Medical Education and Health Disparities
All around the country medical schools are advertising their programs as “committed to diversity” and training physicians who are “prepared to address the disparities that are affecting their patient’s health”. Yet for many students, their medical education has been very different than the one sold to them by admissions and marketing teams. Discussion of health disparities is often included in lectures as a simple fact with no further explanation regarding why those disparities exist or how we as students can use this information to better the experience and outcomes of our patients. For example, we learn that patients of color, and specifically African American patients, have their pain taken less seriously and are therefore given less pain medication as compared to white patients [1]. While it is vital for medical students to learn about these health disparities, the question I am always left with is whether simply knowing that these disparities exist is enough for us to better serve our future patients. From where I stand, the answer to that question is no. Knowledge is a necessary starting point for change, but the depth of that knowledge is of critical importance. In order to better advocate for our patients and work to correct these dangerous health disparities we must understand the history that led to where we are today.
The level of knowledge we possess about current health disparities affects our ability to advocate on behalf of our patients. Take the case of a student or physician witnessing their colleague provide an African American patient with less pain medication. If they were to speak up and tell that physician that they were giving the patient less medication than they would a white patient they are not providing the physician with any new information. The physician knows what they are doing, they chose the dose, and one could assume that they have a reason for their decision. If your knowledge of the issue stops there, you are not in the position to correct their reasoning behind that decision, yet that is where the problem that needs to be addressed lies.
In a study published by the University of Virginia, Charlottesville in 2016 researchers explored why black patient’s pain is under-treated as compared to white patients by examining whether beliefs held by medical students and residents correlated to differences in pain management of black and white patients. Their study found that white medical students and residents who held false beliefs that the black body was biologically different were more likely to perceive black patients pain as less than the patient reported and provided less accurate treatment of their pain [2]. Additionally, they found that of the eleven false beliefs about biological differences between black and white patients that they assessed, 50% of white medical students and residents held at least one of those beliefs [2].
The belief that African Americans are somehow biologically different has long been rooted in medicines history. In 1851 Dr. Samuel Cartwright published his “Report on the diseases and physical peculiarities of the negro race,” where he outlined many differences including that African Americans were “insensible to pain” [3,4]. Medical research has continued to perpetuate this belief by performing surgeries with little to no analgesics or performing medical experiments on African Americans [4]. Additionally, medical education continues to reinforce the notion that African Americans are biologically different through teachings of the GFR, salt sensitivity, and the use of different blood pressure medications for African American patients [5]. With this in mind, it is not surprising that African American patients’ pain is under-treated and under-appreciated. The belief that African Americans feel less pain is not new to the medical field and the use of medical research to support these claims is likely responsible for medical professionals holding these false beliefs as fact in our current day.
After reading the study discussed previously, it becomes clear that the current state of medical education is not effectively preparing students to address disparities in healthcare. By continuing to only present the disparities that exist without exploration of what lead to them, they have not addressed the source of the problem. As recent as 2016, medical students still held beliefs that African Americans are biologically different. Those beliefs are the problem and many disparities in patient care likely stem from that problem alone. In order to address this, we need to begin by reexamining the history that has perpetuated those beliefs into the modern day. Critical race theory calls us to examine history through the lens of the experience of minorities’ in order to gain a more accurate understanding of these events. When we do this in regard to the medical research that states African Americans are biologically different and insensible to pain, we learn that this research was used to support the existence of slavery and the abuses slaves experienced at the hands of slaveowners and physicians alike [4]. By learning the truth about the history of this research, we reveal the fallacy of its conclusions and can dismantle the claims that African Americans are biologically different, as well as begin to address the disparities that it has caused. Teaching medical students about the root of current health disparities by discussing the history that has contributed to them not only allows us to address the current problems we face in medicine but also begins to correct the racist history of our medical system.
1. Goyal MK, Kuppermann N, Cleary SD, Teach SJ, Chamberlain JM. Racial Disparities in Pain Management of Children With Appendicitis in Emergency Departments. JAMA Pediatr. 2015;169(11):996. doi:10.1001/jamapediatrics.2015.1915
2. Hoffman KM, Trawalter S, Axt JR, Oliver MN. Racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between blacks and whites. Proc Natl Acad Sci U S A. 2016;113(16):4296–4301. doi:10.1073/pnas.1516047113
3. Cartwright S. Report on the diseases and physical peculiarities of the Negro race (eBook, 1851) [WorldCat.org]. New Orleans Med Surg. 1851. https://www.worldcat.org/title/report-on-the-diseases-and-physical-peculiarities-of-the-negro-race/oclc/974496424. Accessed June 3, 2019.
4. Washington HA. Medical Apartheid : The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. Doubleday; 2006. https://books.google.com/books/about/Medical_Apartheid.html?id=4ZmJvC3f-m0C. Accessed June 3, 2019.
5. Whelton PK, Carey RM, Aronow WS, et al. 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA Guideline for the Prevention, Detection, Evaluation, and Management of High Blood Pressure in Adults. J Am Coll Cardiol. 2018;71(19):e127-e248. doi:10.1016/j.jacc.2017.11.006
