Jason Hargrove, a 50-year-old Detroit bus driver, died from COVID-19 after being turned away from care multiple times while visibly cyanotic. Rana Zoe Mungin, a 30-year-old teacher in Brooklyn, was sent home several times until she was ill enough from the disease to require intubation and ventilation. She has since died. While there are many reasons for these and other racialized disparities in the current pandemic (which have been clearly expounded elsewhere), stories continue to emerge that highlight the importance of physician bias in COVID-19 outcomes.
I became a physician because I was interested in health equity. The current COVID-19 pandemic is illuminating U.S. American racial health disparities more dramatically than any other crisis in recent memory, and has thrust this phenomenon into the national spotlight, in a flurry of attention that is long overdue. From Chicago to New York to Milwaukee, major metropolitan areas are reporting deaths of Black and Latinx patients at rates disproportionate to their representation in the populations of these cities. At the same time, cases of COVID-19 are occurring at higher rates in Native communities across the nation. Like many of the other disease processes we treat, the risk for COVID-19 starts long before a patient reaches our office or emergency room.
Yet numerous studies and countless non-COVID-19-related anecdotes have highlighted the role of physician bias in health care, which is only amplified under stressful conditions. While the biases students bring to medical school are largely unchecked during their four years with us, most curricula tackle health disparities superficially, if at all. We memorize which diseases are more prevalent in which racial groups, but without nuanced attention to the structural and historical reasons for these differences. Racial categories largely function as buzzwords for particular diseases (which students dutifully memorize for standardized tests), despite the fact that race is not a meaningful biological category. Although the sociological roots of health disparities are well understood, we continue to erroneously teach medical students that race – and not racism, both institutional and interpersonal – is the most important factor in racial health disparities.
The Institute of Medicine and many professional medical societies have long called for greater attention to health disparities. However this awareness has not yet trickled down to medical education in a systematic way. Medical students are expected to complete four semesters of chemistry and two of physics as undergraduates, but sociology or history courses are generally not required. When they arrive in our lecture halls, we mostly fail to teach students the sociological context that frames our patients’ lives long before they come into our care. To expect that students emerge from their training with a comprehensive understanding of the origins of their patients’ disease processes should not be a tall order.
This is not an indictment of my extraordinary colleagues who have risen to the challenge this crisis has presented. Rather, it’s an indication that we need to equip future generations of physicians with the tools to better understand and address racial and other health disparities – not only for future acute health crises but also for the ongoing, chronic crises of disproportionate morbidity and mortality from cardiovascular disease, diabetes, cancers, autoimmune diseases, and mental illness. All medical students should have a basic understanding of critical race and gender theories, either through undergraduate sociology courses or during medical school as embedded threads in our curricula. To separate science from social context is to tell only half the story of illness. Many of us in medicine deeply feel that it is our duty to share our unique knowledge with decision-makers for the sake of public health, and that this knowledge has as much to do with biochemistry as it does the daily realities of our patients’ lives. How can we be strong advocates for change without background knowledge of the systems that create health disparities in the first place?
In the aftermath of COVID-19, as we rethink the systems that gave rise to this inequitable health crisis – both within and outside of medicine – we also should rethink medical education. We may need to consider strategies and partners that are foreign to us – such as using narrative medicine and reflective writing, or inviting historians and sociologists into our medical lecture halls. As educators, we will need to humbly admit that many of us lack the knowledge to enact these changes on our own, but we can collaborate with our numerous colleagues in the humanities who have built entire careers around researching and describing the sociological origins of disease and health. We will need to include not only cultural competency/humility but also structural competency/humility as a core competency. We must deeply examine the biases we – students and teachers alike – bring to clinical encounters. Our future patients deserve physicians who understand them holistically and are prepared to address their own biases; in fact, their lives may depend on it. The COVID pandemic could not illustrate this more clearly.
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