Combating Racism and Placeism in Medicine
the medical profession
may be doing harm to patients and
communities
many years ago as a first year medical
student i took an oath
like thousands of physicians before me
and thousands of physicians after me
that i would first do no harm to the
patients
and the communities that i serve and
since then i have committed my career
for taking care of patients and
underserved communities
just like this one on the near east side
of columbus ohio
but over time i’ve seen that the medical
profession has broken that social
contract
with the communities that we serve
because of racism
and placism now this is going to be best
illustrated if i walk you through the
lives of two of my dear friends
so first let me tell you who they are
many years ago
as a young aspiring physician new to
practice i started my career off in
connecticut
where i had the good fortune of meeting
two wonderful women
who’d become lifelong friends and
honestly like family
and it is through their lenses that i
will walk you through the impact of
racism and placism in medicine
so first i want you to meet wendy
wendy’s a black woman
i met wendy as a middle-aged mother
hard-working woman working so hard to
provide for her kids
through my relationship with wendy i’ve
learned so much about tenacity
grit and honesty i also want you to meet
sarah
sarah’s a white woman i also met her as
a middle-aged woman
a mother hard-working did so much to
provide for her family as well
and through my friendship with sarah
i’ve learned so much about allyship
and loyalty now when i met wendy and
sarah
they lived about six miles apart in
central connecticut
sarah and the wealthier suburbs outside
of west hartford
and wendy in the inner city outside of
east hartford
although they only live six miles apart
their potential interactions with the
healthcare system could not have been
any more different
because of racism and placism
so let’s talk about what those mean and
what those look like in medicine
racism and medicine means that wendy as
a black woman
would be much less likely to have
positive interactions with the health
care system
much less likely to be taken seriously
by doctors and much less likely to have
state of the art healthcare wherever she
lived
because in medical school we are taught
that black patients have a higher
threshold for pain
if wendy came to my office with
presenting with pain
as a black woman she would be
significantly less likely to have that
pain addressed
similarly if wendy as a black woman
presented to the emergency department
with crushing chest pain
she would be 50 less likely to receive
any life-saving intervention
for a heart attack now in medicine and
in nursing we’re often taught to
discount and discredit
the symptoms of black women so if wendy
as a black woman
went through her pregnancy she would be
three to four times as likely to die in
that pregnancy or in the childbirth
than sarah would as a white woman
similarly if wendy gave birth
to a baby she would be twice as likely
to bury
her baby before the age of one than
sarah would as a white woman
and if wendy gave birth to a black baby
and that baby was taken care of by a
white physician
that baby would have an increased risk
of dying in that first year
racism and medicine also means that
although wendy as a black woman would be
much less likely to be diagnosed
with breast cancer or colon cancer if
she were diagnosed
she would be diagnosed with much more
advanced disease
later stage disease and have a 50
percent higher mortality than sarah as a
white woman
and so it’s not really the phenotype of
race it’s the structures of racism
that would lead wendy to toxic
accumulation of stress
that would lead her to earlier heart
disease than sarah so racism is taking
its toll
in medicine now the other issue
is placism and by placism i mean the
ignorance of
a person’s place where they live their
zip code on their health
we know that 80 of a person’s health
status is determined
by social determinants of health not
their interaction with me as their
doctor
the conditions where they live work play
school
housing economic security
jobs safety violence but chances are
your doctor has looked at you and made a
decision on how they will care for you
based on your race
but they have never paid attention to
your place
or your zip code so this is this shows
up in significant health disparities in
life expectancy
if you look at the state of ohio in
green you’ll see
the wealthier parts of the state people
have a life expectancy
into their late 80s almost into their
90s
not too far from some of these same
places in red you see that people have a
life
expectancy in their 60s so there can be
a 29 year difference
in your life expectancy based on where
you live
now if we zoom in on where i am right
now in central ohio
the life expectancy challenges are the
same you can see places that are not
that far away
have over 27 years of a difference in
life expectancy between the poor and the
wealthier
zip codes where i’m standing right now
on the near east side of columbus ohio
a mile away in a wealthier suburb of
bexley
people are expected to live 18 years
longer than the people in the community
that i’m standing in
chances are no matter where you are in
the united states these same health
disparities exist
these same problems based on your place
exist
so back to wendy and sarah when i met
wendy and sarah
they lived about six miles apart
but that meant that sarah was expected
to live to the age of 84.
