in the US face a significant burden of health disparities, or increase risk of chronic disease compared to other Americans. These disparities are the result of a complex network of historic and present-day social determinants, or factors that affect health–such as socioeconomic status, access to quality education and healthcare, and more. You may be feeling overwhelmed by the complexities of how to approach your Black patients. Do you consider their race? If so, how? Consider this article to be a debrief of sorts that will answer both of those questions.
Table of Contents
How to Acknowledge Race in Medical Decision-Making
Considering Individual Experiences
Distrust of the Medical System
Debunking Myths about Black Patients’ Health
The Myth of the “Default Human”
Pain Tolerance
Drug Addiction
Health Literacy/Education
How to Acknowledge Race in Medical Decision-Making
In honor of Black History Month, we’re going to focus on health disparities in the Black community, but there are also notable differences in the health of other racial minorities when compared to the general health of white Americans. Regardless of your patient’s race, how do we properly acknowledge these disparities without making generalizations and assumptions? Imagine a scenario in which a new patient, a pregnant Black woman, comes to establish care with you. What assumptions do you make upon meeting her? Do you assume she is a single mother? What kind of job do you think she has? Have you already surmised that she won’t come to all of her prenatal appointments? Racial bias affects us all, so it’s likely you have made at least some assumption about your patient. But by making assumptions about a patient’s social, economic, education, employment, or health status, we perpetuate racial stereotypes and fail to provide the care that our patients both need and deserve. At the systemic level, this leads to racial discrimination–intentional or otherwise–that is responsible in part for the health disparities themselves. So how do we acknowledge race without considering it too heavily? Make sure your considerations are just that—considerations, not assumptions. Being aware of social determinants of health and how they vary among different populations is a great start, but never assume your patients’ situations.
Considering Individual Experiences
Identifying and characterizing the individual experiences of your patients instead of making generalizations can not only help you build rapport with them, but will also help you provide the best possible care.
The American College of Obstetricians and Gynecologists (ACOG)’s 2018 committee opinion on the importance of social determinants in reproductive care includes guidelines related to cultural awareness, humility, and sensitivity that are applicable to all fields of medicine. Their screening tool for identifying social determinants of health offers categorized questions that can help you pinpoint which factors may be affecting your patients’ health and access to quality healthcare. We’ve adapted this tool below, but the full panel of questions can be found at the link above.
Note that the wording of these questions avoids terms that may make patients feel stigmatized, such as saying “because there was not enough money for food” instead of “because you could not afford food” or “do you need help reading?” instead of “can you read?” Instead of even accidentally assigning blame or fault to the patient, these questions remain neutral and can help providers to identify which patients–regardless of race–are more likely to experience health disparities. The final question in the panel (not pictured) asks, “if you answered yes to any of these questions, would you like to receive assistance with any of those needs?” It’s important to approach patient assistance in a way that helps patients to feel more in control of their health, instead of offering help without permission, which may embarrass patients or make them feel helpless.
Distrust of the Medical System
As recently as 2021, a survey by the Robert Wood Johnson Foundation and Harvard T.H. Chan School of Public Health reported that “fewer than 40% of people” trust federal public health institutions. The study also found that the vast majority of Americans polled do not have much faith in the National Institutes of Health (NIH) or the Food and Drug Administration (FDA). This distrust is hardly unique to federal health institutions, though; a large number of clinical practice recommendations are based on federal recommendations or studies funded by them. This translates to significant mistrust in local hospitals, clinics, and practitioners. And the effects are felt even more heavily by Black Americans. A study earlier that year found that non-Hispanic Black adults were 73% more likely to report medical mistrust than non-Hispanic white adults.
But the tendency of Black Americans to distrust the US healthcare system isn’t new, and it isn’t baseless. It is, however, a contributing factor to why so many Black Americans experience chronic disease or die from conditions that white Americans are more likely to survive–like cancer. Discrimination against racial minorities in the US, actual or perceived (note: perceived discrimination has been shown to affect health significantly), is unfortunately well-deserved, with countless historical and modern-day examples of mistreatment. Below are few notable mentions:
In 1968, a Black man named Bruce Tucker suffered a fatal head injury; the next day, his heart was donated to a white man at the Medical College of Virginia without the consent of Tucker or his family.
