So let’s get one thing out of the way: I am no expert on anything related to the African American experience. I am not even well read on the history of race relations in the United States. I am a white male. The closest I am to “ethnic” is sometimes people mistake my name as having Argentinian roots instead of Italian. When I was in medical school, almost from day one, patients would assume I was the guy in charge. Someone told me my first day on the wards that I looked “young for someone who has accrued so much knowledge.” In the hospital and frankly in most areas of life, my race offers me the advantage of being perceived as someone to be trusted rather than questioned.
My white straight male privilege has blazed me a path of least resistance in life and I am acutely aware of that fact. So given that, maybe I am not the right guy to write this article. However, I believe this is not the time in our history to stay silent on the sidelines. So if my words accidentally come off as “whitesplaining” the ills of our society, I apologize. I promise my intent is in earnest.
Over the course of my career, I have had a lot of absolutely stellar African American colleagues. Some were my professors and mentors during school and residency, some were my co-residents and fellows, some were my students, and some are my current colleagues. Over the years, I’ve noticed a not-so-secret phenomenon: black patients would interact with my black physician colleagues differently than they would interact with me.
Now of course you see this across all ethnicities- a Korean may be more comfortable with a Korean doctor, a Persian with a Persian- but in those cases the preferences are likely established by a cultural commonality. With African Americans, I suspect a singular patient-doctor bond manifests, uniquely rooted in a common struggle. Simply put, only another black person can really understand the experience of constantly being subjected to the ills of systemic racism in America. I understand no matter how empathic I try to be, how woke, I will never really truly understand how it feels to be the victim of structural racism. I have never personally felt meaningful discrimination because of my race either overt or otherwise, and my black patients know that too. Let’s not pretend it is any other way.
It is no secret that a portion of our society rightfully mistrusts the American medical establishment. There has been a long history of neglect and abuse of the African American community. The syphilis experiment in Tuskegee Alabama from 1932-1972 is the most prominent example. A group of poor African Americans were told they were getting free health care from the government. The real purpose was to observe the natural history of untreated syphilis. When penicillin was shown to be a cure, they didn’t offer it. They just let people go blind, go deaf, suffer neurological complications, develop heart disease and eventually die. This study lasted 40 years. It happened. These were white men treating black men. I wouldn’t trust me either.
Today African American men have the lowest life expectancy of all demographic groups. Now this disparity is a result of a lot of complex interconnected causes, including less access to health insurance, lower socioeconomic status, and the negative health ramifications of structural racism in our society. Black men simply don’t go to the doctor as much and thus have higher levels of untreated hypertension, diabetes, and undiagnosed cancers.
I read a study a while ago that I thought was so profoundly important, it should in some ways fundamentally alter the way we choose who to train as doctors.
It was a simple study in Oakland California. (“Does Diversity Matter for Heath? Experimental evidence from Oakland. National Bureau of Economic Research; June 2018) They randomized 1300 black men to see black or non-black doctors in a meeting discussing preventative care. They asked them what sort of preventative screening or tests (off a list) they would like get before they met their doctors. Then they met with their doctor (either black or non-black) and next recorded what tests they agreed to undergo after that meeting. It turned out if the subject met with a black doctor they were 18% more likely to get the preventative screening and invasive tests than were the men who met with a non-black doctor. It was well controlled for confounding variables. The doctors were not told the purpose of the study.
Now this is one small study, but think about what it may mean. When black doctors treated black men, the patients were 18% more likely to undergo preventative action and tests. One calculation claims this increase in preventative testing could drop the black-white gap in cardiovascular mortality by 19%. That is insane.
We must ask how could this happen? Maybe a black patient is more likely to trust a doctor of his own race? He might then agree to undergo more tests and invasive screenings. Or, could it be that a black doctor might put in more effort in trying to convince a black patient to get these tests than may a doctor of another race? Whatever it is, it appears that somehow the doctor/patient communication is better, leading to starkly better results.
Another recent study shows more evidence that concordance (being the same race) between the physician and the patient can have a very unexpected and dramatic impact on health. In the August 2020 Proceedings of the National Academy of Sciences, researchers examined data on hospital births in Florida from 1992 to 2015. They found that when they had white doctors, black newborns experienced 430 more deaths per 100,000 births than white newborns. But when cared for by a black physician, the excess deaths dropped to 173 per 100,000 above that of white newborns. In other words, when the black baby had a black doctor, although still more likely to die than his white baby counterpart, he was half as likely to die if his doctor was black. Survival rates of the babies were no different across different races of the doctor if the baby was white.
