Health Care Disparities: Race

Growing up in Jim Crow–era Tennessee and training and teaching in overwhelmingly white medical institutions, Gus White witnessed firsthand how prejudice works in the world of medicine. While race relations have changed dramatically since then, old ways of thinking die hard. In Seeing Patients: A Surgeon’s Story of Race and Medical Bias, a blend of memoir and manifesto, Dr. White draws on his experience as a resident at Stanford Medical School, a combat surgeon in Vietnam, and head orthopedic surgeon at one of Harvard’s top teaching hospitals to make sense of the unconscious bias that riddles medical care, and to explore how we can do better in a diverse twenty-first-century America.

Pain is universally interesting precisely because it’s universal. Everybody has pain sometimes and some people have pain frequently or even chronically. We’ve all had conversations where we’ve talked about what kinds of pains we have and how badly we’ve suffered from them. There’s even a kind of general curiosity as to what the worst pains are. Kidney stone sufferers often swear that the pain of passing such things is above and beyond. Acute sciatica has its strong advocates for most painful, as do migraine headaches. But childbirth can hardly be relegated to second place behind anything, though root canal infections also make most pains pale by comparison. I’m not sure exactly where long bone fractures fit into the hierarchy, but they are, without a doubt, exceptionally painful.

Let’s imagine that a person — black or white, it doesn’t matter; the physiology is exactly the same — is wheeled into a busy emergency room with a broken tibia, maybe from a bad fall. The tibia, or shin-bone, connects the knee with the ankle bones. It’s the larger and stronger of the two bones of the lower leg. It takes considerable force to break a tibia. But when it is broken, here’s what happens.

The tibia, like all bones, is encased in a thin sheath of tissue called the periosteum. The periosteum itself has two layers. The outer one is richly endowed with blood vessels and what are called nociceptive nerves, that is, nerves that transmit pain. The blow that broke our patient’s tibia undoubtedly caused tissue damage in the region, and the broken bone ripped open its periosteum sheath. Maybe it did this in one place, if the patient has a simple fracture.

But it could have happened in several places. Tibia fractures also frequently involve damage or fracture to the fibula — the thinner and weaker of the two lower leg bones. The broken bone ends can be sharp, and the wound may have left splinters or spikes of bone. If a surgeon isn’t careful, a sharp bone end can penetrate right through her surgical gloves.

But even if the bone ends are not sharp, they’ll move around and jiggle any fragments or spikes. The torn periosteum, with its many pain-sensing nerves, will be flooding the brain with pain signals, and any additional movement will aggravate the nociceptors further, creating more pain. In addition, the periosteum’s broken blood vessels will be bleeding into the area, and the pooling blood may pressure and irritate the surrounding muscles and other tissues, magnifying the pain even more.

All that may happen even if EMTs have splinted our patient, immobilizing the bone to a certain extent. If they haven’t done that for some reason, every movement, the joggling of the gurney or transferring our patient to an X-ray table, for example, will cause excruciating pain.

All that pain has a reason, of course. It’s the body’s way of telling the brain in no uncertain terms not to move the injured limb. The brain has to keep things as still as possible down there. Only that way will healing begin and new bone matter be laid down to start fusing the break. That message has to be very loud and very clear, which explains why the pain volume is so high.

Now, here’s what happens once our patient is in the ER. Let’s assume it’s a big, busy city hospital — which is where the main analgesia studies were done. With all the activity, it may take a while for a nurse to do an assessment and triage the new arrival. A fracture patient who isn’t in shock, whose blood pressure is not down, and who is not bleeding profusely won’t be at the top of the triage, but he will be urgent. Everyone knows the level of pain here. But still, it will take some time for one of the ER docs to get around to him. If the break is so bad he needs surgery, he’ll be medicated and up he’ll go to the operating room. Otherwise, his leg will be immobilized in a large brace or cast and he’ll be fitted for crutches. And regularly, if that patient is black, he’ll be given less pain medication than his white fellow human being. Not infrequently, he’ll get no pain medication at all.

That, by the way, is true for Hispanic as well as African American patients. In fact, the groundbreaking analgesic study of this sort was done on Hispanic fracture patients. I’m discussing African American disparities first because, even though I readily understood that other groups were also subjected to disparate health care in equally serious and meaningful ways, as a black physician my own experiences and thinking were initially focused on race issues. Also, because the racial divide is so exemplary of implicit prejudice, understanding how that works may be a key to unlocking the way prejudice works vis-à-vis other minorities. In any event, the bone fracture researchers were so impressed by their findings that they repeated their Hispanic study in a different city with black patients. After that, other researchers were sufficiently taken by those results that they began looking into postoperative analgesic prescriptions and found large disparities there as well.

While most attuned doctors were disturbed by all of the Unequal Treatment disparity revelations — on cardiac care, transplants, surgical procedures, and others — to me, as an orthopedic surgeon, it was the long bone breaks that really stood out. A bone break is about as simple and straightforward as an injury can get. It has no relation to culture or language or unhealthy lifestyle, or whether African Americans might be adverse to some kinds of treatments. It simply must be fixed, and the considerable pain of it has to be addressed. Broken bones and analgesia are an ideal case to test whether the health-care delivery system is functioning in an egalitarian way, as we expect it to. And the health-care delivery system failed that test miserably. As Professor Jack Geiger wrote in Unequal Treatment after surveying the spectrum of health-care disparities, bone-break cases are “particularly troubling.”

If you try to get at why this particular disparity happens, several explanations suggest themselves. One is the historical assumption that blacks do not experience pain the same way whites do. They have, as one nineteenth-century medical account put it, “an insensibility of the nerves.” Endowed with a more primitive, robust resistance to pain, African Americans don’t actually need as much pain medication as whites. Of course, this is utter nonsense, and nobody today would ever get up in a lecture and state such a thing. But it stands out in the historical literature. That belief became part of the culture of medicine at some level, and it’s still out there in the background ambience. Then there’s the conscious or unconscious assumption that African Americans coming into the ER may be drug addicts, or at least may be seeking drugs. That is to say, you’d better be especially careful with narcotics when you’re dealing with black patients.

There’s another background assumption at work too. An African American psychiatrist, talking about his white colleagues at a major West Coast teaching hospital, said, “I knew a lot of white psychiatrists who thought it was a truism that all black people were angry with whites, that all of their black patients were angry and mistrusting.” Irving Allen, another African American psychiatrist in the Boston area, talks to black patients about how to survive in a medical setting. “Be cool,” he tells them. “Be extremely careful not to appear hostile.” But the fact is that patients in severe pain are often scared and angry. And doctors aren’t different from other people, despite all their training. Confronted with what they perceive as anger or dislike, especially black anger, they will tend to back off, or at least not engage as they would otherwise. The doctor’s response might be, “I don’t really want to deal with this. Let me get this cast on and get on with somebody else.” And that too might impinge on prescribing the appropriate pain medications.

All this is aside from just plain old subconscious or maybe even conscious prejudice. But even without these stereotypes and assumptions — blacks don’t feel as much pain, they might be addicts or drug dealers, they might be hostile — doctors will sometimes simply let things slip, especially in the rush of a busy ER. That happens vis-à-vis white patients too. Pain management often just isn’t handled as well as it should be. But for African Americans it happens a great deal more often.