From 1932 to 1973, the United States Public Health Service conducted an infamous study, known as the Tuskegee Study, on 399 Black men with syphilis and 201 without. The participants were not told the true reason for the study, and did not consent to it. In the 1940s, penicillin was adopted as a treatment for syphilis, but it was not offered to the men who instead received aspirin and mineral supplement. By the time the study was reported and shut down, 28 men had died from syphilis, 40 spouses had gotten it, and it was passed to 19 children during childbirth.
In the early 1830s, James Marion Sims–president of the American Gynecological Society–began a series of surgical experiments to find a cure for vesicovaginal fistulas. During these experiments, he performed excruciating procedures on enslaved women without anesthesia.The women, as enslaved persons, could not consent to the procedures.
Another classic example of the exploitation of Black Americans “in the name of science” is the story of Henrietta Lacks. In early 1951, Henrietta was diagnosed with cervical cancer. Throughout the course of her treatment that year, several cervical biopsies were taken both without her knowledge and consent. What’s more, even after Lacks died in October 1951, additional samples were taken without her family’s knowledge or consent. By then, cancer researchers at Johns Hopkins had already noted that Lacks’ cells divided and survived longer than other cell types they had been studying. It wasn’t until 1975 that Lacks’ family learned that her cells had been used extensively for biomedical research, including in the development of the first polio vaccine several years after her death. To add insult to injury, the family’s medical records were published without their consent in the 1980s.
Debunking Myths About Black Patients’ Health
While you’d think–or at least hope–that medical professionals are immune to the effects of systemic racism in the US and the accompanying biases and stereotypes, this is unfortunately far from the truth. Even today, there are a handful of common assumptions about Black patients that continue to affect the quality of healthcare they receive. This takes the form of undertreatment, low quality care, and underrepresentation in medical research. All of these contribute to the number of health disparities experienced by Black Americans.
Below is a list of a few medical myths that affect Black people.
The Myth of the “Default Human”
The first myth we’re going to debunk is one that has been perpetuated by medical education programs, and it assumes that all patients with the same condition will present in the same way, with the same symptoms. It also assumes that all treatment approaches are appropriate for all individuals, regardless of race. This simply isn’t true, and it’s partly because medical research has historically failed to account for the experiences of racial minorities. This gap in knowledge can lead to major mistakes, including missed diagnoses.
Pain Tolerance
Numerous studies have indicated that a decent percentage of both medical students and medical providers alike have preconceived and incorrect notions about their Black patients’ pain tolerance. Many people believe that Black people have thicker skin than white people, and that they consequently have a higher pain tolerance. Not only is this not true, it is a dangerous assumption that results in undertreatment and neglect of Black people experiencing significant pain.
Drug Addiction
Another factor that may contribute to the undertreatment of Black patients, particularly those in pain, is the widespread belief that Black patients are more likely to be “drug-seeking” than to have actual medical needs that require the prescription of controlled substances. A 2016 study assessing pain management in patients with appendicitis found that Black children are less likely to be given pain medication for moderate or severe pain.
Health Literacy/Education
A high proportion of Black Americans have reported feeling like the need to code-switch, or change the way they talk around people of other races in order to be taken seriously or feel like they belong. Code-switching can be part of a Black American’s everyday life, but is particularly common in medical environments, where they are more likely than others to experience assumptions about education level and health literacy. Negative stereotypes about Black people include the belief that they are not educated, or don’t know anything about their health. This can lead to being neglected by healthcare providers and receiving lower quality treatment.
Putting It All Together
When it comes to providing comprehensive patient care, you may feel overwhelmed by everything we just discussed, but it all comes down to one major point: each patient is just that–one patient. One individual. One person with their own experiences and beliefs and history. Approaching medicine with a “one size fits all” attitude will mean some people get the care they need, and many won’t. But adopting a gentler take, one that considers the cultural and societal effects on race while leaving space for individuality, can help tailor your care to each patient and will ensure that everyone gets exactly what they need.