How are those results possible? It almost seems like these damning results must be a statistical fluke. But more likely, such results seem so inconceivable to me precisely because I am white. Let’s be honest, I am blind to the true impact underlying structural racism, even as I write about it here. Intellectually, I know it exists, but I don’t personally experience the emotional impact of its existence. So when I read that black babies are dying more often if they had a white doctor than black doctor, my first instinct is to analyze the study and looks for errors in methodology or analysis. There is a good chance my African American colleague is instead saying, “Oh yeah, structural racism at work again.”
We must accept that there is something fundamentally wrong in our medical system with the disparity of care across races and start to consider that the limited diversity of doctors could be part of the problem.
African Americans now makeup 13% of the US population, but only comprise 4% of physicians. That is simply unacceptable. The lack of black doctors is literally killing patients in America. A first obvious step toward improvement is to aggressively promote the diversity of medical school applicants and attendees.
Now when we talk about our attempts to increase diversity in any organization, we often easily get confused about why we are doing it. I can’t tell you how many times I have heard the same argument against affirmative action. It goes something like this: “why shouldn’t a poor white kid who comes from a disadvantaged background get special consideration for admission to schools as does a kid from a particular racial minority? They both overcame obstacles during their younger days, right?” Yes, the black kid struggled, but so did whitey. Shouldn’t he get the chance to go to Harvard too? If you don’t really take the time to think about it, that argument makes perfect sense. Affirmative action is trying to level the playing field for admission to schools or access to jobs for those who began life with a disadvantage, right?
This “disadvantaged kid argument” completely misses the point- especially in medicine (but probably in everything). Affirmative action is not needed for the individual, but is rather needed for society. We don’t need to recruit more black people to become doctors so that they can have the personal individual joy of becoming a physician. Honestly, we don’t really give a damn about their professional aspirations. We need to train more black doctors so they can utilize their unique racial background to improve the treatment of our diverse society.
When talking only about race, it may not even matter if an applicant comes from the upper class and attended the best prep school in the nation. A well off African American is not immune from the embedded racism of our society, and can very likely better understand how structural racism can affect his patient’s health.
Will every African American physician take on the fight against embedded structural racism of the healthcare system? Of course they will not. But if you don’t think that just seeing more black doctors walk around a hospital can change our stereotyped image of what a doctor is supposed to look like, you are naive. How many black doctors have been mistaken as the janitor or a low level technologist? I can tell you almost every single one I know. That is a fundamental problem.
We must also seriously reassess who we are admitting into medical school. Let’s remember in medical school, when we talk about diversifying a class we are not talking about rejecting a Rhodes scholar to be replaced by an illiterate idiot. You do not need to be a genius to be a doctor. We weed out applicants by selecting for those who are able to study and massively collate large amounts of information. Training to be a doctor is more about resilience than intelligence. I can tell you with absolute fact that many of my colleagues are not exactly winning any MacArthur genius fellowships anytime soon. We can look beyond test scores.
We select for a certain type of person- a good student. And being a good student doesn’t always make you a good doctor. We can imagine otherwise, but convincing folks to take their anti-hypertensives, control their diabetes, and eat healthy, can have far more profound effects on our society than cutting edge complex medical research and treatment. Most of time we just need to get simple treatments to actually happen. I mean its not like medicine is brain surgery. (well most of it isn’t… except brain surgery).
I could be the best doctor in the world, but when it comes to gaining the trust of my black patients, I have no doubt there is a good chance one of my black colleagues can do a better job. In the intensive care unit, I’m so sure of this fact, I’ve even had some of my African American residents act as the primary communicator with some black families during difficult discussions, such as a need to withdraw care. There is a real chance that families who don’t know me, are more likely to distrust me precisely because I am white. I get it. I may have more knowledge and skill than my resident, but despite my best efforts it is sometimes much harder for me to gain the same level of trust and communication. And honestly a lot of what “real world” doctoring is, is more about gaining patient trust and facilitating communication, than about knowledge and skill.
I’m not saying we want to completely ignore college academic success, but undergraduate pre-medical training has become such a weeding out process that only selects for a very particular skill set- the skill to study. The ability to effectively learn is very useful for medical school, but we are very likely missing others who may excel in other contexts while also being able to do the academic work just fine. This academic rabbit race we all enter to get into medical school ends up excluding so many diverse students who either don’t want to run it, or don’t think they can.
As we are having a national conversation about the racism that exists in our police force, we need to confront the structural and historical biases that infect our medical system. White men like me need more education, more perspective, and more understanding. I’m here, as a white guy, as a guy who has always been invited to the party, saying we have to show that black lives actually matter by actively advocating for the conscious diversifying our physician workforce. I certainly understand that structural racism cannot be solved by me alone, but in reality it also cannot be solved without people like me.
People like me, the recipients of a lifetime of racial privilege can no longer sit on the sidelines and root for diversity within medicine to magically evolve. We need to act, and the time is now.