# data[].attributes.body
At some point, we all need to visit a doctor. For many people, going to the doctor may be a stressful or scary experience, but for others, they may actually fear for their lives in certain medical situations, simply because they are Black. In her book Medical Apartheid, author Harriet Washington outlines 'black iatrophobia,' which she defines as "the fear of medicine present in the black community as a result of a long history of involuntary, unethical and non-therapeutic treatment by medical professionals and institutions." This does not just stem from an unsubstantiated fear- the US government, among other individuals, have done countless dangerous experiments formerly on slaves and, even more recently, on Black citizens. These experiments include forced sterilization, un-anesthetized surgical procedures, and dangerous treatments. So, what happens when the medical institutions, who are supposed to help you, were built against you?

This exhibition explores the specifics of how racism and discrimination are baked into America's medical system and the treatment of Black patients. The webpage explores three topics in-depth: racism in medical education and the training of future healthcare professionals, racism in diagnostic tests and algorithms, and medical racism in current events such as the COVID-19 pandemic and Black Lives Matter.

Racism in Medical Education and Medical Training
This section demonstrates the importance of examining the medical curriculum and of promoting fair and equitable training for all healthcare professionals. According to the Association of American Medical Colleges (AAMC), in 2019, only 5% of active physicians identified Black. With it being so difficult for Black patients to find Black doctors, who may be able to better understand their trepidations, it is even more imperative to train all doctors to treat patients equitably and without propagating racist stereotypes. It is also important to explore options of diversifying the medical field.

Racism in Diagnostic Tests and Algorithms
No matter how well we train our doctors, there is evidence that the actual medicine and 'mathematical' formulas used to diagnose or determine treatment plans for patients are skewed against Black patients. This section outlines the various ways this manifests in medical practices, as well as steps that are being taken against these practices.

Current Events: COVID-19 Pandemic & Black Lives Matter
The COVID-19 Pandemic is the gravest medical emergency of our lifetimes and systemic racism and discrimination are proving to be integral in Black individuals' higher risk of contracting and dying of SARS-CoV-2. Additionally, the resurgence of the Black Lives Matter movement in June 2020 has reignited the importance of medical professionals and medical institutions diving deeper into their contributions to racism and inequity.

Conclusion
The extensive effects of systemic racism greatly complicate the discourse surrounding the second-class care Black patients receive in healthcare, yet there are specific and tangible changes that can be made to improve patient care and patient health. Black patients do not deserve to be unfairly and incorrectly treated. Medical Racism is a malignancy embedded deep into the medical body, and we must do everything in our power to diminish it.

# data[].attributes.headline
"The US medical system is still haunted by slavery"

# data[].attributes.subject
"The US medical system is still haunted by slavery"

# data[].attributes.body
From Vox, published December 7, 2017

This video provides necessary context and background information on medical racism, racist experiments, and the role that slavery played in the creation of stereotypes and the ability for white physicians to leverage control over Black patients. From this source, one can easily trace the remnants and strongholds of racism in practically all fields of contemporary medicine.

# data[].attributes.attachment_link.title
The US medical system is still haunted by slavery

# data[].attributes.headline
"Diagnosing and Treating Systemic Racism" - NEJM Response to the 2020 Black Lives Matter Protests 

# data[].attributes.subject
"Diagnosing and Treating Systemic Racism" - NEJM Response to the 2020 Black Lives Matter Protests 

# data[].attributes.body
From the New England Journal of Medicine published November 18, 2020

This incredibly moving response is important coming from the NEJM, which is the world's leading medical journal. The authors acknowledge and speak on the role of systemic racism, slavery, social justice, COVID-19, and police brutality affect the medical profession and treatment of Black patients.

For physicians, the words “I can’t breathe” are a primal cry for help. As many physicians have left their comfort zones to care for patients with Covid-19–associated respiratory failure, the role of the medical profession in addressing this life defining need has rarely been clearer. But as George Floyd’s repeated cry of “I can’t breathe” while he was being murdered by a Minneapolis police officer has resounded through the country, the physician’s role has seemed less clear. Police brutality against black people, and the systemic racism of which it is but one lethal manifestation is a festering public health crisis. Can the medical profession use the tools in its armamentarium to address this deep-rooted disease?

# data[].attributes.headline
"Black doctors want to vet vaccine process, worried about mistrust from years of medical racism"

# data[].attributes.subject
"Black doctors want to vet vaccine process, worried about mistrust from years of medical racism"

# data[].attributes.body
Article written by Meryl Kornfield published by The Washington Post on September 26, 2020

With the race to test and distribute a COVID-19 vaccine, Black doctors have expressed fear and trepidation concerning the process. Combined with the political influences that have become intertwined with the vaccine, medical racism lends itself to a sense of mistrust in medicine. A panel of Black doctors will vet the process to help assuage fears in minority communities.

# data[].attributes.attachment_link.readable_text
Jeremiah Young, 11, receives one of a series of vaccinations during his back-to-school physical exam with Dr. Janice Bacon, Aug. 14, 2020, while at the Community Health Care Center on the Tougaloo College campus in Tougaloo, Miss. A Black primary care physician practicing in Mississippi for nearly four decades, Bacon works at an all-African American-run trio of community health centers in Hinds County, where the population is overwhelmingly Black - and where the most coronavirus cases have been reported in the state. (AP Photo/Rogelio V. Solis)

Please Note

The Washington Post is providing this important information about the coronavirus for free. For more free coverage of the coronavirus pandemic, sign up for our Coronavirus Updates newsletter where all stories are free to read.

When Black physician Tina Carroll-Scott started working at South Miami Children's Clinic, she said none of her Black patients would consider getting a flu shot.

A complicated history with forced vaccinations and experiments had undercut trust of medical procedures and immunization within Black communities. For more than a decade, Carroll-Scott, the clinic's medical director, toiled to build a relationship with those in the diverse South Florida neighborhood, where the majority of residents are Hispanic and nearly 14 percent Black and African American, according to U.S. Census data.

