GRSJ224/Discrimination and Racial Disparities Faced By African American Patients By Healthcare Providers in US

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Overview

In the United States, African Americans tend to receive lower quality of healthcare than non-minorities even when factors such as income and insurance are controlled. These disparities are linked to the historic segregation and discrimination this minority subgroup has faced and continues to face. Research suggests that racial differences in access to care, receipt of medical care and access to treatments may be the result of healthcare providers bias- conscious or unconscious[1]

Racial Health Disparities in the United States

In the United States, racial minorities, especially African-Americans, face disparities in access to health care, the quality of care received and health outcomes. U.S. racial disparities against African Americans are a consequence of multiple factors including the disproportionate prevalence of low socioeconomic status, less healthy lifestyles, resource-poor neighbourhood environments, and more inadequate access to care[2].

According to the National Healthcare Disparities Report, White patients receive better quality of care than African Americans who also face more barriers to accessing care including preventive services, acute treatment and chronic disease management[3]. Compared to all other U.S. major racial groups, African Americans also have the highest rates of morbidity and mortality for almost all diseases and decreased life expectancy[4].

Differences in healthcare occur in the context of greater historic and contemporary social inequality and persistent racial discrimination in the U.S. According to Smedley et al. (2002), discrimination is defined as “biases, prejudices, stereotyping, and uncertainty in clinical communication and decision-making” [1]. Although covert discrimination towards African Americans has diminished, subtle forms of discrimination and bias have been linked to racial disparities in health outcomes. Racial disparities occur when healthcare providers produce discriminatory patterns of behaviour towards minority (African American) patients during a clinical encounter. These include clinical uncertainty when interacting with the patient and stereotypes and bias/prejudice held about the health of the patients. Consequently, these mechanisms lead to racial health disparities, via processes of clinical decision-making[5].

Provider Contribution to Race Disparities in Healthcare

The IOM report Unequal Treatment written by Smedley et al. reviews the disparities literature and determines that an important contributor to racial disparities in health status is healthcare provider attitudes and behaviour.

Research suggests that healthcare providers' diagnostics, and decision-making on treatment, as well as their feelings about the patients, are influenced by a patient's race. In one such study, results showed that doctors referred white male, female and African American male patients for cardiac catheterization 91% of the time, but only 79%; significantly less likely to recommend catheterization procedures for who exhibited the same symptoms[6]. Differences remained significant even after controlling for symptoms, physicians' estimates of the probability of the coronary disease and patient's clinical characteristics.[5] Further evidence for a provider contribution to race inequities include disparities in access to kidney transplant, access to cardiac procedures, psychiatric care, and pain control.[7]

Clinical encounters can explain one view of the origin of healthcare disparities with healthcare providers; physicians' attitudes, expectations and behaviours towards minority patients during physician-patient interaction. When such encounters systematically produce racial disparities, it can lead to discrimination. Here, the focus is on disparities that originate from physician's behaviour, including and demand-side reaction from them.[5]

Healthcare Provider Mechanisms

The 2 mechanisms that operate in healthcare disparities from the healthcare provider's side are:

  • Clinical Uncertainty during provider-patient interaction
  • Stereotypes and Bias/Prejudice held by the provider about behaviour of health minorities

Clinical Uncertainty

A source of healthcare disparities is the presence of greater uncertainty in interpreting symptoms of the disease for minority patients[5], that is, the doctor's decision-making process is rooted in uncertainty. Any degree of uncertainty a physician may have about a patient can contribute to disparities in treatment.

Upon meeting the patient and learning about their condition, doctors decide on what is likely to cause the problem and what actions to take to improve the patients' health based on signals or symptoms observe. They do so by depending on inferences about the severity based on what they can observe about the condition and on what else they can see about the patient (e.g., race)[1]. The physician is therefore perceived as operating with prior beliefs about the likelihood of the patient's condition, "priors" that will be different according to socioeconomic status, ages, and race or ethnicity. When these priors are considered alongside the data gained in a clinical encounter, both influence medical decisions.

If a physician has difficulty interpreting the symptoms of the patient's illness, there is greater uncertainty. The higher the uncertainty, the more weight is placed on the prior and less weight on the signal or symptom[5]. Consequently, information gained influences medical decisions and thus recommended treatment.

