By Lucy Berrington, MS, Vital Signs editor
Illustration by Chris Twichell
This is an extended version of a story that appeared in the print edition of Vital Signs.
To what extent is the medical profession a meritocracy? In the context of the #metoo movement against sexual harassment, with its spillover scrutiny of bias and discrimination in general, medicine has not escaped criticism. Researchers continue to measure and substantiate the ways that medical careers are less accessible to minorities and women than to white men, even as the profession emphasizes the importance of a diverse workforce in delivering culturally competent care and reducing health disparities. Professional guidelines and leadership addressing this issue are scarce.
Vital Signs talked with physicians about discriminatory incidents and workplace dynamics, and how to address them. Biases in the medical workplace — in patients, peers, administrators, or instructors — may not be easily visible to colleagues. “Unconscious bias is when people think what they do is normal because everyone does it. I want to help people understand this exists,” says Sharon Marable, MD, MPH, FACP, vice-chair of the MMS Committee on Diversity in Medicine. Ron Dunlap, MD, past president of the MMS, says, “Discrimination is still significant. Most colleagues are unaware of it and don’t see it as a problem.”
Physicians’ Unconscious Bias
Bigotry in the workplace appears to be becoming less overt. More commonly, physicians describe the everyday unconscious or implicit biases that underlie more obvious cumulative effects of discrimination, such as pay gaps and promotion gaps.
Researchers have established the presence of physicians’ pro-white bias (except in black physicians, who exhibit far less racial bias) and explored how it may contribute to differential clinical decision making and health outcomes. Physicians of color report that the same biases in colleagues impact their training and careers, even though diversity in medical schools is associated with improved outcomes for the profession and patients.
The perspectives and insights of minority students, which have broad educational value, can themselves be isolating. “If I hear things said about patients that are not appropriate — stereotypes relating to ethnicity without a clear understanding of the historical context of our minority patients — it’s hard to always be the person who’s calling it out. You can be seen as combative and it gets tiring,” says Margee Louisias, MD, MPH, an associate physician at Brigham and Women’s Hospital and instructor at Harvard Medical School.
Dr. Marable’s experiences of marginalization go back to medical school in the 1980s. “I didn’t understand it then, but I understand it now. I was invisible. Initially I thought maybe I was not speaking up enough; then I realized over time that my mixed-gender team of white colleagues did not even want to interact with me. When you’re the only racial/ethnic minority, medical colleagues will make negative assumptions about your intelligence, what you know; they have to somehow discredit you.”
Racial Disparities in Medicine
In December, a Spotlight investigation by the Boston Globe pointed to the scarcity of black physicians as a factor in the racial segregation of health care in Boston. Boston is not an outlier. In 2015, the New England Journal of Medicine reported that only 2.9 percent of faculty members at US medical schools were black.
In a 2000 study, black physicians reported that their biggest stressors were racism on the job, others’ doubt in their abilities, and the need to prove themselves (Journal of the National Medical Association, 2000). “When you walk into a room on any given day, you have to decide ‘Am I up for this, for breaking the ice, establishing my credibility again?’” says Dr. Dunlap. “The average white male doesn’t realize what it’s like to walk into a room of people with high qualifications, with which you certainly compare, and have to be subject to that. There’s still a level of surveillance and doubt regarding qualifying one’s self that is extraordinary.”
Such experiences may amplify the risk of burnout. “If you didn’t have resilience, that strength and character, internal confidence that you didn’t have to necessarily depend on others to reinforce for you, I think there’d be no way to continue in medicine,” says Vincent C. Smith, MD, MPH, a neonatologist at Beth Israel Deaconess Medical Center. Clinicians experiencing bias may “choose” less competitive career paths, says Dr. Dunlap. “In many cases, candidates (residents, fellows, and junior staff) lower their goals and don’t pursue a career in academic medicine, because the track record for promoting minorities is still quite poor at most medical schools.”
Gender and Sexuality Biases
Even as women physicians have become established in medicine, they remain marginalized in measureable ways — on values as obviously significant as pay gaps to as granular as how speakers are introduced at academic lectures (male physicians as “Doctor” and women physicians by their first names, according to the Journal of Women’s Health, 2017). Last year, a working paper by a Harvard PhD candidate showed that gender played a major role in physicians’ referrals to surgeons after a patient death (physicians reduced their referrals to women surgeons, while sustaining their referrals to male surgeons in the same circumstances).
Several physicians described to Vital Signs the challenges of addressing bias in the workplace. “Recently the medical director and I had a difference of opinion,” says a member of MMS who asked not to be identified. “I was assertive in the meeting and spoke my mind. He said, ‘You’re being aggressive!’ I’m so used to being stereotyped I don’t even get angry any more. I said, ‘Are you aware that when you call me aggressive, you’re perpetuating a stereotype of women in the workplace?’ He didn’t respond. It was clear to me he did not truly understand what he was saying — like a little kid using a curse word without knowing the implication — because he’s so used to thinking it. I wish he could have focused on what I said instead of just labelling me. I went to the leadership and suggested a training workshop. I got no response from them, either.” (The barriers facing women in medicine were explored in the September 2017 issue of Vital Signs).
