When we hear or chant, “Black Lives Matter,” what all does this refer to? Is it the gruesome police brutality in the death of George Floyd? Or the murder of Ahmaud Arbery? Absolutely. But what else should it refer to? We know that black lives aren’t equal in the face of COVID-19. As physicians, have we considered all the ways that black lives may matter less in health care despite our best intentions?
A recent JAMA article highlights a survey comparing infection and mortality rates in predominantly black and white counties. No subtle differences here. The infection rate was three times higher among the black counties. The death rate six times higher.
Across the U.S., African-Americans have three times the risk of dying from COVID-19 than Caucasian and more than twice the risk of Latinos.
These figures highlight disparities at multiple levels—access to care, access to timely care, barriers to effective social distancing measures as related to economic and housing factors, and pre-existing medical conditions related chronic gaps in care (Louisiana only expanded Medicaid under the ACA in 2016—millions were uninsured previously. Over 70 percent of COVID-19 deaths in Louisiana were among African Americans who are 32 percent of the population.)
Among these, perhaps we also have to consider what is difficult to discuss as a potential contributor: bias in the health care setting. After all, inequality doesn’t start and end with police officers.
It is particularly challenging for us to explore our role, even indirectly, because we take an oath to first “do no harm.” We aim to heal, not hurt. It seems antithetical to be somehow complicit in these staggering disparities.
Yet we are also a profession built on a foundation of the Socratic method. We are never immune from questioning so long as it may benefit the patient. We must always be able to learn to become better.
Please understand that I am not asking us to question the frontline workers on their skill or expertise or anything actually. This is a much wider lens. It is one that captures what I first noticed as a correctional psychiatrist, that 40 percent of those behind bars were black men, but they make up 13 percent of the population.
I don’t recall learning about this astonishing fact once during my nine years of training. In fact, I never hear about this demographic, and according to me, this should be the topic of every political debate. But it never is. Perhaps because they will never be able to vote, even when released. Forever invisible politically.
Here, the judicial system overlaps with the health care system, but our lane is much broader. We have opportunities to prevent ‘the invisible demographic’ phenomenon in our domain. After all, the disparities in health care won’t likely end with COVID-19.
To make the invisible more visible, maybe starting with patients is a good first step. And how we ask is as important as what we ask. Studies show that Patient Satisfaction Surveys actually discriminate against African American and female physicians. So scratch that. Make it relevant and easy to complete, like a PHQ-9? Ask every patient, so staff isn’t faced with trying to identify people’s race:
- What race do you identify as?
- In general, do you feel medical staff talk down to you? If so, do you think it is because of your race?
- In general, do you feel judged when you visit a medical establishment? If yes, do you feel it is because of your race?
- If you feel sick, do you avoid going to a medical establishment because (circle all that apply):
- lack of trust in the care
- previous negative experience
- fear of not getting the help you need
- being judged or blamed for your illness
If you circled any of the choices, do believe your race is related to your concerns?
If you answered yes to any of the above, what do you recommend for us to improve?
Why is this needed if most of us are required to complete annual “cultural competency” training? Well, we are checking off boxes for compliance, but two meta-analyses so far indicate very weak patient outcomes that correlate with these trainings.
And when the current Surgeon General publicly declares to people of color to “step up and help stop the spread so that we can protect those who are the most vulnerable,” maybe its worth asking how what is missing in competence training.
For one, the premise of cultural competence is problematic as it assumes one can become ‘competent’ in another’s cultural experience. By design, it places the physician in a pejorative position.
An alternative model, “cultural humility,” also called “cultural safety,” approaches this complex issue, not with a checkmark as “You’re done! You’re competent!”, but rather as an ongoing process where the physician is taught to contemplate the power differential in the patient-physician relationship with the goal being to increase the patient’s power (knowledge, independence, partnership). The physician’s focus is themself: the potential impact of their own culture on clinical interactions. It is a process. One doesn’t complete competence in the culture of the “exotic” other.
Although the box is checked for the institution’s compliance, it can later hurt the physician if a problem arises. (How could that happen? We trained you. Here’s the box that’s checked.)
In truth, as physicians, we go along with many things that we know don’t really work or make sense because we don’t have time to change them. We do as we’re told and get back to the work of seeing patients. We are rarely asked for feedback.
But what if we could improve patient outcomes by creating a new, more effective way to make black lives matter in our lane?
Clearly, we cannot fix entire systems or every variable that contributes to one demographic’s higher risk of morbidity and mortality when we see a patient for our 15 min of face to face time, but if we can start with addressing at least one that relates to us—one that we can perhaps improve—maybe we will become more insightful and our patients, more visible, more engaged. Maybe then we could close one gap, empower patients instead of claiming competence in their culture. We do have the power to use our lane to make all lives matter more, including black lives.
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