“No doctor has ever reminded me that I am black before,” the patient said, laughing and nodding his head to let me know he appreciated my advice.
Just as he was startled by my open recognition of his race, so too was I startled by his reaction.
As his physician, I felt the issue I’d raised wasn’t worth ignoring; if anything, I viewed it as the “elephant in the exam room,” desperately begging to be called out: Black patients continue to suffer higher morbidity and mortality from colon cancer, compared to any other racial group, according to a 2016 study published in the Journal of Clinical and Translational Gastroenterology, and that is a fact that warrants discussion in the doctor’s office.
In 2002 the Institute of Medicine, a national consortium of experts, published a 700-page report on racial and ethnic disparities in health care. The group examined more than 100 individual studies and concluded, overwhelmingly, that health disparities exist. While the report emphasized that the reasons behind health status disparities “are complex and poorly understood,” evidence suggests that both socieconomic differences and “direct and indirect consequences of discrimination” are at play.
We are nearly two decades out from the original publication of many of the studies examined by the IOM, yet we are still grappling with stark disparities in both disease outcomes and treatment. And, although “the incidence and mortality rates of colorectal cancer in the United States has steadily declined” over the years, according to the 2016 study, “reductions have been strikingly much slower among African-Americans.”
This fact shouldn’t shock anyone, given the reality that health systems, and health training environments, are poorly equipped to tackle the crisis of disparate treatment and disparate outcomes.
In 2016, the Accreditation Council for Graduate Medical Education conducted a study of physician training programs nationwide and concluded that few programs “appeared to have a formal strategy for addressing health care disparities or a systematic approach to identifying variability in the care provided to … known vulnerable patient populations.”
Furthermore, there is growing evidence published in recent years, highlighting the fact that practitioners’ implicit biases often shape treatment decisions and health outcomes.
Being a young black child with appendicitis, for instance, means you are less likely than a white child to get pain medication in an emergency room. Being a black patient in an intensive care unit means you might not get as much time with your physician as a white patient. And when it comes to colon cancer, physicians are much less likely to even bring up screening modalities with black patients compared to whites.
The data have led me to believe that we, as a scientific community, have done an amazing job highlighting a problem. Truthfully, the problem of health disparities has not only been highlighted, it’s been written in bold font and ALL CAPS.
What we have yet to do, however, is come up with systematic approaches for tackling this issue and supporting our most marginalized patients.
For the patient I brought up earlier, who was sitting in my exam room asking me if he should get a colonoscopy, I knew we had to discuss it.
As a black man, the numbers are not in his favor. By acknowledging race with him, I hoped that whatever implicit bias I might have as a practitioner would become explicit. By bringing race to the forefront, I hoped it would no longer fall to the side.
We have to chisel away at this disparity, and as a primary care physician, I can do so by starting the conversation, one patient at a time.