‘We don’t get treated the same’: Implicit racial bias is another barrier to quality health care

Latisha Littles recently dropped her primary care physician. The decision was long in coming.

Littles, who is 49 years old and Black, suffers from lupus and end-stage kidney disease. She said her former doctor, who was white, treated her differently from her white patients, not just because of her race but because she is on Medicaid. The difference was at times subtle, other times blatant.

“I felt my doctor dropped the ball on me a lot,” said the Middletown resident. “She made me feel I wasn’t important enough because of my situation. I felt that when I called her, she would drag her feet. She wouldn’t call me right away. I would have to call the office two or three times to just get a call from her.”

The breaking point for Littles came when she asked her doctor for a referral for a specialist. Littles said she had to ask repeatedly over the course of three months. In the end, she asked at least six times.

“I knew it was not right and it was never going to be right,” Littles said. “I couldn’t put my finger on it but it was time to go.”

Her experience is far from unique.

Studies have long shown that people of color face disparities in access to health care, the quality of care they receive and health outcomes. The COVID-19 pandemic — with Black people four times more likely to die of COVID-19 than white people — has focused more attention on those disparities.

Increasingly, though, Black patients are bringing attention to what they say is a major factor in the quality of health care they can access: implicit bias from a predominantly white community of medical professionals.

“In my 40 years in practice when I’ve had to refer a patient to special care they so often come back to me and say they don’t want to go back just because of the way they were treated,” said Dr. Gwendolyn Poles, a retired physician who is Black. “It’s a long-standing issue. It’s not new but it’s new to the consciousness of the community.”

In 2015, the American Journal of Public Health published a study that found that in the U.S. people of color face disparities in access to health care and the quality of the health care received. The study found that most health care providers appear to have implicit bias — positive attitudes toward caucasians and negative attitudes toward people of color.

For two decades now, the National Healthcare Disparities Report has found that white patients received better quality of care than Black Americans, Hispanic, American Indian, and Asian patients. And a study published in 2020 in the New England Journal of Medicine found that algorithms used by physicians to make health care decision in areas ranging from cardiology to obstetrics are imbued with implicit racism that their designers were unaware of, but which often result in inferior health care for Black people.

Poles, who has helped shape policy for the Pennsylvania Medical Society to address disparities in health care, said the bias on the part of medical professionals often is implicit — stemming from attitudes outside their conscious awareness. Other times, though, she said, the bias is explicit, and driven by a doctor’s conscious volition.

“I don’t like saying that but I say it because I’ve had such a lifelong experience in terms of my own personal experience but also that of patients I served,” said Poles, a retired UPMC internist. “Regardless of the diagnosis and the way they were treated, some of the things people have said to patients and my own experience leads me to say it’s explicit.”

For Poles, a routine medical appointment underscored those experiences.

A sickle cell patient, Poles knows she is a “difficult stick” when it comes to drawing blood. An encounter at a blood lab not long ago ended with the technician, who was white, calling security on her simply, Poles said, because she was put off by the fact that Poles asserted her knowledge about her veins.

“To make a long story short, for whatever reason, she felt threatened,” Poles said. “She got on the phone and called security. To me that was explicit bias. That wasn’t implicit. They may not use the N- word. They may not say I don’t want to treat you because you are Black, but their actions are so egregious. It’s very prevalent.”

Poles filed a report with the laboratory, and was told the technician underwent on-the-job training.

Health disparities are routinely framed against social and economic determinants that affect access to quality health care for Black people. Experts often point to the lack of healthcare insurance as an obstacle to health care access for many Black patients, and certainly to quality health care.

Littles knows that first hand.

She said she has often been left feeling uncomfortable about the way she’s treated by doctors or their staffs, and has even, at times, been denied service because she is on public insurance. Littles’ most recent encounter with her former doctor left her feeling disrespected. She said her doctor simply did not extend to her the same warm engagement that she did to white patients.

“We don’t get treated the same,” Littles said. “People think that when people like myself are on public assistance insurance or disability, they think we are lazy or we don’t want to work. They kind of shun us. It’s that stigma that African Americans don’t want to work or they are trying to take the easy way out to beat the system and to get something from people.”

Medical professionals cite lower reimbursement rates and a high administrative burden as reasons to refuse Medicaid patients. That leads to reduced access to care, according to various studies.

