Black Patients Dress Up and Modify Speech to Reduce Bias, California Survey Shows

By Annie Sciacca

A YOUNG MOTHER IN CALIFORNIA’S ANTELOPE Valley bathes her children and dresses them in neat clothes, making sure they look their very best — at medical appointments. “I brush their teeth before they see the dentist. Just little things like that to protect myself from being treated unfairly,” she told researchers.

A 72-year-old in Los Angeles, mindful that he is a Black man, tries to put providers at ease around him. “My actions will probably be looked at and applied to the whole race, especially if my actions are negative,” he said. “And especially if they are perceived as aggressive.”

Many Black Californians report adjusting their appearance or behavior — even minimizing questions — all to reduce the chances of discrimination and bias in hospitals, clinics, and doctors’ offices. Of the strategies they describe taking, 32% pay special attention to how they dress; 35% modify their speech or behavior to put doctors at ease. And 41% of Black patients signal to providers that they are educated, knowledgeable, and prepared.

The ubiquity of these behaviors is captured in a survey of 3,325 people as part of an October study titled “Listening to Black Californians: How the Health Care System Undermines Their Pursuit of Good Health,” funded by the California Health Care Foundation. (KHN receives funding support from the California Health Care Foundation.) Part of its goal was to call attention to the effort Black patients must exert to get quality care from health providers.

“If you look at the frequency with which Black Californians are altering their speech and dress to go into a healthcare visit,” says Shakari Byerly, whose research firm, Evitarus, led the study, “that’s a signal that something needs to change.”

One-third of Black patients report bringing a companion into the exam room to observe and advocate for them. And, the study found, more than a quarter of Black Californians avoid medical care simply because they believe they will be treated unfairly.

“The system looks at us differently, not only in doctors’ offices,” says Dr. Michael LeNoir, who was not part of the survey.

Dr. LeNoir, an Oakland allergist and pediatrician who founded the African American Wellness Project nearly two decades ago to combat health disparities, found the responses unsurprising, given that many Black people have learned to make such adjustments routinely. “There is general discrimination,” he says, “so we all learn the role.”

There is ample evidence of racial inequality in healthcare. An analysis by the nonprofit Urban Institute published in 2021 found that Black patients are much more likely to suffer problems related to surgical procedures than white patients in the same hospital. A study published in November by the National Bureau of Economic Research found that Black mothers and babies had worse outcomes than other groups across many health measures. And a study published in January, led by Dana-Farber Cancer Institute investigators, found that older Black and Hispanic patients with advanced cancer are less likely to re- ceive opioid medications for pain than white patients. (Hispanic people can be of any race or combination of races.)

Gigi Crowder, executive director of the Contra Costa County chapter of the National Alliance on Mental Illness, says she frequently sees delayed mental health diagnoses for Black patients.

“I hear so many stories about how long it takes for people to get their diagnoses,” Crowder says. “Many don’t get their diagnoses until six or seven years after the onset of their illness.”

Almost one-third of respondents in the California Health Care Foundation study — which looked only at Black Californians, not other ethnic or racial groups — reported having been treated poorly by a healthcare provider because of their race or ethnicity. One participant said her doctor advised her simply to exercise more and lose weight when she reported feeling short of breath. She eventually discovered she had anemia and needed two blood transfusions.

“I feel like Black voices aren’t as loud. They are not taken as seriously,” the woman told researchers. “In this case, I wasn’t listened to, and it ended up being a very serious, actually life-threatening problem.”

People KHN spoke with who weren’t part of the study