Hope and (Some) Change for Black Medical Patients

Equity advocates are tackling health care disparities and outcomes in Black neighborhoods, but some wonder if it is enough?

This is part two of “Dismantling Dismissal” Word In Black’s patient advocacy series, exploring the ways Black Americans navigate the health care system and what equity leaders are doing to make health care more accessible. Read the series.

By Anissa Durham

Physicians, patients, and experts would agree that the health care system as it currently exists is deeply fractured and broken. Efforts to advance health equity for communities of color are being made, but the question is, will it be enough?

Historically, racist health care practices have made health care outcomes worse for Black Americans when compared with whites. For example, medical racism, experiments on Black bodies, and medical mistreatment, have contributed to deep feelings of mistrust and fear of health care settings, so much so that some Black Americans report apprehension about going to the doctor.

Today, nearly 80% of Black adults have heard about medical researchers in the past experimenting on Black people without their knowledge or consent, and 55% believe it sill happens today. Although the data and lived experience of Black Americans can seem pessimistic, some in the community are more hopeful that things can change.

Uché Blackstock, founder and CEO of Advancing Health Equity, and bestselling author of Legacy: A Black Physician Reckons with Racism in Medicine, says just because someone decides to be a health care profession doesn’t negate the fact that we are living in a white supremacist and racist society that makes it easy for white doctors to absorb those cultural norms.

“It doesn’t mean all of that goes out the window, right?” Blackstock. “That’s still impacting the way you care for your patients and make decisions for your patients.”

A 2016 study found that, white medical students and residents held false beliefs that Black people have thicker skin and feel less pain than white people. Within hospital systems, Blackstock says, there needs to be procedures and practices in place to make sure patients get equitable care. One example would be implementing a system that would monitor physicians’ prescribing habits to see if there is a disparity of who is getting pain medication.

When the nation experienced a call for racial reckoning in 2020, the health care system was no different. While sweeping nationwide changes are difficult to roll out, some efforts were made. For example, a handful of medical students developed an education intervention, with the goal to increase knowledge about racial disparities and provide tools to mitigate implicit biases.

But it’s not just about revamping medical school curriculum. It matters who is teaching the next generation of health care professionals. Part of the problem is many of the current faculty and professors were educated and trained decades ago, Blackstock says, and they taught the clinicians practicing now.

To break that cycle, Blackstock proposes continued medical education to make sure medical school faculty are disseminating equitable, accurate, and fair information.

“We are always the ones that are creating solutions for ourselves,” she says.

NEW ORLEANS, LOUISIANA – JULY 01: Dr. Uché Blackstock speaks onstage during the 2022 Essence Festival of Culture at the Ernest N. Morial Convention Center on July 1, 2022 in New Orleans, Louisiana. (Photo by Paras Griffin/Getty Images for Essence)

DEI in Hospitals

For one hospital in Los Angeles, striving for equitable health outcomes has recently come with prestigious accolades.

Medell Briggs-Malonson, emergency medicine physician and chief of health equity, diversity, and inclusion for the University of California-Los Angeles hospital and clinic system, oversees more than 300 clinics and six hospitals. Her role includes identifying health inequities that happen within any group and coach people within the health system how to address the needs of patients.

Earlier this month, UCLA Health received a certification from The Joint Commission, a major accreditation organization, for their health care equity efforts. And the hospital is ranked first in California for exceptional health care. But what is their health equity team doing differently than other hospitals across the country?

Briggs-Malonson explains the systems they have in place and the results. Everyone who works at UCLA, from doctors to nurses to cafeteria workers, undergoes mandatory anti-racism and anti-discrimination training to help them understand bias and micro aggressions. There are several systems set up for patients and hospital employees to report potential discrimination or bias. Those allegations are sent directly to the UCLA Civil Rights Office to be reviewed.

Depending on the complaint, Briggs-Malonson says, they don’t shy away from accountability. But what accountability looks like depends on the complaint. Complaints can be addressed by requiring an employee to undergo further counseling or face disciplinary action from a health care professionals’ highest level of leadership, or even a Civil Rights Office recommendation for next steps.

Having an accountability structure in place is important, Briggs-Malonson says.

“We are a country built on racism,” she says. “While we have clear evidence of … bias within medicine, there’s been a large amount of effort to eliminate that and to hold people accountable for their biases. My job is to ensure … that there is no bias that creeps in.”

Photo of Dr. Medell Briggs Malonson. Courtesy of UCLA Health.

Generational trauma is one reason Black Americans feel mistrustful and are on guard in a hospital or doctor’s office. But Briggs-Malonson encourages folks to go into health care settings with an open mind, and without the assumption of being dismissed or mistreated.

“Give your doctors a chance,” she says.

It’s important to approach health care professionals as partners instead of immediately having your guard up, she says. Starting there can make it difficult to build a partnership with a health care professional but if something is off, there are ways to escalate those concerns and hold the clinician to account.