and wendy to the age of 68 a 16-year
difference based on six miles
so you may wonder what if we just moved
wendy over to where sarah lived
would that change unfortunately because
racism would follow her wendy’s life
expectancy would not change
it would be as if wendy lived in the
same place
for her whole life and that is because
racism is the father of placism
places him as the derivative of racism
structural housing discrimination
redlining and many other structural
factors have led to the reasons why
people in certain communities
have lower life expectancies so how then
can i have
lifelong friendships with wendy and
sarah i want us all to live and have our
relationships until we’re in our 80s
this is where i believe that we can make
a difference through changes in
education
and leveraging technology so with
education
we need to dismantle and deconstruct
racist oppressive prejudicial biased
education that we provide to medical
students nursing students and other
health professions students
the same mythology and stereotypes that
were used to justify slavery
are still used in medicine today we need
to dismantle and deconstruct
that sort of education and instead
replace it with anti-racist
anti-oppressive scientifically focused
stereotype free
and informed care that allows us to give
equitable care to our patients
but what do we do then if we change the
educational system we know educational
reform takes a long time
what do we do about the thousands and
thousands of physicians
physicians like me who are not going
back to school anytime soon
but they have been unfortunately
indoctrinated with these awful
stereotypes and beliefs about their
patients
this is where i believe the second
solution can help us technology can help
us be anti-racist
and anti-places so what might this look
like
chances are if you go to a doctor’s
office they are using an electronic
medical record where they’re collecting
so much information about you
and i believe that we can use clinical
decision algorithms
that will allow us to be anti-racist and
anti-places at the point of taking care
of you
because most doctors have looked at your
race but they have not asked about your
place
so what would this look like in real
life let’s say a patient molly came to
my office
and in the course of care which is
customary my medical assistant before i
see her would collect her height her
weight
her blood pressure and ask her about her
pain on a scale of zero to ten
with zero being little pain and ten
being her worst pain
what if molly said she had a seven out
of ten pain but as often happens to
black patients i didn’t pay attention to
it what if the technology could call
that pain to my attention
and stop me before i could do anything
else in that electronic health record
and say
studies tell us that black women are
much less likely to have their pain
addressed are you sure you do not want
to address molly’s pain
i could say yes i’m sure i do not want
to address her pain
i want to be racist or i could go back
and i could do something different
similarly if i was not managing her high
blood pressure
with the top of the line agents we know
that black patients often get the third
of the fourth line agent for their
hypertension
what if the technology stopped me here
too and forced me to be anti-racist
and reminded me that african-american
patients are much less likely to get
prescribed first-sign agents
are you sure you do not want to change
molly’s medication i could say yes
i’m sure i want to continue to be racist
or i could go back and do something
different
same thing could apply to colon cancer
screening if i did not screen my patient
as often happens
to black patients the system could ask
me it could force that into my
consciousness
it could force me to do no harm
what can we do about placism so chances
are we have not paid attention to your
zip code nor would we know what to do
with it if we saw it
so what if we use community mapping
tools and a lot of the geospatial
imaging that we have to tell us about
social determinants of health
not only your risk based on your zip
code but also what to do about it
what if the technology called out my
patient’s zip code and told me that she
lived in this zip code where she’s
likely to die early
from heart disease will you discuss
heart health and disease prevention with
your patient
i could say no i want to continue to be
places or i could go back
and do something different i believe we
can do this
i believe we can turn the tide and renew
that contract with medicine
but it’s going to take patients
institutions and doctors to all play
their part
so patience be empowered to ask more
from your doctors
you have a right to full health ask us
to address your pain
ask us what screenings you should be
having based on your age or your gender
ask us if we were really on the first
line medications for your condition
but institutions you also have a role
you need to retrain
your doctors your nurses your health
professionals deconstruct and
reconstruct that educational model that
you have
teach your physicians your nurses your
health professionals to see patients as
whole people
teach them to be humble culturally
empathetic
and to see their patients as their own
and finally
doctors my peers my colleagues
we took an oath we promised our patients
and our society that we would take care
of them that we would do no harm honor
your oath
and give patients the love and the care
that they need
and together we can give life love
hope and healing to the communities that
we serve
and together we can do no harm
thank you