The Black Lives Matter (BLM) Movement is an international human rights movement campaigning against the violence and systemic racism faced by black people. Alongside exposing racially-driven police brutality and legal injustices, the BLM movement has now firmly pushed examples of racial inequality in medical teaching and practice into the international spotlight. With numerous case studies of diseases that present differently in different ethnic groups being brought to our attention via Instagram posts, Facebook shares and Change.org petitions, many of us feel bewildered as to how we are only finding out about these issues now.
The answer is a relatively simple one: our society has grown comfortable with the idea of using the presentation of disease in white individuals as the de facto standard in medical diagnosis. But BAME communities have not and fuelled by the recent surge in BLM activism, they are now speaking out.
While conducting research for this article, I surveyed 34 individuals who will attend, are attending or have attended various medical schools within the UK. This ethnically-diverse selection of individuals ranged from Year 12 students just submitting their UCAS applications to recently qualified doctors now working on the wards.
80% of the black students I spoke to attributed their awareness of medical racial stereotyping to years of adverse personal experiences when interacting with healthcare professionals. For example, one individual's mother was told by her doctor who had trouble applying a sticker to her skin that it must've been all the "cocoa butter" - this individual's mother neither uses cocoa-butter nor made any indication to it in the consultation. It is in situations like this, and many others, that seemingly light-hearted comments can have a profound daily impact on the BAME community. However, when raising concerns, BAME individuals are often labelled as being defensive and inflammatory instead of listened to. The just another "angry black girl" label reeks of familiarity for many.
In comparison, an overwhelming majority of white students said they had only recently become aware of these problems as direct results of the increased media (and social-media) attention.
These problems are not new; they have become embedded in the foundation of medical practice over many years. The 1985 Report of the Secretary’s Task Force on Black and Minority Health concluded that “Despite the unprecedented explosion of scientific knowledge and the phenomenal capacity of medicine to diagnose, treat and cure disease, Blacks, Hispanics, Native Americans, and those of Asian/Pacific Islander heritage have not benefited fully or equitably from the fruits of science or from systems responsible for translating and using health sciences technology.” (USDHHS, 1985) However, in 1995, 10 years after this report was published, the African American mortality rate remained 60% higher than the white mortality rate, i.e. the same as it had been in 1950. (Williams and Rucker, 2000; Williams, 1999). Indeed, despite concerns about racial and ethnic bias and stereotyping appearing more frequently in medical literature throughout the late 1990s (Smedley, Stith and Nelson, 2003), little has been done to address these issues in practice.
The BLM Movement is changing that.
“People have realised that there is no change unless they speak up.”
“It’s becoming more crucial to shed light on all the inequalities faced by black people. It’s now or never.”
“In lockdown, we’ve all had a lot more time to focus on what really matters. Everything around us has been moving at light speed our whole lives and now that it’s ground to a halt, we are able to understand that the systems that exist are just cages to hold us back.”
“Social media has played a massive role - it has shone a light on injustice. People are having to stop and think about every aspect of life, including medical practice, in which prejudice may be obvious.”
In numerous universities across the UK, the issue of medico-racial disparity is one many students, both those of colour and white alike, feel is one heavily neglected by the medical curriculum.
For example, only 1 of the papers studied on the medical course at the University of Cambridge is directly related to exploring social race-related issues affecting medical practice. SECHI (Social / Ethical Context of Health and Illness) is a relatively short low-content paper that is sat in the 1st year of the degree. While the mere existence of the paper is a positive step forward in understanding biases, the paper itself “inadequately brushes over” the most important issues associated with medical racism. As a direct result, many young Cambridge medics feel they lack the knowledge to confidently approach and address these concerns themselves. Moreover, several students were able to complete the module with the assumption that learning about racial differences was “optional”.
Nevertheless, it is crucial to note the SECHI module is hugely important in introducing medical students to key examples of racial and social inequality. For example, the course highlights research conducted by Goyal et al in 2015 concerning the differences in opioid and non-opioid administration between races. The study, which monitored 1 million children attending A&E departments in the US following appendicitis, showed blacks with moderate pain to be 10% less likely to receive any pain medication than whites. It, additionally, reported that blacks with severe pain were 20% less likely to receive opioids. Another study featuring heavily on the SECHI course revealed that women with Arabic sounding names were a 1/3rd more likely to have a baby with low birth weight after 9/11 (Lauderdale, 2006).
The issue lies in the lack of expansion on these issues. Despite SECHI equipping students with plenty of contextual knowledge, we are taught very little about what we, as future clinicians, should do in practice to address these issues when encountering them in clinical settings. It is not just Cambridge that fails to do this - students at Leicester, UCL, Kings and Manchester reported similar experiences. Many of these students felt they had been "told time and time again to respect patients’ cultures/races/religions and to avoid bias as a doctor but had received very little in the way of dealing with racial issues in the workplace".
A theoretical understanding of the variety of socio-economic situations facing PoCs is undeniably valuable. However, without medical schools placing a practical emphasis on these issues, students entering clinical school or foundation year placements feel increasingly unsure and uncomfortable when treating PoCs. This problem is especially pertinent to those practising in ethnically diverse communities, like London.
