Last month I was at a speech given by Minnesota Department of Human Services Commissioner Lucinda Jesson where she laid out the possibilities and challenges of the Affordable Care Act and its impact on our state’s medical options. She then showed slides from a Commonwealth Fund study identifying Minnesota as simultaneously one of the best states for overall quality of health care and one of the very worst in terms of racial disparities in health care. How is this possible? In asking this question of physicians, nurses and health care administrators, the answer is most typically an overgeneralized referencing to “the system” or “economic factors” or “the complicated nature of health care these days”, but rarely are these (majority white in Minnesota) health care providers willing to say “and part of it is the bias I, as a white provider, have been socialized to hold regarding People of Color.”
In a colleague’s PubMed search regarding racial disparities in health care, over 4,000 articles were found – a majority of which identified provider bias as one of a handful of reasons for racial health care disparities in the U.S. Additionally, the National Health Care Disparities Report of 2011 also names provider bias as one of the key determining factors regarding racial disparities in health care. This report builds on over a decade of knowledge regarding the role of provider bias stemming from the Institute of Medicine’s report “Unequal Treatment”, mandated by Congress in 1999 and published in 2002 which found that provider bias and stereotyping were a significant contributor to racial disparities and that extensive training for providers is needed. This was eleven years ago: racial disparities have not lessened, and providers are still not being trained. The influence of “provider bias” is not exclusive to health care and is widely present in other major sectors of U.S. society such as education, law, government, non-profits and for-profits – areas that I happen to do a lot of racial equity training and consulting in. And while these other sectors of U.S. society can be quite challenging to train in because of resistance, denial, or misinformation, I have found that no sector has been as difficult to even get in the door as the health care system. Mind you, their reticence to be trained has not stopped these providers and their major employers from holding summits and colloquia and conferences on racial disparities in health care. It has not stopped them from saying that racial disparities are a significant problem. It has not stopped them from suggesting that “something must be done”. And yet, in the last two years of trying to gain any traction in providing a race, racism and whiteness (RRW) training specifically designed for health care providers, I have hit wall after wall after wall. Some of it has been the simple fact that I am not an M.D. or an R.N. and therefore “cannot possibly have anything to say” to doctors or nurses. The rest of it, however, is whiteness and the insidious ways it seeks to preserve its hold on the health care system in the United States.
The current and historic white centrality of this overall institution is substantial, and runs deep (see Harriet Washington’s work, Medical Apartheid). I was at a presentation a few months ago where a white, male speaker was quite forthrightly naming RRW and its problematic effects on health care. During the question and answer period, a researcher who has been looking at provider bias for some time stood up and said that if you try to address provider bias through the lens of RRW you might make some people (read, “white” people) defensive and shut down their willingness to learn. Instead, this person suggested that we use terms like “cultural competency” and “diversity” training in order not to alienate anyone (again, read “white” people). It was quite amazing to hear her say this given that she is a well-known researcher in the field. More disconcerting, however, was the fact that “diversity” and “cultural competency” frameworks, while fine in their own right, are awful approaches for racial issues because they are not in any way designed to address race, racism or whiteness. As a result, the solution she offered belies the decades of research she herself has been conducting on racial bias, and in fact would allow the racial dynamics of racism and whiteness in health care to stay safely in tact due to the utilization of a completely ineffective “diversity” approach.
But where does this deeply rooted bias in providers come from? When looking over the arc of a doctor or nurse’s educational career, here is what we know: if they have a standard U.S. P-12 education, they have been woefully mis-educated about issues of race, racism and whiteness. And, if they have gone to most undergrads in the U.S. they have been exposed to very little racial justice content (an examination of most undergraduate general education credits will reveal this). Follow that with a nursing or medical school education where there is virtually no content regarding race, racism and whiteness and add to this a society whose messages are steeped in racial stereotypes and biases, and we get white providers who, through no fault of their own, are likely drowning in bias and preconceived notions about their patients of color. And so, unless a physician or nurse has actively sought out racial justice content either via an undergrad major, a medical school specialty, or through other avenues of professional development, there is no reason to presume that a white provider graduating with an M.D. or R.N. will have any awareness of issues of race, racism and whiteness beyond the standard stereotypes seen in mainstream media.
The answer to this in the short term is professional development for those already in the field. The answer in the long term is intentional and thorough undergrad (pre-med), nursing, and medical school education regarding racial issues and their impacts on health and health care. Both of the above bring me to my earlier point – I have been trying for two years through grant applications, conference presentation proposals, formal and informal meetings with hospital administrators, pitch presentations to groups of providers, and written appeals to health care leaders to get the chance to offer doctors and nurses a deep and comprehensive race, racism and whiteness training firmly grounded in health care and the daily realities of providers. And, as I mentioned, I have hit resistance, obfuscation, and simple silence at almost every turn. This is frustrating for obvious reasons – if provider bias is a key factor in racial disparities, then providers need to be trained. It is problematic for another reason, however, in that training providers is one of the most expeditious and efficacious ways to address racial disparities in health care. While large, structural changes in health care might take years or decades to enact and lead to observable, addressing provider bias can be done effectively and substantially in a much shorter time frame. In a study with a colleague, even a very short RRW training series helped a group of residents make important (and measurable) changes in their practice. Knowing this, it is even more problematic that the barriers to training providers on issues of RRW seem so intractable.
It may be hyperbolic to say in everyday life that “White Liberalism kills”, but it is not too much of a stretch to say it when it comes to health care and the desperate need that some of the most vulnerable people in this society find themselves. For example, hospitals who gage their ER efficacy on whether or not patients return with the same presenting symptoms will often conclude that their ER has done a good job because a patient did not return. However, if that hospital does not take into account that perhaps the patient did not return because they experienced racism and poor treatment, they are likely misreading that data and are quite possibly contributing to the persistence of racial disparities. This unconscious racial bias and its concomitant manifestations of racism and white privilege are clearly harmful to the patient (and whole communities of patients) in that they do not receive the care they need. However, it is also harmful to the entire health care system and the providers within it because it degrades their capacity to truly care for those in need. Perhaps I am being naïve here, but I believe that most if not all of these providers do what they do because they truly and deeply care for the health of their patients. I believe that they take their oaths seriously and know that the care they provide is literally life and death on a daily basis. And, I choose to believe that if they were aware of the ways that unconscious bias was impacting their ability to care for their patients, they would do something about it immediately. That is why I will continue to knock on the doors of health care, that is why I will continue to hold out hope that one will open, and that is why I am sure that at the end of the day providers’ willingness to lean into this difficult and often painful content will not only help their patients but also help them to heal as well.