Dr. Augustus A. White is Professor of Medical Education and Orthopedic Surgery at Harvard Medical School, and the author, with David Chanoff, of Seeing Patients: Unconscious Bias in Health Care. After growing up in the Jim Crow-era South, Dr. White went on to become the first African American graduate of Stanford University’s medical school, and later the first African American department chief at Harvard’s teaching hospitals. Seeing Patients draws on both original research and Dr. White’s own experiences to examine how care is affected by the unconscious prejudice of providers. You can listen to a podcast interview with Dr. White here. Below, Dr. White responds to a few questions about his book and health care disparities.
Q: Much has changed in terms of access to health care for different groups of people since you began your career in medicine. What are some things that haven’t?
I think that while there may be diminishment of conscious bias on the part of caregivers and the healthcare system, unconscious bias may still persist. But when I started my career, healthcare was largely segregated in the United States, and, especially in the South, patients would go to their private physicians (that is, Caucasian physicians) either on a special day, or through the back door, and sit in separate waiting areas. That is, segregation accompanying the discrimination. That separation is essentially nonexistent at this point, and I would presume that some of the unconscious bias may have diminished as well, but clearly there remains unfortunately substantial conscious and unconscious bias, experienced not just by people of different races, but many other differences are operative. That is, essentially 13 groups of people currently still receive disparate treatment -- African Americans; Native Americans; Asian Americans; Latinos; prisoners; the Appalachian poor; disabled individuals; immigrants; certain religious groups; gay, lesbian, bisexual, transgendered people; obese people; elderly people; and women.
Q: Can you give some common examples of the manifestations of the “unconscious biases in health care” that you describe in Seeing Patients?
I can give any number of examples, though I cannot always know which are unconscious and which are conscious, because clearly both mechanisms are operative. African Americans receive lower rates of cardiac surgeries, fewer hip and knee replacement surgeries, fewer kidney and liver transplants. African Americans receive more open surgeries, rather than less dangerous laparoscopic procedures. Diabetic Blacks are more often amputated than diabetic Whites. Women (not just minority women) with osteoarthritis of the knee are less likely to receive total joint replacements than men. Women with heart disease receive less angioplasty than men. Women with heart attacks are almost twice as likely to die as men. It even takes more time for emergency services to transport women with heart attacks to hospitals. Hispanics receive less pain medication during cancer treatment and during childbirth. Elderly people are not being treated with the degree of attention, consideration, and dignity that younger patients are given. Gays, lesbians, bisexuals, and transgendered people are prone to high rates of suicide, alcoholism, and tobacco use. Homosexual women have less health issues related to their sexuality. However, in contrast, male homosexuals and bisexuals are at a special risk for a variety of serious and sometimes fatal ailments that often go unnoticed in primary care examinations.
These are some examples. Some of them are occurring at a subconscious level while others to varying degrees are occurring at a conscious level.
Q: What kinds of research did you conduct for the book?
I relied on my own experience of about 40 years in the field of medicine, and on the literature, largely the Institute of Medicine Report. I conducted interviews with other caregivers, exploring and inviting their perspective and their experience, some of them being minority caregivers, some being women, one is an openly gay individual, surgeons and non-surgeons, as well as medical educators. I also reviewed books and individual publications by psychologists and psychiatrists and others who are involved in medical education.
Q: How do you think the health care profession could best address these biases and their effects?
Education, education, education! It requires a lot of attention. It requires a re-orientation of thinking in terms of knowing how to effectively use interpreters, how to effectively use knowledge of other cultures other than mainstream Euro-centric American culture, and how to use that in a way that benefits the patient without stereotyping the patient. Studying and evaluating one’s own biases in terms of understanding where our prejudices and stereotyping tendencies lie. This is another way to use education to offset disparities. First of all, to make caregivers, nurses, doctors and others aware of the fact that these disparities exist, and give them some understanding as to why they exist. We should use administrative and financial resources to adjust the environment so that patients can feel more welcomed and can be educated as to how best to work within the system to get the excellent care that they deserve.
Q: From your perspective as someone who works toward and writes about equal access to quality medical care, can you offer some thoughts on last year’s major health care reform bill?
Certainly, access is a key issue to health care disparities. Access, itself, has nothing to do with biases of the caregiver but rather has to do with the system that the health care of the nation is being managed under. So, one important aspect of the health care reform bill is to make more people have access to the system, in part by getting rid of some of the abusive practices of some of the insurance companies. The more people who have access to some form of payment for care, the more the overall health of the nation will improve.
Health care reform should include educational endeavors, as previously mentioned. It is important that the educational elements include training in the use of interpreters, and that there be resources to provide interpreters in situations where language barriers exist. And it should be recognized that equitable care, good quality care for all, has to do with the overall quality of the health care system. So quality care equals lack of disparity among other things. The health care should be equitable and accessible.
One of the major things in the health care reform bill is to upgrade one of the units of the National Institutes of Health. Under the bill, the National Center for Minority Health and Health Care Disparities is upgraded from a Center to an Institute to address health care disparities. An Institute has more resources, more clout if you will, more influence, more of an opportunity to positively impact other Institutes within NIH. This is a very helpful advance to address a very difficult challenge.