"After being at the clinic for 13 years and educating patients about the flu vaccine and dispelling any myths they had about it," Carroll-Scott said, "I've now gotten my patients to a point where they talk to me, and they're willing to take it."

But now, as the Food and Drug Administration and Centers for Disease Control and Prevention repeatedly assure the public that the vaccine for the novel coronavirus will be safe, indications that the review process may be undercut by politics has turned off people in minority communities to getting the vaccine when it becomes available - worrying physicians that communities disproportionately devastated by the covid-19 pandemic are most at risk of being left out of immunization efforts.

To assuage fears within minority communities, a panel of Black doctors will vet the federal review of companies' vaccines, said Leon McDougle, president of the National Medical Association, the largest and oldest group of Black physicians in the country.

"We have concerns," McDougle told MSNBC Thursday about the vaccine's review process. "There's been a cloud of political influence dating back to hydroxychloroquine ... following that, convalescent plasma," he said, referring to the various treatment options promoted by President Trump and other government officials. "We want to be that nonpartisan, independent voice, speaking to the African American community and our physicians of the National Medical Association."

When asked what would happen if the panel does not approve a vaccine vetted by the FDA, McDougle said that Black doctors are trusted within their communities and if they don't believe in the safety and efficacy of the vaccine, "it's not going to move forward."

McDougle told NPR that he spoke to members of Operation Warp Speed, the project working on a vaccine for the virus, to make the trial data on it publicly available.

Anti-vaccination leaders fuel black mistrust of medical establishment as covid-19 kills people of color

The FDA referred The Washington Post to its past statements about the review process when asked about the panel, including testimony by Commissioner Stephen Hahn on Wednesday that its investigations into coronavirus vaccine candidates would be thorough.

"I want to assure you and emphasize every one of the decisions we have reached has been made by career FDA scientists based on science and data, not politics," Hahn said. Hours later, Trump hinted in his news briefing that he may not sign off on stricter review guidelines recommended by the FDA, calling the change "a political move more than anything else."

The National Medical Association is not the only group vetting the oversight of vaccines, as New York will also conduct a review, Gov. Andrew M. Cuomo (D) announced Thursday.

Additional checks by outside organizations can further the scientific process, according to Richard J. Baron, the president and CEO of the American Board of Internal Medicine, which is based in Philadelphia. Baron said any disagreements between the NMA and New York on the one side and the FDA and CDC on the other should raise concerns about the federal agencies.

"I would not lay the blame at the feet of the organizations that are trying to maintain a scientific approach," he said in an interview. "I would lay it down at the feet of the federal organizations that are chartered to oversee a scientific approach and don't seem to be demonstrating a public commitment to that."

Polls show Americans have increasingly expressed concern about a vaccine that is available within the year. Three-quarters of U.S. adults surveyed by Pew Research Center in September said it is at least somewhat likely that a coronavirus vaccine will be approved before it's fully known whether it is safe and effective.

The trust of a first-generation covid-19 vaccine is significantly less among Black Americans compared to White or Hispanic people: Less than 30 percent of Black people said they would be willing to take the vaccine, as opposed to 51 percent of White and 56 percent of Hispanic people, an Axios-Ipsos survey in August found. The gap waned when those surveyed were asked about getting a flu shot.

Suma Vupputuri, an epidemiologist and research scientist for Kaiser Permanente, who studied the rates of flu vaccination across races, said oversight over the safety of a vaccine may be a more effective way to recruit Black patients and garnering trust than a blind effort to disseminate a vaccine in Black communities that is not safe.

Coronavirus kills far more Hispanic and Black children than White youths, CDC study finds

"You almost go the other direction if you're trying to push a vaccine that may not be safe at a Black community, and if something does go wrong, and there are ill effects, then all of a sudden, all those good intentions went exactly in the opposite direction," Vupputuri told The Washington Post.

More Black voices are needed in science, argued Kevin M. Ileka in the Harvard Business Review, citing a recent racist suggestion by two French scientists that trials to determine the effectiveness of a tuberculosis vaccine against the coronavirus should take place in Africa.

Ileka, an analytical chemist at pharmaceutical company Bristol Myers Squibb, compared the proposal's apathy to Black lives to the infamous Tuskegee Syphilis Study, where doctors beginning in the 1930s left hundreds of Black men untreated with syphilis for four decades to evaluate how the disease ravaged their body even after penicillin was developed.

A trial for coronavirus vaccine researchers: Making sure black and Hispanic communities are included in studies

In South Miami, Carroll-Scott informally surveyed her own patients about their likelihood of getting a coronavirus vaccine and found "a lot of the patients were concerned about the speed."

"Overwhelmingly the answer was no. I would say that that was the consensus. I don't think I had one patient who said that they would be willing to take this vaccine," she said.

Trump's rhetoric calling for the speedy arrival of a vaccine has concerned patients, Carroll-Scott said, as some worry that Trump's priority is "reelection rather than a safe and effective vaccine."

"I think just the name, 'Operation Warp Speed,' invokes a lot of fear and suspicion," Carroll-Scott said of the name given to the White House's efforts to scale up vaccination. "The education is paramount, and, unfortunately, this whole conversation with the vaccine and the pandemic, there's a sense of urgency, and I feel like we are behind the 8-Ball in terms of educating the community."

Carroll-Scott said she welcomes the news of the NMA panel because the oversight may help to assure those most at risk of the virus's life-threatening symptoms.

"We are the trusted messengers in these communities," she said of Black doctors. "And so if we're questioning things and not fully confident in this process, there's no way that we're going to be able to get our patients on board."

Updated October 14, 2020

Coronavirus: What you need to read

The Washington Post is providing some coronavirus coverage free, including:
The latest: Live updates on coronavirus
Coronavirus maps: Cases and deaths in the U.S. | Cases and deaths worldwide
Newsletter: Sign up for What Day Is It?, our new 7-day email series that will help you recover your sense of time during the pandemic
What you need to know: Vaccine tracker | Coronavirus etiquette | Summertime activities & coronavirus | Hand sanitizer recall | Your life at home | Personal finance guide | Make your own fabric mask | Follow all of our coronavirus coverage and sign up for our free newsletter.