Nature of Stereotypes (Beliefs) and Healthcare Provider Biases/Prejudice

Empirical evidence suggests that physicians hold stereotypes based on patient characteristics (e.g. race), which may influence their interpretation of patient behaviours and symptoms, and consequently their clinical decisions.[8] Multiple studies in psychology have explored how stereotypes evolve, persist and affect interpersonal interactions between the physicians and patients.

According to psychologists, stereotyping refers to "the process by which people use social categories (e.g. race, gender) in acquiring, processing, and recalling information about others"[5].Generally, in healthcare, the beliefs (stereotypes) and attitudes that physicians hold aid them in processing information and simplifying complex health-relevant situations to facilitate accurate judgement.[9] However, although stereotypes are functional, stereotypes and attitudes tend to be systematically biased. These biases may exist in overt, explicit forms but due to social categorization, subtle and unintentional biases may also exist, often unconsciously, among people with egalitarian attitudes and who genuinely believe that they are not prejudiced.[10]

Empirical evidence shows that in the US, because of shared socialization influences, even well-meaning White people who are not overtly biased typically display unconscious, implicit negative racial attitudes.[1] In the Moskowitz et al. (2012) study, results showed that when primed with an African American face, doctors reacted more quickly for stereotypical diseases, indicating an implicit association of certain diseases with African Americans. These included diseases that African Americans are generally predisposed to such as hypertension and sickle cell anaemia as well as conditions and social behaviours with no biological association including obesity and drug use.[9] Similarly, there are situations when physicians "may be especially vulnerable to the use of stereotypes in forming impressions of patients since time pressure, brief encounters, and the need to manage very complex tasks are common characteristics of their work."[7]These conditions of time pressure and resource constraints are likely to produce negative results due to lack of information, to stereotypes and, to biases.

A study conducted by van Ryn and Burje (2000) based on clinical encounters, found that physicians believe blacks are more likely to abuse drugs or alcohol, less likely to comply with medical advice/treatment, and less likely to participate in rehabilitation therapy.[7] Holding such beliefs can result in doctors to be less likely to recommend treatments to blacks, or less likely to put effort into discerning the nature of the black patient's problems if the patients is not taking care of herself/himself.

References

  1. 1.0 1.1 1.2 1.3 Smedley BD, Stith AY, Nelson AR, Institute of Medicine. 2003. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: The National Academies Press. doi: 10.17226/10260.
  2. Hall, William J (2015). "Implicit Racial/Ethnic Bias Among Health Care Professionals and Its Influence on Health Care Outcomes: A Systematic Review". American journal of public health. 105,12: 60–76.
  3. "National Healthcare Disparities Report". Agency for Healthcare Research and Quality. August 3, 2011.
  4. Shavers, Vickie L (2012). "The state of research on racial/ethnic discrimination in the receipt of health care". American journal of public health. 102 (5): 953–66. doi:10.2105/AJPH.2012.300773 – via Alphapublications.
  5. 5.0 5.1 5.2 5.3 5.4 5.5 Balsa, A; Mcguire, TG (2001a). "Prejudice, Uncerrtainty and Stereotypes as Sources of Health Care Disparities" (PDF). Journal of Health Economics. 22: 89–116 – via Boston University.
  6. Ayotte, Brian J; Kressin, Nancy R (2010). "Race differences in cardiac catheterization: the role of social contextual variables". Journal of general internal medicine. 25 (8): 814–8. doi:10.1007/s11606-010-1324-y.
  7. 7.0 7.1 7.2 Van Ryn, Michelle (2002). "Research on the Provider Contribution to Race/Ethnicity Disparities in Medical Care". Medical Care. 40 (1): I140–I151 – via JSTOR.
  8. Finucane, Thomas E; Carrese, Joseph A (1990). "Racial Bias in Presentation of Cases". Journal of General Internal Medicine. 5 (2): 120–121. doi:10.1007/bf02600511.
  9. 9.0 9.1 Moskowitz, Gordon B (2012). "Implicit Stereotyping and Medical Decisions: Unconscious Stereotype Activation in Practitioners' Thoughts About African Americans". American Journal of Public Health. 102 (5): 996–1001. doi:10.2105/ajph.2011.300591.
  10. Dovidio, John F (2001). "On the Nature of Contemporary Prejudice: The Third Wave". Journal of Social Issues. 57 (4): 829–849. doi:10.1111/0022-4537.00244.