Introduction
Racial bias in healthcare is a harmful and widespread issue that leads to mistrust between doctors and patients, particularly among marginalized communities. It not only affects the quality of care that patients receive but erodes the foundation of the doctor-patient relationship, which relies on trust, communication, and mutual respect. Racial bias in healthcare is rooted in historical and systemic factors, and it has significant consequences for patient outcomes, healthcare access, and health disparities. A predominant way in which racial bias manifests itself in healthcare is through implicit bias, or unconscious attitudes and beliefs that affect decisions and behavior. Biases in healthcare can impact a doctor’s decision-making, treatment recommendations, and communication style, which has the potential to lead to unequal treatment based on race. The relationship between the doctor and the patient is a fragile one, and when regarding health, can have severe implications.
Implicit Bias
Implicit bias refers to the unconscious attitudes and stereotypes, often held towards people of color and racial minority groups. These biases shape the healthcare experience for many patients. Implicit biases, which result from widespread systematic forms of discrimination (Sabin 2022), such as racism or sexism, have numerous implications in the healthcare setting. Sabin reports that physician review studies have found that implicit racial bias results in increased diagnostic uncertainty, more negative clinical interactions, and inadequate provider communication for Black patients. These aspects combined with racial stereotypes diminish the strength of the doctor-patient relationship, as patients of color may not feel able to fully trust their provider or the care they are receiving.
In her oral history, Kesha Neely speaks about the considerable stereotyping and stigmatization that occurs in the predominantly black area of Fayetteville, North Carolina. She says that in addition to the prevalence of drug use and prostitution in that area, much of the stigma comes from the large population of people of color. This stereotyping is seen throughout Fayetteville, with the social and cultural environment shaping the biases and prejudices of the people who live there. Neely’s description of the divide that exists between the people of Fayetteville ties back to the distrust between doctors and patients. Patients who witness the stigmatization of the area in which they live are more likely to be distrustful of their provider and have concerns regarding stigmatization or bias towards them. If patients do not feel comfortable enough with or have faith in their healthcare provider, they are less likely to express their medical issues and concerns, and may even stop visiting altogether. Even perceived bias could have detrimental effects on patient care that align with effects of a physician with actual implicit bias. To strengthen trust and ensure a secure relationship, providers should aim to build strong communication with their patients and address any bias or stereotyping concerns.
Health Disparities and Access to Healthcare
Racial bias may lead providers to make assumptions about their patients based on race or ethnicity, rather than symptoms. As Damon Tweedy mentions in his book, Black Man in a White Coat, many diseases have higher prevalence in African Americans patients compared to white patients. However, simply the fact that a higher percentage of Black people develop hypertension compared to white people (Lackland) should not prevent a provider from thoroughly exploring all diagnostic options. Other systemic barriers contribute to the unequal medical treatment between white patients and patients of color; “physician flight” refers to the relocation of physicians and other medical professionals to practices in more “affluent neighborhoods” (Yearby 2018). This departure of medical professionals from predominantly black or low income communities leaves its residents struggling to find continual or specialized medical care. The aforementioned lack of trust on the side of the patient can impede open communication and lead to an incorrect or delayed diagnosis. Additionally, the doctors that people of color are able to see long term could have more negative outcomes as a result of provider linked racial bias and burnout (Dyrbye 2019). Ultimately, there are a variety of factors that make it more difficult for people of color to receive regular, quality healthcare that result from both organized racial barriers and the breakdown of trust between doctor and patient.
Historical Sources of Mistrust
As previously mentioned, the effect of racial bias on trust is especially poignant in communities that have a history of discrimination and medical mistreatment, many which continue to face these issues. Further on in her oral history, Kesha Neely describes the history of the largely black area of Fayetteville known as “the Murch.” Neely says that:
“most people would say a ghetto. But I think that there is a lot that could be done with the area. I just think people don’t want to because of, you know, because of where it is … I think when people are able to do what they can with whatever resources they have, it’s just where it is … And I also think that when you’ve been set back for so long, you want to get ahead, but it goes back to maybe Fayetteville being segregated, and so this is where those people lived, and so it becomes a generational thing.” (0:32:43.5 – 0:34:10.3)
Historical segregation and slavery still have substantial geographic implications. Carol Fields addresses regional differences in healthcare and racism between Los Angeles, CA and Clinton, NC, stating that in Clinton “Black people have no power” (00:20:00 – 00:22:00). Medical studies done on slaves without anesthesia due to the belief that they could not feel pain or experiments with complete lack of informed consent like the Tuskegee Syphilis Study serve as reminders of suffering and mistreatment for people of color. While this history may seem distant to some and “rarely visible to those that are privileged by it”, its effects still have monumental effects on healthcare and other aspects of society (Elias and Paradies 2021).
In conclusion…
the systematic factors of racism and racial bias have countless effects on healthcare and medicine. These negative impacts culminate into the breakdown of trust between patients and their doctors. Societal attitudes must shift to eliminate bias in healthcare and rebuild the trust in minority patients.
References
Dyrbye L, Herrin J, West CP, et al. “Association of Racial Bias With Burnout Among Resident Physicians.” JAMA Network Open. 2019;2(7):e197457.
Elias, Amanuel, and Yin Paradies. “The Costs of Institutional Racism and its Ethical Implications for Healthcare.” Journal of Bioethical Inquiry vol. 18,1 (2021): 45-58.
Fields, Carol. Interview with Shelby Smith. 12 August 2019 (Y-0097). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Lackland, Daniel T. “Racial differences in hypertension: implications for high blood pressure management.” The American Journal of the Medical Sciences vol. 348,2 (2014): 135-8.
Neely, Kesha. Interview with Madelaine Katz. 10 July 2019 (Y-0117). Southern Oral History Program Collection (#4007), Southern Historical Collection, Wilson Library, University of North Carolina at Chapel Hill.
Sabin, Janice A. “Tackling Implicit Bias in Health Care.” The New England Journal of Medicine vol. 387,2 (2022): 105-107. doi:10.1056/NEJMp2201180
Tweedy, Damon. Black Man in a White Coat: A Doctor’s Reflections On Race and Medicine. First Picador paperback edition. New York, N.Y., Picador, 2016.
Yearby, R. (2018), “Racial Disparities in Health Status and Access to Healthcare: The Continuation of Inequality in the United States Due to Structural Racism.” Am J Econ Sociol, 77: 1113-1152.