The critical issue putting doctors' careers and patients' lives at risk

As thousands poured into the streets of American cities, and around the world, to protest police killings of Black citizens this past spring, some physicians took to social media and the opinion pages to confront racism’s role in medicine. Doctors of color and their colleagues pointed out individual instances of racism and bias and larger flaws in the healthcare system.

Nearly 5 months later, the discussion roars on. “We cannot run away from our history,” Uché Blackstock, MD, told attendees at an American Academy of Family Physicians conference in mid-October. “We have to reconcile it. Physicians need to know this history.”

But even as the microscope has focused on racism in medicine and elsewhere, some have questioned whether it’s really as prevalent as purported. Fortunately, medicine relies on science, not politics or hunches, for its insights. Over the years, research has borne out that racism exists in healthcare and does indeed pose challenges for people of color.

Here are some of the ways racism has taken root in US healthcare—and what physicians can do about it.

Effects of racism on physicians

In the month preceding this year’s racial reckoning, the journal Family Medicine published a paper on how physicians of color experienced racism in healthcare settings. The findings, gleaned from surveys of 71 participants, revealed that 23.3% had encountered a patient who declined care due to the doctor’s race or ethnicity. Just under 22% of participants said a patient had refused care, but they didn’t know whether it was because of the physician’s race or ethnicity. A majority reported experiencing racism from patients, peers, or their institution. Such incidents ranged from inappropriate comments to fewer opportunities for climbing the career ladder.

The qualitative portion of the study offers a striking look at how patients treated physicians of color.

Respondents, for instance, reported that patients questioned their credentials and capabilities. “I have had several patients assume my graduate degree was from outside the country and ask extensively about my education, to the point of intrusion,” one physician said.

Sometimes patients’ racism was detrimental to their own health. In one incident, an intubated patient in the intensive care unit refused to allow care from a Black physician because of their skin color, a respondent noted. Another patient refused care “because he thought that I was ‘incompetent’ and that ‘everyone in the hospital does not trust my judgment and they told him that,’” according to another respondent. That physician considered the incident threatening, as the patient “refused to acknowledge my presence and had [a] white supremacy tattoo on his arm.”

However harrowing such patient encounters may be, participants said they were more likely to experience racism from their colleagues, the authors observed. Respondents reported more than 25 microaggressions and assumptions from hospital staff, including a nurse who assumed a physician held a lower position because of their race, as well as instances of “subtle comments” drawing on racial stereotypes.

In some cases, respondents said racism had affected their careers.

“I was treated differently compared to my other non-Black counterparts and overlooked for leadership positions,” a participant said, echoing 22 similar concerns reported in the study. Another reported receiving a salary that was $40,000 less than a comparable colleague. Some participants said racism had negatively impacted their scheduling, expectations, and voice within the organization. When these physicians experienced microaggressions in the workplace, some said their institution failed to respond.

The running theme: being non-white hurts their prospects. “I am systematically excluded from going to lunch or dinner with the ‘good old white boys and girls,’” a participant said. “It is during these after-hours getting-together activities that important decisions are made and connections are established.”

Respondents said they experienced stress, though the data didn’t unearth any causal links between instances of racism and mental health. Participants, however, said these kinds of encounters affected their well-being. “These experiences have many times made me depressed, where I’ve had to seek a therapist, and have made my morale at work low,” a respondent said. Others described feeling “worn out,” while a single participant said “benign comments of ignorance” no longer bother them because they were so common.

“Our results indicate that physicians of color often face racism and discrimination in the workplace,” the authors wrote, “and this represents an occupational hazard that has the potential to negatively impact their career advancement and sense of well-being.”

Harvard Medical School has also acknowledged discrimination faced by physicians of color. In a blog post, an author noted that her colleague “has been questioned, insulted, and even attacked by patients, because she is a Muslim woman who wears a headscarf.” The author said this isn’t an isolated incident, as Black, Indian, and Jewish physicians have faced similar acts of bigotry.