How to help: Your community | Seniors | Restaurants | Keep at-risk people in mind

Have you been hospitalized for covid-19? Tell us whether you've gotten a bill.
Show More Show Less

# data[].attributes.attachment_link.title
Black doctors want to vet vaccine process, worried about mistrust from years of medical racism

# data[].attributes.attachment_link.description
Please Note The Washington Post is providing this important information about the coronavirus for free. For more free coverage of the coronavirus pandemic, sign up for our Coronavirus Updates newsletter where all stories are free to read. When Black physician Tina Carroll-Scott started working at South Miami Children's Clinic, she said none of her Black patients would consider getting a flu shot.

# data[].attributes.headline
"Dermatology Has a Problem with Skin Color" 

# data[].attributes.subject
"Dermatology Has a Problem with Skin Color" 

# data[].attributes.body
written by Roni Caryn Rabin, published by The New York Times on August 30, 2020

This fascinating article deeply articulates the problems in the dermatology field with diagnosing skin conditions on Black patients. Because many students do not learn how skin conditions present on skin darker than white, many cannot diagnose or recognize these conditions. Dermatology is incredibly important, as it can often serve as the first signs of a larger, more serious problem inside the body.

"Black patients are generally less likely than whites to see a dermatologist and less likely to undergo screening for skin cancer. Even when they do see a dermatologist, studies have shown, Black patients are less likely to get certain treatments than white people with the same conditions, like oral antibiotics for acne."

# data[].attributes.attachment_link.readable_text
Dr. Jenna Lester, director of the skin of color program at University of California, San Francisco. "If you're only trained to look at something in one color, you won't recognize it in another color," she said. Credit... Sarahbeth Maney for The New York Times

Common conditions often manifest differently on dark skin. Yet physicians are trained mostly to diagnose them on white skin.

Dr. Jenna Lester, director of the skin of color program at University of California, San Francisco. "If you're only trained to look at something in one color, you won't recognize it in another color," she said. Credit... Sarahbeth Maney for The New York Times

In the spring, teenagers started showing up at doctors' offices in droves with angry red and purple blisters on their fingers and toes. The latest unexpected feature of the coronavirus infection fascinated the public, and suddenly photographs of so-called Covid toes were everywhere on social media.

But almost all of the images depicted glossy pink lesions on white skin. Though people of color have been affected disproportionately by the pandemic, pictures of Covid toes on dark skin were curiously hard to find.

The problem isn't unique to Covid toes or to social media. Dermatology, the medical specialty devoted to treating diseases of the skin, has a problem with brown and black skin. Though progress has been made in recent years, most textbooks that serve as road maps for diagnosing skin disorders often don't include images of skin conditions as they appear on people of color.

That's a glaring omission that can lead to misdiagnoses and unnecessary suffering, because many key characteristics of skin disorders - like red patches and purple blotches - may appear differently on people with different complexions, experts say.

"Pattern recognition is central to dermatology, and a lot of the pattern recognition is training your eye to recognize certain colors that trigger you to think of certain diseases," said Dr. Jenna Lester, director of the skin of color program at the University of California, San Francisco.

"But the color in question is impacted by the surrounding color," she said. "It can look different in darker skin. If you're only trained to look at something in one color, you won't recognize it in another color."

Dr. Lester recently reviewed 130 images of coronavirus skin disorders published in medical journals and found they were overwhelmingly of white people.

As the coronavirus spread, dermatologists started an international registry to catalog examples of skin manifestations of Covid-19. The registry compiled more than 700 cases, but only 34 of disorders in Hispanic patients and 13 in Black patients were submitted.

It wasn't until July that Dr. Roxana Daneshjou and her colleagues at Stanford University published some of the first pictures of Covid toes in nonwhite patients in the Journal of the American Academy of Dermatology.

"We know for certain that if dark skin images are not well represented, skin doctors - but also other doctors who are not skin experts - are at a disadvantage for making a proper diagnosis," said Dr. Hao Feng, an assistant professor of dermatology at the University of Connecticut.

Dr. Feng reported recently that the omissions are still pervasive in textbooks, where only 10 percent of images illustrate dermatologic diseases in dark skin. When pictures of Black patients were available, they most often described syphilis. He found that one digital resource, VisualDx, had a more diverse display of images: 28.5 percent represented dark skin.

"If you have no experience with this in people of color, it's like saying you don't know how to examine the lungs or the heart," said Dr. Art Papier, a dermatologist who co-founded VisualDX.

All doctors observe the skin for clues to disease. Changes in the skin can be the first indication of life-threatening conditions like sepsis, cellulitis or severe drug reactions to medications.

Images of skin cancer in dark skin were underrepresented in educational materials examined in Dr. Feng's study - yet skin cancer, though less common in people with darker skin, is more deadly in Black and Hispanic patients, and often diagnosed at a later stage.

The five-year survival rate is 66 percent for non-Hispanic Black patients, compared with 90 percent for non-Hispanic white patients.

Black patients are generally less likely than whites to see a dermatologist and less likely to undergo screening for skin cancer. Even when they do see a dermatologist, studies have shown, Black patients are less likely to get certain treatments than white people with the same conditions, like oral antibiotics for acne.

"I can tell you from my own clinical experience a lot of things get missed because people don't recognize the disease process in darker skin," Dr. Feng said.

Even relatively common skin conditions can stump physicians if they have never seen them in people of color.

When Dr. Lester was in medical school, she recalled, a Black patient came to the clinic with a mysterious rash that had a purplish hue. "No one knew what it was," Dr. Lester said.

A biopsy revealed it was a common skin condition that doctors usually diagnose on sight, without tests or procedures: psoriasis. Yet it often goes unidentified and untreated in people of color.

