An incredibly interesting read which delineates the negative impact racism has on healthcare delivery and patient outcomes, particularly for people living in the United States. I loved how this book went beyond the mainstream discourse of access and affordability to instead focus on the concept of “unconscious racism” or implicit bias, an important but often neglected factor in the suboptimal health of minority patients. Matthew believes implicit bias to be the most important determinant of health and argues that our failure to effectively respond to it is injust and morally untenable. She brings forward an innovative plan to try to reduce these implicit biases, and frames her argument using not only her own expertise in civil rights and constitutional law, but also using thoroughly researched evidence from existing social science literature and additional data generated from her own interviews with physicians, nurses, and patients.
“Providers discriminate against patients and patients discriminate against providers. This cycle of discrimination produces inequality throughout the health care system. The inequality itself is not news. But the fact that it is avoidable challenges the complacency that allows their racial and ethnic discrimination that produces them to persist.”
– Dayna Bowen Matthew
I really appreciated how well the entire book was laid out – it was very clear to follow and transitioned perfectly from first explaining how implicit bias plays a role before, during, and after clinical contact, to then providing some interventions and policy changes to disrupt these racial/ethnic biases. The author emphasizes how the main problem is not that majority of physicians are racists, but rather, they are simply unaware of their implicit biases (“attitudes, preferences, and beliefs about social groups that operate outside of human awareness or control”) which ultimately drive clinical decisions and result in worse health outcomes for patients of colour. She believes that the disparity in healthcare for minorities caused by implicit biases are present in not only physicians but also their patients. To explain how this works in greater detail, she developed the “Biased Care Model” and majority of the book focuses on describing the six mechanisms of this model:
| 1. Physician’s Biased Perception of Patients 2. Physician’s Biased Statistical Interpretations 3. Physician’s Biased Conduct and Communication 4. Patient’s Biased Conduct and Communication 5. Physician’s Disparate Diagnostic and Treatment Decision-making 6. Patient’s Biased Post-Clinical Decisions |
One part which really stood out to me was when Matthew talked about how the country’s focus has always been on achieving equal access to healthcare, but not on achieving equal healthcare quality for all Americans. As someone who has personally had experience conducting research in the health services sector, I’ve often considered access to care to outweigh the importance of quality in the sense that “any care is better than no care at all”. However, after reading this book I really took the time to reflect on why truly equitable care requires more than just making it accessible; access cannot change the disparate health outcomes minority patients face if the care that they are provided with is rooted in discrimination. And so, if we don’t actually tackle this problem of inferior medical treatment due to unconscious racism, then injustices will continue to persistent even if care is equally available to all. To solve this problem, Matthew ultimately recommends enacting legal changes, particularly reforming specific sections of the Civil Rights Act of 1964.
The only downside to this book was that it was quite heavy with American legal jargon (sadly the only law knowledge I have comes from a singular healthcare law course I had taken over 3 years ago, so most of this went right over my head). I would love to see a similar book that discusses the same concepts in a Canadian context!
KEY TAKEAWAYS:
- Implicit biases have drastic effects on shaping the clinical encounter. Research using the Implicit Association Test (IAT) demonstrates that most physicians possess some level of implicit bias toward people of colour. This bias occurs due to the stored clinical and social knowledge of a patient’s group; it is automatic, unconscious and occurs without intention. How close a physician sits, listens to their patient, answers questions, and offers relevant detailed information is all impacted by the prior biases physicians bring into the room before even interacting with their patient. This in turn affects the referrals and diagnoses they make, medications they prescribe, and treatment/test recommendations, leading to racially/ethnically disparate health outcomes.
- In order to reform discriminatory healthcare, both interventional and structural solutions are needed. Even though implicit bias stems from social knowledge and learning that is slowly acquired over time, these associations are not static and can be changed. This can be done through an on-going process in which we learn how to inhibit expression of these biases after they are formed and revise our attitudes and beliefs based on new encounters and informational inputs. Matthew proposes several interventions which have been tested for their efficacy in reducing implicit biases, including ‘stereotype negation training’, ‘promoting counter stereotypes’, and ‘social and self-motivation.’ She also argues that in addition to implementing interventions, enacting evidence-based legal remedies is critical to help reframe social norms about justice, fairness and quality in healthcare. She proposes making unconscious racism illegal and permitting litigation of civil rights claims against entities that allow physician implicit bias.
- As researchers, we need to do a lot more. Matthew talks about how the methodologies scientists employ, and even the questions they pose in their research, are often designed to simply illuminate the problem, but not necessarily correct it. She emphasizes how research alone cannot drive the contextual changes or alter the most fundamental factors needed to address unconscious discrimination in healthcare. While research is necessary, it is not sufficient to implement the social changes needed to eradicate unconscious racism. She also discusses the limitations of research due to the way disparate treatment and health outcomes are measured – we tend to only focus on collecting data on socioeconomic status, patient preferences and clinical metrics, rather than race or ethnicity as predictors of health disparities.
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