Healthcare’s racism problem isn’t uniquely American. In 2014, a report on well-being among clinicians in the United Kingdom’s National Health Service found that the organization is a prime model of a bad example. “[F]ar from being an exemplar for staff wellbeing, the NHS helps to illuminate the impact and consequences of lower well-being, as well as specific drivers for differences in well-being between different ethnic groups.” 

Unconscious racial biases can affect who gets to practice medicine (via medical school admissions committees) and which specialties they pursue (due, in part, to residents of color experiencing social isolation, discrimination and daily microaggressions, and the burden of becoming a racial “ambassador”), according to a literature review published last year in The Journal of Infectious Diseases.

How racism harms patients

Bias in medical care—conscious or unconscious—puts patients’ lives at risk.

Consider the findings of a 2019 literature review on racism and its relationship with health, published in the Annual Review of Public Health. The authors gathered key insights related to structural, cultural, and individual racism and how they affect patient health. Broadly, the review found higher rates of disease and death among marginalized racial groups, differences in health after researchers adjusted for socioeconomic status, and a drop in health for Hispanic people who immigrate to the United States.

Other findings included:

• Residential segregation (ie, white-only neighborhoods, Black-only neighborhoods) is associated with poorer health, from more stillbirths, especially among Black patients, to delayed breast and lung cancer diagnoses for Black patients.

• Racism by individual clinicians leads to inferior care for patients of color, who undergo fewer medical procedures and receive lower-quality care.

• Perceived racial discrimination is linked to mental health symptoms, psychiatric disorders, and preclinical indicators of disease, such as inflammation and coronary artery calcification among marginalized racial groups.

“This body of research illustrates the myriad ways in which the larger social environment can get under the skin to drive health and inequities in health,” the researchers concluded, calling for additional research geared toward better understanding and curbing racism’s health effects.

Each day spent waiting for the results of that research represents risks for the next generation. Throughout the years, studies have linked racism to poor maternal health and infant mortality as well as health disparities and mental health conditions in children and adolescents, including prolonged exposure to stress hormones like cortisol and the related predisposition to chronic disease. 

Even so, researchers have had some understanding of how racism affects health for decades. In 2000, for example, a literature review found that institutional and individual discrimination merged with “the geographic maldistribution of medical resources, racial differences in patient preferences, pathophysiology, economic status, insurance coverage [and] trust, knowledge, and familiarity with medical procedures” to contribute to racial health disparities. 

Racism, meanwhile, has been linked to certain patients delaying or skipping medical care altogether. In one study of 1,756 older patients of color, participants were 3.92 times more likely to forgo or postpone care when they believed they were experiencing racism. When physicians communicated poorly, patients were 3.18 times more likely to perceive racism.

What can doctors do about racism?

While health systems and leaders of all kinds implement structural changes and include more people of color in decision-making roles, the writers of a recent New England Journal of Medicine editorial suggest physicians take the matter into their own hands in each patient encounter.

“It is time to reimagine the medical interaction and the doctor-patient relationship, recommitting ourselves to the quiet work of doctoring and building trust with individual patients,” they wrote.

“We can become more conscious of our biases when we care for minority patients and push ourselves to go the extra mile,” they added. “Even if we can’t change the social determinants of health for any individual patient in any given encounter, we can think more seriously about how they affect what the patient can and can’t do, tailor the patient’s care accordingly, and show that we’re invested.”

The key is to acknowledge the problem. Physicians must “recognize, name, and understand” racist beliefs and actions, and they must be willing to confront their own biases,” according to the author of the Harvard Health Blog. Instead of permitting or perpetuating bigotry, doctors can “practice and model tolerance, respect, open-mindedness, and peace for each other.” From there, it’s critical to educate others.

Healthcare’s fight against racism may ultimately depend on institutional change, but individual physicians can work toward building a culture of dignity and respect in their workplace. “To that end,” the blog author wrote, “the call to action to address racism and discrimination in medicine is for all of us, providers and patients.”