The role of social and ethical modules in medical courses is one of paramount importance in our ever-diversifying society. Ergo, these modules should play a more prominent role in medical education. Exploring issues about race, poverty, disability and religion should not be seen as optional but emphasised at the forefront of medical education.
So why is it not?
Section 20d of the GMC’s Tomorrow’s Doctors (a document outlining the outcomes and standards for undergraduate medical education) tells us to “respect all patients, colleagues and others regardless of their age, colour, culture, disability, ethnic or national origin, gender, lifestyle, marital or parental status, race, religion or beliefs, sex, sexual orientation, or social or economic status.”
But what does being respectful, in this context, entail?
The Cambridge English Dictionary defines respect as “the feeling you show when you accept that different customs or cultures are different from your own and behave towards them in a way that would not cause offence.”
The Oxford Advanced Learners Dictionary defines respect as “polite behaviour towards or care for somebody/something that you think is important.”
On the surface, these definitions may seem interchangeable but expressing superficial politeness toward an individual is very distinct from profoundly accepting someone’s culture. The idea of promoting “polite behaviour” rather than appreciation, understanding and acceptance of our differences within medicine may be more harmful than we realise.
Dovidio (2011) describes implicit bias as being unconscious - individuals are often unaware of it. On the other hand, explicit bias is conscious, deliberate and can be self-reported.
With all the professional requirements placed upon doctors to follow GMC advice and not discriminate against patients and colleagues, why is racial bias still evident in medical treatment and practice guidelines today? One must hope the majority of doctors do not deliberately intend to be racist but that many have simply been misguided as a direct result of implicit biases. Indeed, many healthcare professionals are unable to provide all patients with the best possible standard of care despite intending to do so.
Dovidio points out that “even though those in helping professions typically see themselves as unbiased, White physicians display strong implicit preferences for Whites over Blacks.” He then goes on to note that “the distinction between explicit and implicit prejudice may be especially relevant to understanding biases in (1) medical decision-making and clinical communication by physicians and (2) patient perceptions of bias in medical encounters.” (Dovidio, 2012)
Certain circumstances, in medical practice, amplify the adverse effects of implicit biases. These can dramatically increase the likelihood of harming, or even killing, patients of colour. One of the most pertinent is time pressure. A study found that under time pressure, 94% of white patients presenting with chest pain were referred to specialists in comparison to 48% of blacks (Stepanikova, 2012). More notably, this treatment gap didn't exist without time-pressure.
There are many reasons why an individual might express certain implicit biases - it would be woefully wrong to not acknowledge this. These range from the effects of societal shaping to environmental upbringings and family influences. However, for many soon-to-be-doctors, medical school is where the foundations are laid for a career in medical practice. Therefore it is crucial for medical schools to play a proactive role in exposing implicit biases and breaking them down.
Yet, in medical school, we are often taught to recognise many clinical markers for diagnosis based on how they present in white individuals, e.g. the appearance of rashes on white skin. An alarmingly low number of students know how common diseases, e.g. Addison’s Disease (characterised by hyperpigmentation), are expressed in PoCs.
If you Google Addison’s disease, or indeed almost any medical condition affecting the skin, the first images that appear are usually of white individuals. In the case of Addison’s, these images involve hyperpigmented white individuals with now almost olive skin tones.
These images are the same images utilised by textbooks. Yet what many of today's practising doctors don’t know is how this hyperpigmentation would present in patients whose tone of skin was originally olive or darker. Identifiable presentations of Addison's Disease in PoCs, like darkened knuckles and speckled areas of pigmentation with vitiligo patches, are rarely included in textbooks and teaching.
Image Credits: OMICS & Healthline
This is not an isolated case. There are numerous other examples of PoC medical presentations being neglected in medical teaching.
Image Credits: @Brwnskinmatters
There is an overwhelming consensus amongst the surveyed students that this practice is not only unfair but hugely unethical. Many, even those who had graduated, said they felt unprepared and worried by their capability to diagnose and treat PoCs correctly. Others felt angry and ashamed of the “white-washed” British curriculum.
Black medical students themselves noted a “loss in faith that the medical world will ever cater to people of colour.” Likewise, a FY2 doctor feels “saddened and hypocritical as a PoC doctor.” One student told us she believes “universities are teaching us not to prioritise everyone’s health equally.” She, therefore, feels "insecure about entering into the medical profession where [she] will be treating a diverse group of patients, having never explored these things.” Another noted her frustration at feeling she now had a “greater duty and responsibility to be an eccentric driving force as a young black woman.”
“I sometimes feel like I’m entering a profession that isn’t made for me.”
In Cambridge anatomy lectures, students are taught that variation in the human body is normal - only 10% of individuals have the palmaris longus muscle, 10% of individuals are left cardiac dominant and 0.2% of individuals have a horseshoe kidney. Yet, no medical school in the UK presently teaches about the fact that black men have more cortical bone at the midshaft of their radial and tibial bones to allow for greater bending strength. Neither do they teach that black men in the UK have a higher areal bone mineral density than white men (a difference that persists after age, weight and height adjustments). When learning about knee anatomy, they do not inform us that white patients usually have a smaller femoral aspect ratio than east-asians and a larger tibial aspect ratio than black individuals.