The medical literature describes psoriasis as "salmon pink patches with silvery white scales, but that's not what it looks like in dark skin," Dr. Lester said. "It has more of a purple hue, and a lot of my Black patients put tons of moisturizer on when the skin is dry, so the scales aren't as visible."

Many garden-variety rashes will vary in appearance in different complexions. Eczema, which is typically described as making skin red and itchy, tends to be more bumpy in Black people, Dr. Lester said. Pityriasis rosea is usually described as having a distinctive pattern composed of a large spot with smaller spots branching out from it - but it may not appear this way in people with dark skin.

Melanoma, the most serious form of skin cancer, often develops in Black people in spots where doctors may not think to look for it: on the palms of the hands or soles of the feet.

Doctors often miss rosacea in Black patients, too, because clinicians expect to see redness and visible blood vessels on the face, said Dr. Amy McMichael, chair of the dermatology department at Wake Forest Baptist Health in Winston-Salem, N.C.

"You don't see as much red if the background skin color is brown," she said.

Pallor, which can be an indication of anemia as well as reduced blood flow and oxygen, will also have a different appearance in Black patients, said Dr. Lynn McKinley-Grant, an associate professor at Howard University College of Medicine and president of the Skin of Color Society, which promotes awareness and education about these variations.

"It's a different color, kind of a grayish color," she said. "I have actually thought of George Floyd. When he's on the ground, his skin is a gray brown, showing lack of oxygen."

Kawasaki disease, a children's disease that bears similarities to a Covid-19 complication called multisystem inflammatory syndrome, causes inflammation in blood vessels and presents with redness, but "how it appears in darker skin tone is very different," said Dr. Susan Taylor, associate professor of dermatology at the University of Pennsylvania Perelman School of Medicine.

"You don't want to miss that in a kid because you don't know how to look for the rash and your eye isn't trained to see it," she said.

Dr. Taylor is a co-author of "Dermatology for Skin of Color," one of the first textbooks that focused on the treatment of skin conditions in moderately to heavily pigmented skin. But new textbooks are not the solution, she said.

"We shouldn't have to write separate textbooks - that information should be integrated into the quote-unquote standard textbooks," Dr. Taylor said.

Nearly half of dermatologists and dermatology residents say they were not adequately trained to treat skin conditions in people of color. For Black patients, that often translates into a prolonged, disheartening search for the right diagnosis.

When Tierra Styles, 31, of Auburn, Ga., asked her pediatrician about a rough patch of skin on the back of her toddler's neck, the doctor said it was nothing. On later visits, it was diagnosed as scabies, then eczema. But the prescribed ointments had no effect.

Finally, Ms. Styles took her son to a dermatologist who was Black. She said the sandpaper-like patch was a benign skin condition called keratosis pilaris.

"The doctor tried to pull up a picture on the internet, but she couldn't find one," Ms. Styles said. "There was not one picture of an African-American person that she could show me."

Ellen Buchanan Weiss, a white mother of a multiracial child in Raleigh, N.C., was so frustrated by her fruitless online searches for information on her child's skin rashes that she started her own repository of skin images in an Instagram feed called Brown Skin Matters.

Anyone can submit a photo; a physician reviews the images before they are posted.

"It started as a casual reference for other mothers," Ms. Weiss said. "What's been surprising to me is that it's been used mostly by clinicians - doctors, nurses, professionals teaching in medical schools."

Many Black patients prefer to see Black dermatologists, who may be more familiar with and have a greater understanding of not only skin issues - like acne, which can leave dark, hyperpigmented spots on dark skin - but hair predicaments, said Dr. Natalie Moulton-Levy, a dermatologist in Manhattan.

Image

Dr. Natalie Moulton-Levy, a dermatologist in Manhattan. Credit... Jeenah Moon for The New York Times

"We as Black people don't do hair the same way a non-Black person does," Dr. Moulton-Levy said. "When you're giving treatment options, some dermatologists are not familiar with that and say, 'OK, you have to wash your hair every day.' We don't wash our hair every day."

But getting in to see a dermatologist can be difficult, and waits are notoriously long. There is a shortage of dermatologists generally, and a shortage of dermatologists of color in particular: Only 4 percent of practicing dermatologists identify as Hispanic, and only 3 percent identify as Black or African-American, according to one study.

Black and Hispanic patients are far more likely than white patients to use the emergency room for dermatology problems, especially in rural areas and smaller cities where there are fewer dermatologists, studies have shown. People of color are half as likely as white patients to see a dermatologist for the same conditions.

Health insurance can also be a barrier to care. A 2014 study by the physician staffing firm Merritt Hawkins reported that dermatology was among the specialties least likely to accept Medicaid, with only 27 percent of dermatologists accepting payment from the government health plan compared with 63 percent of cardiologists.
[Like the Science Times page on Facebook.| Sign up for the Science Times newsletter.]
At some safety-net hospitals, waits as long as a year to see a dermatologist have been recorded. Delayed doctors' appointments, especially for pediatric dermatologists, can have serious consequences.

A Connecticut woman said that when her biracial daughter first developed patches of blanched, hypopigmented skin at age 10, it was misdiagnosed as a benign condition called pityriasis alba.

The woman, who asked not to be identified, to protect her daughter's privacy, tried to get her child an appointment with a dermatologist, but few in the area took Medicaid and those who did had an eight-month wait.

When the mother switched jobs and obtained commercial health insurance, she made an appointment with a specialist at Yale University, who diagnosed her daughter with a rare cancer, primary cutaneous T-cell lymphoma, also called mycosis fungoides.

The treatment, which consists of ultraviolet light therapy, has been successful, and the blanched spots are no longer visible on her daughter's "medium brown skin," the mother said. But it took two years to get the diagnosis. When she searched online, she said, "I couldn't find anything that looked like my daughter, and it was mostly images of white skin."

Physicians often say that they "do not see color," Dr. Moulton-Levy said. "They are trying in a nice, benevolent way to say skin color doesn't matter."

"But it absolutely matters, in dermatology and all of health care," she said. "'Colorblind' is a very difficult term for me to hear."

