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Combating Medical Racism: The Case for Compulsory Physician Training
Jeffrey B. Ritterman, MD
Recent events have encouraged many of us to challenge our personal racism and to uproot the racism within our institu tions. This is a national project, long overdue.
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Despite the rigors of medical school education and years of Continuing Medical Education, few of us know much about medical racism. We may know the bare outlines of the Tuskegee Syphilis Study and we may know about the origin of HeLa cells from Henrietta Lacks’ cervical cancer without her knowledge or approval. But we know little else.
Medical racism still permeates the ongoing practice of medicine. The American Heart Association called structural racism “a fundamental driver of health disparities.” The editors of Family Medicine Journals issued a statement “Systemic Racism and Health Disparities” in which they said that “racism is associated with poorer mental and physical health outcomes.” The American Academy of Pediatrics issued a similar statement.
The medical and lay communities were shocked when we viewed the video of Dr. Susan Moore struggling for breath and explaining how she had to beg for pain relief and for adequate treatment during her recent bout with COVID-19. Attended by a white physician she complained that “He made me feel like I was a drug addict…if I was white I wouldn’t have to go through that.” She died from COVID.
The undertreatment of pain due to racial bias is also seen in children presenting to the emergency room with appendicitis, and with long bone fractures. Physician misperception of a patient’s pain is due in part to ignorance and stereotyping. A recent study showed that half of the medical students and medical residents tested had the misbelief that Black patients are less sensitive to pain than white patients. They would have undertreated Black patients in a clinical situation. Perhaps no illness demonstrates the intersection race and health care more than sickle cell anemia. Undertreatment of pain is a major problem. Sickle cell patients, who are predominately Black, wait significantly longer during emergency room visits than other pain patients. The authors of a study on this phenomenon concluded that: “The AfricanAmerican race of the SCD patients, and their status as having SCD itself, both appear to contribute to longer wait times for these patients. These data confirm patient anecdotal reports.” The anecdotal reports are striking: “Every time, it’s a battle,” one patient said about her ER experiences. She complained that staff members suspect her of faking her condition in order to score opiates and view her as a non-emergency because she only has pain. “I always dress professionally,” said a retired school administrator. “Nice shoes, interesting earrings, every hair in place, and Vogue-worthy makeup. It’s crazy that you, as an African-American, have to do this so you aren’t treated like a drug addict.”
The Institute of Medicine was asked by the federal government to do a comprehensive review addressing unequal medical treatment. Their findings confirmed unequal treatment and unequal health outcomes. This was true for cancer and cardiovascular and renal disease.
The algorithms used for calculating renal function are also biased against Black patients, making it more difficult for them to get dialysis and transplantation. Similar race-based algorithms are used in obstetrics to determine if a C-section is needed and in emergency medicine to help diagnose kidney stones. Each has been challenged as biased against Black patients. Significantly higher death rates have been noted among Blacks from hypertension, diabetes, septicemia, kidney disease, hypertensive renal disease, cardiovascular disease and infant mortality.
COVID-19 also results in excess mortality among Blacks. While this is explainable by the greater burden of disease in the Black population, the problems with inferior healthcare access, and the greater exposure to the social determinants of disease, concerns about bias in COVID-19 treatment have also been raised. This is particularly worrisome as the understandable Black mistrust of the medical system compromises vaccination efforts.
There is acceptance in medicine that medical racism exists and that it results in unequal treatment and unequal outcomes. We cannot leave it up to individual physicians to commit to the self-education required to deepen their knowledge and understanding. When it became clear that physicians were undereducated and underperforming in pain management and end of life care, it became a requirement to get training in these areas in order to maintain a medical license.
Let’s take a big step toward uprooting racism from medicine by designing an added dimension to physician training—and a new requirement for maintaining a medical license. Lives are at stake.
Jeffrey B. Ritterman, M.D. is a retired cardiologist from Kaiser Richmond, and on the Board of Directors, San Francisco Physicians for Social Responsibility.
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MEDICAL RACISM:
Jeff Ritterman, MD
We continue to learn about medical racism:
■ Pain is undertreated due to racism. Black children seen in the ER with either a long bone fracture or appendicitis receive less pain medication compared to their white counter parts. Sickle cell anemia patients who come to the
ER in painful crisis wait longer than other ER pain patients due to racism. They are viewed as drug addicts and mistreated. ■ The algorithms used for renal function are biased against
Black patients delaying their care and making it harder for them to get dialysis and transplantation. ■ The social determinants of health are politically biased against Black patients. Black communities have more exposure to toxic chemicals, more food deserts, and suffer more over policing, all resulting in worse health outcomes. ■ COVID claims a disproportionate number of Black lives because of poor health access, jobs that lead to more COVID exposure, crowded housing and racist medical treatment.
Racist treatment was painfully evident in the case of
Dr. Susan Moore. ■ As we continue to learn more about medical racism or what author Harriet Washington has called medical apartheid, we have started to act. ■ The SF Physicians for Social Responsibility is working with the Bayview Hunters Point Community to help the vaccination effort. Medical racism has resulted in a loss of trust. Developing a culture of trustworthiness is needed to help with the vaccination effort. We are working to make the medical information of the vaccines relevant to the community. ■ SF PSR will be hosting a webinar on May 26, 7 PM about
“Policing as a Public Health Crisis.” We are partnering with the Ella Baker Center and Impact Justice. Zach Norris, the
Executive Director of the Ella Baker Center, and the author of the amazing book “Defunding Fear” will speak along with
Ashlee George, co-director of Impact Justice’s Restorative
Justice Project. ■ Next year PSR will sponsor a speaking engagement with
Wesley Lowery, author of the New York Times bestseller,
“They Can’t Kill Us All.” ■ The Kaiser Oakland Ally Book Club will be convening a task force to discuss how we can improve health equity and promote physician education on health equity.
Comments/questions welcome: Jeffritterman@gmail.com