When asked how they believe medical teaching should be altered to highlight implicit discrimination and bias in the profession, this is how some students responded:
Include experiences of BAME patients when discussing case studies, Use people of different skin colours when teaching, dispel any myths that students may have about people of colour and highlight the importance of understanding the socio-economic situations that many BAME people are in so that staff and patients can work cooperatively. Change must happen from the top, by encouraging these practices and making them an integrated part of medical teaching. - Student at UCL
Responsibility is on the GMC and directors of the medical schools, not on BME individuals. Teaching should be altered to have mandatory lectures about the implicit bias in the profession and the in health gap in medicine - Student at Cambridge
More examples with different demographics of people, more teaching on how to handle patients with different views (in terms of ethics and morals), more teaching on doctor-patient communication (what not to say and what to say, how to react to comments made) and ensuring that there is 0% tolerance for any form of discrimination- QMUL Medicine Offer Holder
Students should be taught by a wide range of professionals - I know that this is a huge generalisation, but when you think of university lecturers, the stereotype is “old white man” - Cambridge Medicine Offer Holder
An important suggestion in reducing implicit racial discrimination was made by Burgess in 2007: Clinicians should be made to sit implicit bias tests throughout their careers. This would aim to increase self-awareness amongst clinicians about racist behaviours.
While this fundamental issue is far from being resolved any time soon, there are several things everyone can do right now to proactively help make strides in the right direction.
Write and sign open letters to your university's medical school asking to include BAME representation in clinical teaching and combat institutionalised racism
Educate yourself on how different conditions may present in people of different ethnicities, @Brwnskinmatters is a great place to start doing this
Educate yourself on ways you can reduce healthcare discrimination by reading the research and recommendations of socio-medical researchers like Burgess and Dovidio
Listen and learn about the culture and socio-economic conditions of various black communities that might influence medical practice, Why I'm No Longer Talking To White People About Race (Reni Eddo-Lodge), In Our Mad and Furious City (Guy Gunaratne) and Ordinary People (Diana Evans) are good examples of literature to start doing this with
Challenge the usage of white values as the norm the next time you are confronted by a situation doing this. Consider how such situations might transpire differently for PoCs.
Call out any racial discrimination you may encounter and don't ‘let it slide'
Bibliography:
Burgess, D., Van Ryn, M., Dovidio, J. and Saha, S., 2007. Reducing racial bias among health care providers: lessons from social-cognitive psychology. Journal of general internal medicine, 22(6), pp.882-887.
Dictionary.cambridge.org. 2020. RESPECT | Meaning In The Cambridge English Dictionary. [online] Available at: <https://dictionary.cambridge.org/dictionary/english/respect> [Accessed 13 June 2020].
Dovidio, J.F. and Fiske, S.T., 2012. Under the radar: how unexamined biases in decision-making processes in clinical interactions can contribute to health care disparities. American journal of public health, 102(5), pp.945-952.
Goyal, M.K., Kuppermann, N., Cleary, S.D., Teach, S.J. and Chamberlain, J.M., 2015. Racial disparities in pain management of children with appendicitis in emergency departments. JAMA pediatrics, 169(11), pp.996-1002.
Heckler, M (1985). Report of the Secretary's Task Force on Black & Minority Health. Washington, DC: United States Department of Health and Human Services. p1.
Lauderdale, D.S., 2006. Birth outcomes for Arabic-named women in California before and after September 11. Demography, 43(1), pp.185-201.
Oxfordlearnersdictionaries.com. 2020. Respect_1 Noun - Definition, Pictures, Pronunciation And Usage Notes | Oxford Advanced American Dictionary At Oxfordlearnersdictionaries.Com. [online] Available at: <https://www.oxfordlearnersdictionaries.com/definition/american_english/respect_1> [Accessed 13 June 2020].
Smedley, B.D., Stith, A.Y. and Nelson, A.R., 2003. Racial and ethnic disparities in diagnosis and treatment: a review of the evidence and a consideration of causes. In Unequal treatment: Confronting racial and ethnic disparities in health care. National Academies Press (US).
Stepanikova, I., 2012. Racial-ethnic biases, time pressure, and medical decisions. Journal of health and social behavior, 53(3), pp.329-343.
Williams, DR, 1999. Race, Socioeconomic Status, and Health The Added Effects of Racism and Discrimination. Annals of the New York Academy of Sciences, [online] 896(1), pp.173-188. Available at: <https://pubmed.ncbi.nlm.nih.gov/10681897/>.
Williams, DR and Rucker, TD, 2000. Understanding and Addressing Racial Disparities in Health Care. Health Care Financing Review, [online] 21(1), pp.75-90. Available at: <https://pubmed.ncbi.nlm.nih.gov/11481746/>.
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