# data[].attributes.attachment_link.title
Dermatology Has a Problem With Skin Color

# data[].attributes.attachment_link.description
Common conditions often manifest differently on dark skin. Yet physicians are trained mostly to diagnose them on white skin. Dr. Jenna Lester, director of the skin of color program at University of California, San Francisco. "If you're only trained to look at something in one color, you won't recognize it in another color," she said.

# data[].attributes.headline
"Absence of images of skin of color in publications of COVID‐19 skin manifestations"

# data[].attributes.subject
"Absence of images of skin of color in publications of COVID‐19 skin manifestations"

# data[].attributes.body
From the British Journal of Dermatology in 2020

This recently published article demonstrates a continuation of the issues highlighted in the NYT dermatology article but with specific concern to COVID. The analysis of photographic representations of skin manifestations highlights yet another ingrained contributor to medical and systemic racism.

# data[].attributes.headline
Pearson's Apology for Encouraging Racist thinking in Nursing Textbooks 

# data[].attributes.subject
Pearson's Apology for Encouraging Racist thinking in Nursing Textbooks 

# data[].attributes.body
Apology video for racism found in nursing textbooks posted by Pearson on October 19, 2017

In 2017, textbook company Pearson 'became' aware of their published nursing textbooks which included incredibly racist assumptions and stereotypes about minority patients. These assumptions dangerously contribute to the teaching and training of future healthcare workers. They insinuate that they should treat patients differently because of their race/ethnicity, unsubstantiated concepts that studies have shown many physicians falsely believe. One section of the book was titled "Cultural Differences in Response to Pain" and categorizes it as follows:

"Arabs/Muslims: may not request pain medicine but instead thank Allah for pain if it is the result of a healing medical procedure”

"Blacks: believe suffering and pain are inevitable.”

“Asians: Chinese patients may not want to ask for medication because they do not want to take the nurse away from a more important task"

# data[].attributes.headline
"Racial bias skews algorithms widely used to guide care from heart surgery to birth, study finds"

# data[].attributes.subject
"Racial bias skews algorithms widely used to guide care from heart surgery to birth, study finds"

# data[].attributes.body
Article written by Sharon Begley, published by Stat on June 17, 2020

Multiple studies have found numerous algorithms, tests, and values that are skewed against Black patients and prevent them from receiving equal treatment to White patients, many based on largely unsubstantiated and racist stereotypes or assumptions. These include the Heart Failure Risk Score, a risk factor used by cardiothoracic surgeons used to determine the risk of surgery, kidney failure, kidney donation, a tool that estimates risk for breast cancer, and an algorithm for giving birth.

# data[].attributes.attachment_link.readable_text
ecision aids that U.S. physicians use to guide patient care on everything from who receives heart surgery to who needs kidney care and who should try to give birth vaginally are racially biased, scientists reported on Wednesday in the New England Journal of Medicine.

It is the latest evidence that algorithms used by hospitals and physicians to guide the health care given to tens of millions of Americans are shot through with implicit racism that their creators are often unaware of, but which nevertheless often result in Black people receiving inferior care.

The new findings cut across more medical specialties than any previous study of race and algorithm-driven patient care.

advertisement

Malika Fair, an emergency physician and senior director for health equity partnerships and programs at the Association of American Medical Colleges, called the study "impressive."

"I am delighted that the use of race in medical decision-making is being questioned in such a thoughtful analysis," said Fair, who was not involved in the study. "As a medical community, we have not fully embraced the notion that race is a social construct and not based in biology."

advertisement

The findings build on earlier studies that focused more narrowly. Last year, for instance, other scientists found that a widely used algorithm that identifies which patients should get additional health care services such as home visits routinely put healthier, white patients into the programs ahead of Black patients who were sicker and needed them more. The bias resulted from the algorithm's developers equating higher health care spending with worse health. But white Americans spend more on health care than Black Americans even when their health situations are identical, making spending a poor and racially biased proxy for health.

The new study finds that algorithms used for medical decisions from cardiology to obstetrics are similarly tainted by implicit racial bias and adversely affect the quality of care Black patients receive. Among them:

Heart Failure Risk Score: Developed by the American Heart Association to determine which hospitalized patients are at risk of dying from heart disease, the algorithm assigns three points to any "nonblack" patient; more points mean higher risk of death. Those deemed at higher risk (non-Black patients) are more likely to be referred to specialized care, said David Shumway Jones of Harvard Medical School, the study's senior author. That possibility is not merely theoretical: At one Boston hospital, Black and Latinx patients arriving in the emergency room with cardiac symptoms were less likely than white patients with the same symptoms and medical history to be admitted to the cardiology unit, a 2019 study found.

Chest surgery: In a risk calculator used by thoracic surgeons, being Black increases the supposed likelihood of post-operative complications such as kidney failure, stroke, and death. "That could make surgeons steer Black patients away from bypass surgery, mitral valve repair and replacement," and other life-saving operations, Jones said. "If I have a Black patient and the risk calculator tells me he has a 20% higher risk of dying from this surgery, it might scare me off from offering that procedure."

Kidney failure: It's very difficult to measure kidney function directly, so physicians use creatinine levels in the blood as a proxy: less creatinine, better kidney function. A "race adjustment" in a widely used algorithm lowers Black patients' supposed creatinine levels below what's actually measured. That makes their kidney function appear better, potentially keeping them from receiving appropriate specialty care. The rationale for "adjusting" creatinine levels by race is that Black people are supposedly more muscular, which can increase the release of creatinine into the blood. As it is, Black people have higher rates of end-stage renal disease than whites.

Kidney donation: An algorithm used by transplant surgeons says that kidneys from Black donors are more likely to fail than kidneys from donors of other races. Because Black patients are more likely to receive an organ from a Black donor, the algorithm reduces the number of kidneys available to them.