Similarly, lesbian, gay, bisexual, and transgender medical professionals experience ongoing (if lessening) discrimination at work. “There’s definitely been an improvement over the last two decades, but there’s still a whole lot of narratives about bad experiences,” says Carl Streed, MD, a fellow in internal medicine at Brigham and Women’s Hospital and chair of the MMS Committee on LGBT Matters.
A study that Dr. Streed co-authored last year explored the stressors facing LGBT health care professionals: “10% reported that they were denied referrals from heterosexual colleagues, 15% had been harassed by a colleague, 22% had been socially ostracized, 65% had heard derogatory comments about LGBT individuals, 34% had witnessed discriminatory care of an LGBT patient, 36% had witnessed disrespect toward an LGBT patient's partner, and 27% had witnessed discriminatory treatment of an LGBT coworker. Few had received any formal education on LGBT issues in medical school or residency” (Journal of Homosexuality).
Institutional Barriers
People of certain demographics face specific, practical barriers to practicing medicine. In a recent New York Times editorial, Cheri Blauwet, MD, a physical medicine and rehabilitation specialist at Brigham and Women’s Hospital, wrote, “Few people with disabilities are admitted to medical school: Medical students with disabilities also have higher attrition rates than nondisabled students.” Most medical schools do not meet the ADA standard of accommodations for students with disabilities, according to a 2016 analysis in Academic Medicine.
Bias also amplifies when ethnicity is a factor, says Lauren Meade, MD, FACP, a primary care physician at Baystate Medical Center who works closely with international medical graduate residents. “We have many Muslim doctors — more than half our community hospitals, nationally, are supported by internationally born graduates — and many Muslims pray five times a day. If the hospital culture doesn’t condone or support it, you have to disappear and pray in closets or bathrooms, and you’re not there for important stakeholder opportunities.”
Bias from Patients
Physicians of color and women physicians commonly report negative judgments from patients. In a survey of more than 800 physicians, more than half (59 percent) had experienced derogatory comments, usually related to their youth, gender, race, or ethnicity; 47 percent had experienced a patient requesting a different doctor (survey by WebMD, Medscape, and STAT, 2017). A survey of 255 Muslim physicians in the US found that one in four reported frequent religious discrimination (AJOB Empirical Bioethics, 2015).
That discomfort is also readily apparent to international medical students and graduates. “I had never lived in the US before I went to medical school,” says Aurian Garcia-Gonzalez, a MD/PhD candidate at UMass Medical School and chapter president of the Latino Medical Student Association. “I came from a place in Puerto Rico where there was no need to discuss diversity; it was a heterogeneous population. I never thought of myself as a minority or diverse until I came here and had this new stamp on my forehead everywhere I went. In the US, I had to encounter these discussions that had this uncomfortable and negative tone.”
For physicians of color, it is not unusual when clinical interactions with patients start with an uncomfortable discussion of the physicians’ racial and ethnic origins. “It doesn’t take them long at all to know I’m some sort of foreigner and not a primary English speaker. There is a value judgment about my ability to provide care,” says Garcia-Gonzalez. “There are questions explicitly about trying to understand my origins, a discussion that has to happen before I can effectively manage their care, though to me that is irrelevant: Where did you grow up? Are you a US citizen?”
The significance of those inquiries is not lost on
physicians. “It’s more what
is not said, what that might reveal about implicit bias regarding our
skills: ‘Where were you trained? Are you a real doctor?’” says Elisa Choi, MD,
FACP, an internist and infectious disease and HIV specialist, governor-elect
of the MA Chapter of the American College of Physicians, and commissioner of
the Commonwealth of Massachusetts Asian American Commission. “We
are subject to racial profiling or bias that should have no place in our
physician-patient relationships. The questions being asked of us —'Where
are you from?’ or ‘What are you?’ — imply we are an outsider, that we do not
belong in this country or in the medical profession. International medical
graduates face much more of this discrimination if they have an accent or
English is not their first language.” (Dr. Choi spoke to Vital Signs about her own views; these opinions do not necessarily
reflect those of any organizations with which she is affiliated.)
The political climate can make prejudice more visible in everyday encounters. “Right now, it’s particularly bad. A lot of people are saying things that they had been feeling all along. Our current environment has given them license to not hold back,” says Dr. Smith. “It does weigh you down after a while. All you want to do is just work and not have to deal with this.”
Lack of Professional Guidelines
Leadership around this issue is vital, said Leon McDougle, MD, MPH, chief diversity officer of the Ohio State University Wexner Medical Center, to AAMC News last year: “How senior residents and faculty address these types of issues can really make a big impact.”
But in the absence of training and policies on how to handle bias and discrimination, physician leaders are mostly left to figure this out on their own. “When patients say they don’t want to be treated by a brown-skinned doctor, or don’t want a doctor who wears hijab, there’s a high impact in terms of physicians’ isolation,” says Dr. Meade. “Most doctors do not report that, and most leaders don’t know what to do when it happens.”
Physicians: “How to Address Bias in Medicine”