But comprehensive healthcare insurance doesn’t guarantee a doctor won’t have an implicit bias.

Gloria Martin Roberts, a retired public health professional, has a litany of personal experiences that affirm that view.

“It’s not pretty. It makes people uncomfortable but it’s real,” said Martin Roberts, who spent eight years on the Harrisburg City Council, four of them as president, and is a former CEO of the Hamilton Health Center. “Not only have I worked in the medical field and have my own personal experience, but I have insurance and good insurance, but I still have gone to providers who made me feel I was not a priority. Actually they made me feel they could care less if I was there or not.”

Martin Roberts said she remains appalled at the treatment her late husband received in hospital prior to his death last year from heart disease.

“It was a terrible experience,” she said. “He kept saying, ‘the doctor doesn’t care about me. He won’t listen to me. He is dismissive.’”

In a field driven by science and data, however, it’s sometimes difficult to substantiate something as ephemeral as a gut feeling. And that is usually what it boils down to.

“People of color feel very dismissed, judged and even denied basic health care because of the color of their skin,” Martin Roberts said. “It’s not something we make up or something we are saying. It’s racism. It’s not something we are trying to assign without being warranted.”

Beyond the relationship a medical professional has with a patient, many Black patients say that implicit racial bias has a profound impact on health outcomes and health decisions.

Not only does it affect the decision-making process, Poles said, but, as studies show, patients of color under the treatment of a white clinician tend to have significantly different course of treatment than their white counterparts. Sometimes the treatment is too aggressive; other times subpar.

“When you are talking about vascular disease, when someone should have a good investigation, the difference between folks of color and white folks and especially white males is like night and day,” Poles said.

Phyllis Hicks, executive director of the Kidney Foundation of Central Pa., said no more tangible a measure of the intersection of implicit and explicit bias in medical care in this country exists than the long-standing practice of evaluating clinical lab test results for kidney patients based on race.

For decades, kidney patients who were Black were evaluated on a different scale, often resulting in far less aggressive treatment and life-saving transplants. Decades old, the diagnostic equation was based on now recognized flawed biological variables based on race and fueled by racist constructs.

“How many people have been wait-listed for a transplant or not put on dialysis because their physicians have been using a flawed decision-making process?” said Hicks, who is Black. “I can only imagine the thousands of people that have been relegated to this flawed science. The unfortunate part of this is that this is not opinion. This is not me talking about the social determinants of health or perception. It’s talking about facts and numbers. What influences health care decisions and determines whether and when patients get care.”

A national task force in September recommended the immediate implementation of a new diagnostic equation for measuring kidney function that does not factor in a patient’s race.

Hicks said the new standard will promote health equity and increase access to kidney transplants for Black patients.

Less tangible barriers to health care for Blacks, unfortunately, she said, remain in place.

“When a patient feels discriminated against because of race, ethnicity, economics or gender, the important thing is to give that person a voice,” Hicks said. “I don’t get to tell people ‘it’s in your head. He’s a good doctor. She’s a good doctor.’”

But patients say situations can sometimes be uncomfortable.

“Patients don’t want to ask,” Hicks said. “Doctors have power over you. The power of life and death. People don’t feel comfortable doing it. What if the doctor doesn’t want to see them anymore? What if they don’t want them to ask questions?”

Advocates say that one solution is to nurture more medical professionals of color. Indeed, a report last year out of PennMedicine found that patients had better favorable experiences when their doctor shared their racial or ethnic background.

But Poles worries that the negative experiences that young Blacks have in the educational system and the medical system keep many from pursuing careers in medicine.

Despite efforts to diversify recruiting by medical schools, for example, the number of Black men entering medical schools has remained stagnant for nearly 40 years. In 1978, 1,410 black men applied to U.S. medical schools. In 2014, that number was 1,337, according to the Association of American Medical Colleges.

“You can’t wait until college,” Poles said. “These kids, their dreams have been crushed since elementary school.”

Martin Roberts notes that ultimately patients have recourse. They can file complaints or report a medical professional to the appropriate medical health system or entity.

Many people, she said, don’t do so simply because they do not know how to navigate the medical system.

“There’s always a recourse but remember how we are taught in this country,” Martin Roberts said. “Poor people, disenfranchised people, people of color, they are taught that what the doctor says they have to accept. So they either stop going or continue to go and take the abuse and offense and there’s nothing healthy about that.”

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