Giving birth: Recognizing that cesarean deliveries are more dangerous for both mothers and babies, obstetricians recommend that women who had a previous surgical birth not be automatically scheduled for another cesarean, as was once common practice. But the algorithm they use to determine whether a woman faces too high a risk from vaginal birth automatically says that Black and Latinx women face a higher risk. That was based on a study that found being unmarried and not having insurance also increases that risk. Neither of those socioeconomic factors are included in the algorithm.

Breast cancer: An online tool that estimates risk of developing the disease calculates a lower risk for a Black or Latinx woman than a white one even when every other risk factor (such as age at menarche, close relatives with breast cancer, and a history of benign biopsies) is identical. That could deter minority woman from undergoing screening.

Kidney stones: When patients come to an emergency department with pain in the back or side, doctors use an algorithm with a 13-point scale to assess whether the cause is kidney stones. A higher score means less likelihood of that. Being Black automatically adds three points to the score. An assessment of the algorithm by independent researchers found no scientific support for the assumption that Black people's pain is less likely to indicate kidney stones.

"Many of the algorithms are widely used and have a substantial impact on patient care," said Brian Powers, a physician and researcher at Brigham and Women's Hospital in Boston, who was not involved in the study. "Cataloguing these algorithms is an important first step. What's needed now is a better understanding of whether these algorithms exhibit racial bias, or are contributing to health inequities in other ways."

All 13 of the algorithms Jones and his colleagues examined offered rationales for including race in a way that, presumably unintentionally, made Black and, in some cases, Latinx patients less likely to receive appropriate care. But when you trace those rationales back to their origins, Jones said, "you find outdated science or biased data," such as simplistically concluding that poor outcomes for Black patients are due to race.

Typically, developers based their algorithms on studies showing a correlation between race and some medical outcome, assuming race explained or was even the cause of, say, a poorer outcome (from a vaginal birth after a cesarean, say). They generally did not examine whether factors that typically go along with race in the U.S., such as access to primary care or socioeconomic status or discrimination, might be the true drivers of the correlation.

"Modern tools of epidemiology and statistics could sort that out," Jones said, "and show that much of what passes for race is actually about class and poverty."

Including race in a clinical algorithm can sometimes be appropriate, Powers cautioned: "It could lead to better patient care or even be a tool for addressing inequities." But it might also exacerbate inequities. Figuring out the algorithms' consequences "requires taking a close look at how the algorithm was trained, the data used to make predictions, the accuracy of those predictions, and how the algorithm is used in practice," Powers said. "Unfortunately, we don't have these answers for many of the algorithms."

Even before the new analysis, some hospitals and specialty groups were questioning the algorithms. The Society of Thoracic Surgeons, which developed and whose members use the algorithm that tells them Black patients are more likely to suffer post-op complications, admitted that including race in the algorithm "might 'adjust away' disparities in quality of care."

Kidney specialists at hospitals in Boston and San Francisco have stopped using race to make a Black patient's kidney function score better. This month, the University of Washington School of Medicine announced that its physicians would also stop using the racially tinged kidney function algorithm. But at least two other Boston hospitals, whose officials were given a presentation about the creatinine algorithm, declined to stop using it several weeks ago.

Jones does not think the algorithm developers were racially motivated. "Well-meaning individuals acting without racist intent can still produce work with racist consequences," he said, "such as redirecting medical resources from one group to another."

He and other physicians hope that shining a light on the use of racially biased decision tools will make more in the medical community question the practice.

"By perpetuating the use of race in our decision-making, we can further exacerbate inequities, make it longer to get needed treatments or procedures, or referrals to specialists," said AAMC's Fair. "For the medical community, this is an example of structural racism and is one area we can address quickly and decisively."
This story has been updated to include additional outside comment.

# data[].attributes.attachment_link.title
Racial bias skews algorithms widely used to guide patient care - STAT

# data[].attributes.attachment_link.description
ecision aids that U.S. physicians use to guide patient care on everything from who receives heart surgery to who needs kidney care and who should try to give birth vaginally are racially biased, scientists reported on Wednesday in the New England Journal of Medicine.

# data[].attributes.headline
"UW Medicine to exclude race from calculation of eGFR (measure of kidney function)"

# data[].attributes.subject
"UW Medicine to exclude race from calculation of eGFR (measure of kidney function)"

# data[].attributes.body
published May 29, 2020

University of Washington Medicine is one of the first institutions to announce it will no longer use the "race factor" when looking at kidney function, an algorithm that often prevents Black patients from getting necessary dialysis and from being put on the transplant list early enough. This decision stems from a 2018 conversation where UW School of Medicine students began raising questions about the strength of the evidence underlying the differing values for Black patients.

# data[].attributes.attachment_link.readable_text
UW medical students initiate one of the first of its kind transition to the calculation of estimated glomerular filtration rate that is not adjusted by race.

A serum creatinine test measures the level of creatinine in your blood and provides an estimate of how well your kidneys filter (glomerular filtration rate).

When measuring kidney function, virtually every laboratory in the United States, including UW Medicine, automatically calculates an estimated glomerular filtration rate (eGFR) every time serum creatinine is measured. This test has traditionally used the Modification of Diet in Renal Disease (MDRD) equation to calculate eGFR to determine levels of creatinine in each sample.

The eGFR results are then reported with race factored as a precision variable. The usual approach is to report two values - one for Blacks and another for non-Blacks.

In 2018, the conversation was initiated by UW School of Medicine medical students questioning the strength of evidence underlying the reporting of eGFR by race.

"So how did we make this change? We made it by questioning lecturers when the MDRD was taught. We did it by not letting the issue go and continuing to push discussions in class about the use of this equation...

We did it by having meetings with teaching faculty, sending articles to them like the one in JAMA, forcing discussions in small group sessions, and making use of the advocacy framework that we built via ARAC."

- UW School of Medicine MD/MPH Student, Naomi Nkinsi via Twitter

In addition to a lack of rational for using a race coefficient, the MDRD equation can underestimate GFR in many individuals and be unreliable in informing clinical actions. Advocacy by students and the UWSOM Anti-Racism Action Committee led to iterative assessments of approaches for eGFR testing across the UW Medicine community, including faculty from the Departments of Family Medicine and Laboratory Medicine, and the Division of Nephrology in the Department of Medicine.

This interdisciplinary team determined that the use of race in the biomedical environment is an imprecise variable and does not meet the scientific rigor UW Medicine expects of diagnostic tools.

As of June 1, 2020, laboratories at UW Medicine will transition from the use of MDRD equation to the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation in the calculation of eGFR. The new protocol excludes race as a variable. Instead, CKD-EPI results are based on serum creatinine, age, and sex and is normalized to 1.73 m² body surface area.

"This is a momentous change where UW Medicine is leading the way," said Dr. Rajnish Mehrotra, interim head of the Division of Nephrology.

This recent shift in diagnostic protocol further demonstrates the need for medical professionals and medical centers to question the appropriateness of racial attributions in medicine and emphasizes the teaching and practice of medical advancements that do away with using race as a proxy, indicator, or adjustor.

"The historic decision by UW Medicine to no longer use race as a variable to estimate kidney function is significant in multiple ways," says Nkinsi. "First, it shows that our medical system refuses to participate in the perpetuation of racism in medical practice, and has taken a stand to end the false narrative that Black bodies are inherently inferior to White bodies.

Secondly, the move signals that medical students have a powerful voice that is already shaping the future of academic medicine. This was an effort led by medical students, especially Black students, who have advocated to remove racism in the medical school curriculum and in clinical practice for many years.

This decision shows that students can have a profound impact. It is because students persisted in asking questions and having sometimes difficult conversations that an institution, and the field of medicine more broadly, changed."

# data[].attributes.attachment_link.title
UW Medicine to exclude race from calculation of eGFR (measure of kidney function)

# data[].attributes.attachment_link.description
UW medical students initiate one of the first of its kind transition to the calculation of estimated glomerular filtration rate that is not adjusted by race. A serum creatinine test measures the level of creatinine in your blood and provides an estimate of how well your kidneys filter (glomerular filtration rate).

# data[].attributes.headline
Undoing Racism and Bias in Medical Education

# data[].attributes.subject
Undoing Racism and Bias in Medical Education

# data[].attributes.body
video from Icahn School of Medicine (Mount Sinai, in New York City)

This video, created by medical students, "relays how leadership and medical students are collaboratively combating racism and bias in medical education." This doctors-in-training of color identified racism in their medical school curriculum and met with their administration to make a change. Since that meeting, students and faculty have attempted to work together to identify racism and help better train physicians for the future.

# data[].attributes.attachment_link.title
Undoing Racism and Bias in Medical Education

# data[].attributes.headline
"To Be Young, A Doctor And Black: Overcoming Racial Barriers In Medical Training" 

# data[].attributes.subject
"To Be Young, A Doctor And Black: Overcoming Racial Barriers In Medical Training" 

# data[].attributes.body
Segment on NPR, published July 1, 2020

Dr. Hairston, among other physicians, outlines her experience as a Black physician, navigating racism in the medical school curriculum, and overcoming the racism she experiences as a minority in the medical field.

"If you're ignoring this part of their experience, if you're not understanding the impact of being Black on them in this country and on their mental health, you're doing a disservice to them, and I don't know how you can treat them effectively."

# data[].attributes.attachment_link.readable_text
Dr. Danielle Hairston grew up in a family that included many role models of what she refers to as Black excellence.

"I had the example of a Black woman pediatrician, so it never occurred to me I couldn't become a doctor," says Hairston, who is now the psychiatry residency director at Howard University, where she herself now trains and mentors young Black doctors.

Yet, she says, she and her Black colleagues are routinely questioned in the hospitals and clinics where they work about their rightful place in the halls of medicine. They're questioned entering the physicians' lounge; in the elevator, one woman accosted Hairston: "Oh, my God, you're a doctor? You? You?"

One of her white colleagues mistook her for a patient's caregiver. "I don't even necessarily think that he's racist," Hairston says. "It's just that that's the bias."

Black Americans make up more than 13% of the U.S. population, yet only 5% of physicians are black. That lack of representation isn't just a problem within medicine, Hairston notes, but it perpetuates a sense that medical and mental health care is not of - or for - the Black community.

As institutions everywhere confront the impacts of racism and inequity in their systems, medicine is not immune. Lack of access to health care isn't just a problem for Black patients, who continue to face economic, social, and cultural barriers. The gaps are evident in the profession itself. Black physicians remain in a disproportionately small minority. And many African American doctors say that's because medical training itself alienates them, perpetuating those gaps which, in turn, affects the care patients receive.

"If you're ignoring this part of their experience, if you're not understanding the impact of being Black on them in this country and on their mental health, you're doing a disservice to them," says Hairston. "And I don't know how you can treat them effectively."

Part of the problem - and the potential solution - lies in the pipeline of young talent coming through the U.S. system of medical training.

Altha Stewart, who became the first Black president of the American Psychiatric Association, says she considered herself lucky to have Black mentors during her residency training in the late 1970s. They not only helped shepherd her, she says, they taught her about the needs of the African American community, and how the stress of racism affects both physical and mental health. But such peer support remains rare.

"I know residents who don't have that even today, in 2020," she says.

Medical training felt profoundly lonely and isolating for Dr. Anthony Chin-Quee, a Black ear, nose and throat surgeon who finished his training in Detroit four years ago.

"The number of Black men in medicine is very, very small; the number of Black men in surgery is orders of magnitude smaller, and the number of Black men in specialized surgeries like ENT is tiny, tiny," says Chin-Quee.

Chin-Quee says mistreatment came shrouded in subtlety; in fact, for years, he didn't even suspect racism.

"They wouldn't say that 'Tony's lazy' to my face; they would say, 'Tony's not efficient," he says, in spite of the fact Chin-Quee's work and hours matched his white counterparts. He responded by working harder. Already stressed and sleep-deprived, he showed up to shifts earlier, or stayed later. When the criticisms persisted, making Chin-Quee question his sanity, he fell into a major depression.

"That's the danger of this whole profession, and being Black in this profession," he says. Racism is hard to identify. "Because it's so silent and because it's so invisible, you just think you're going crazy for thinking it, because you can't prove it."

But Chin-Quee's struggles became an open secret. The only other black physician turned a blind eye, Chin-Quee says, which made things worse.

"It helped to bolster this idea that what was happening to me had nothing to do with race because I was thinking to myself, if it did, this Black doctor would reach out and let me know," he says. "But he didn't."

Chin-Quee gritted out the training and his depression.

"And it was only last year, actually, that I sat down with my colleague - who went through residency alongside me and brought it up to me," he says.

Over that dinner, Dr. Matt Smith told Chin-Quee some of their non-Black supervisors had made repeated comments during their residency that Smith took to be racist.

"While nothing was overtly said as an inflammatory comment, I would say that there are those kind of biting remarks that lead to microaggressions and build up over time," says Smith, who is white and now a pediatric ear, nose and throat surgeon in Cincinnati. The comments were undeserved, Smith says. "He is one of the smartest people I've ever met."

During their residency, Smith says, he objected to the comments directly to the supervisors - but said nothing about that to Chin-Quee. "I thought, if he didn't know those things were being said, then it wouldn't affect him necessarily directly."

Now Smith is an outspoken advocate for social justice with the medical students he supervises, as an assistant professor in pediatric otolaryngology at the University of Cincinnati. He's also starting a mentor program for minority schoolchildren, hoping to get them into medicine. "Until there are changes made in the pipeline, all you're going to get is what you put into the system," he says.

His friend Chin-Quee agrees, and notes that increasing the number of Black doctors in every medical specialty is important for Black patients, as well as for the doctors.

"Having someone who cares for your health, who understands and has lived through the struggles personally and culturally that you've experienced is super, super super important," Chin-Quee says. It's part ofthe systemic change needed, he says, to bridge some of the long-standing racial gaps in medical care.

# data[].attributes.attachment_link.title
To Be Young, A Doctor And Black: Overcoming Racial Barriers In Medical Training

# data[].attributes.attachment_link.description
Dr. Danielle Hairston grew up in a family that included many role models of what she refers to as Black excellence. "I had the example of a Black woman pediatrician, so it never occurred to me I couldn't become a doctor," says Hairston, who is now the psychiatry residency director at Howard University, where she herself now trains and mentors young Black doctors.

# data[].attributes.headline
UNO's Dedication to Achieving Racial Equity in Organ Transplantation

# data[].attributes.subject
UNO's Dedication to Achieving Racial Equity in Organ Transplantation

# data[].attributes.body
June 15, 2020

Following the murder of George Floyd and the Black Lives Matter protests, the United Network for Organ Sharing (UNOS) put out a statement dedicated to racial equity. While action means more than words, an acknowledgment of their role in medical racism is a good first step.

"However, we must acknowledge as a transplant community that racial disparities continue to exist in transplantation, as evidenced in several recent publications...the reasons for these disparities are medically and socially complex, and we must continually strive to reduce these inequities."

# data[].attributes.attachment_link.readable_text
The recent events of 2020 have shed a brutal spotlight on the issue of racism in our country and throughout the world. We have witnessed the rise of anti-Asian discrimination as fallout from the coronavirus pandemic and now, as a nation, face the extraordinary reckoning over racial injustice toward the African American community following George Floyd's death.

As transplant providers, we are committed to saving and improving lives through transplantation, regardless of background, including race and ethnicity. In fact, equity is so central to the fundamental goals and values of our transplant community that we have it in the Final Rule, which mandates the Organ Procurement and Transplantation Network ensure "the equitable allocation of cadaveric organs."

However, we must acknowledge as a transplant community that racial disparities continue to exist in transplantation, as evidenced in several recent publications including the Clinical Journal of the American Society of Nephrology, Surgery, the American Journal of Transplantation, and the Journal of the American Medical Association. The reasons for these disparities are medically and socially complex, and we must continually strive to reduce these inequities.

In developing policy, the donation and transplant community work with United Network for Organ Sharing to carefully examine the potential impact of policy changes on race and ethnicity. The OPTN Minority Affairs Committee, or MAC, is charged with ensuring that policy development and implementation uphold equitable allocation across racial groups and vulnerable populations. Each policy proposal that could potentially impact access to transplant by race is carefully vetted and debated by the MAC and part of our regulatory commitment is to provide feedback to policy-sponsoring committees to consider racial impact.

During this difficult time, we have reflected individually and as a community on how we can strive to be better and to eradicate inequity. We are committed to that end, and will continue to listen, educate, advocate for, and serve one another and our patients.
Irene K. Kim, M.D. is co-director of the Comprehensive Transplant Center, a liver and kidney transplant surgeon, and associate professor of surgery at Cedars-Sinai Medical Center. She serves as chair of the Minority Affairs Committee. Paulo Martins, M.D., Ph.D., is a liver transplant surgeon at UMass Memorial Health Care and associate professor of surgery at University of Massachusetts Medical School. He serves as vice-chair of the Minority Affairs Committee.

# data[].attributes.attachment_link.title
Achieving racial equity in organ transplantation | UNOS

# data[].attributes.attachment_link.description
The recent events of 2020 have shed a brutal spotlight on the issue of racism in our country and throughout the world. We have witnessed the rise of anti-Asian discrimination as fallout from the coronavirus pandemic and now, as a nation, face the extraordinary reckoning over racial injustice toward the African American community following George Floyd's death.

# data[].attributes.headline
"Physician Silence is Violence" - Doctors and the Black Lives Matters Movement 

# data[].attributes.subject
"Physician Silence is Violence" - Doctors and the Black Lives Matters Movement 

# data[].attributes.body
from Axios article published on June 10, 2020

Many healthcare professionals participated in the BLM Protests. Recognition is an important first step, yet it is imperative to examine and make changes to the medical field from the point of education into practice.