“Just like patients bring in baggage, doctors may bring in baggage,” Briggs-Malonson says. But she tells her health care professionals to check their baggage at the exam-room door: “You’re the health care professional. If somebody has had trauma with health care in the past … it’s your job to recognize that trauma.”

The narrative that there has been so much dismissal in health care is something that Briggs-Malonson agrees with: “I’ve been dismissed myself as a Black woman.” But she doesn’t want folks to ignore the significant amount of work health equity leaders are making.

However, for individuals who can’t access UCLA Health, where does that leave the millions of Black folks whose source of health care is not investing in health equity initiatives? Briggs-Malonson was blunt.

“There is an attack on DEI across the country right now.” The DEI movement ignited after the murder of George Floyd. Now that several years have passed, people are moving away from investing in health equity.

“Everyone deserves the right to receive the best health care possible. That should be a human right across the board,” she says. But if things aren’t working out, it may be time to change clinicians: “I say you’re never married to your doctor.”

Unfortunately, prioritizing health equity is not consistent in hospitals across the country. Part of the inconsistency is the varying degrees of initiatives. For example, some hospitals include health equity in the form of policies, others have a systematic and shared accountability approach, and it can look like culturally appropriate patient care or diverse representation in the hospital system.

In a 2021 annual report by the American Hospital Association, of the 4,359 general medical and surgical hospitals in the survey, 45% provided information on their health equity strategies. That means more than half of U.S. hospitals don’t have health equity efforts. But there is legislation under the Civil Rights Act of 1964 to protect patients from discrimination based on race, sexual orientation, gender identity, disability and pregnancy status.

“The norm should just be, you go and see a doctor, and you’re gonna get good care from your doctor,” Briggs-Malonson says.

Should You Just Get a Black Doc?

In previous reporting by Word In Black, it’s common for Black patients to have to advocate for themselves. It’s also not unusual for Black women to seek out a Black doctor or search for culturally competent care. For some, it’s a matter of life and death.

However, finding a Black doctor can be difficult, in part, because only about 6% of U.S. doctors are Black — and the result shows in worsening health outcomes. While the reasons for a shortage of Black docs varies between systemic racism and the expense of the career, a lesser-known reason is the 1910 Flexner report.

Abraham Flexner, a white educator, was tasked by the American Medical Association and the Carnegie Foundation with reviewing all 155 medical schools in the U.S. and Canada, and judge them on performance and standards.

An excerpt from chapter 14 of his report titled: The Medical Education of the Negro, says “The negro must be educated not only for his sake, but for ours. He is, as far as the human eye can see, a permanent factor in the nation.” It continues in another paragraph by saying, “A well-taught negro sanitarian will be immensely useful; an essentially untrained negro wearing an M.D. degree is dangerous. Make-believe in the matter of negro medical schools is therefore intolerable.”

Excerpt from Flexner Report. Graphic by Anissa Durham

“I had not even heard of the Flexner report until I was a practicing physician,” Blackstock says. “Given all the anti-Blackness there is in U.S. culture, you start to think, is there something wrong with us? Why can’t we get into medical school?”

According to recommendations from the report, about 75% of U.S. medical schools closed – which includes 5 of the 7 Black medical colleges. The two Black medical schools that remained were Howard University and Meharry Medical College. In her book, Blackstock outlines that an estimated 25,000 to 35,000 Black doctors would have been trained and practicing if the 5 medical schools would have remained open.

For some, the solution is to find a Black doctor. But is getting a Black doctor really a viable solution?

“Listen, I ask people for recommendations, because I want Black doctors,” Blackstock says.

To this day, HBCUs still produce the most Black doctors, despite there only being four of them that have medical schools. Regardless, Blackstock says, the onus should be on health care institutions and organizations to earn the trust of Black communities.

“I think we need a more holistic way of delivering health care to our communities so that our patients feel fully seen, heard, and appreciated – because we know that they do not,” Blackstock says.

Health in the Community

Health care goes beyond the hospital. About 80% of health outcomes are driven by social determinants of health. The U.S. Department of Health and Human Services defines those determinants as economic stability, education access and quality, health care access and quality, neighborhood and built environment, and social and community contexts.

Shonta Chambers, executive vice president of health equity initiatives and community engagement at the Patient Advocate Foundation, says you can’t talk about the clinical elements of a patient’s health care experience without talking about those social drivers. If a patient struggles to pay rent or put food on the table, for example, they may prioritize those things rather than their health.

The intersections of these different drivers create an interdependent ecosystem, Chambers says. When health care is discussed, it’s often seen as an individual and isolated experience, in reality, these different systems can influence health outcomes for entire communities.

“Our path forward is really more about team-based care,” she says. The health care model involves more than just a physician. For example, it can include a financial navigator, social worker, nutritionist, and health navigators. This model can streamline a system that is more responsive to the needs of all individuals, Chambers says, “and not just those who have the skills to advocate for themselves.”

Courtesy photo of Shonta Chambers.

“Health takes place first in community, that is also where the absence of health shows up most abundantly,” she says.

Due to this absence, Chambers organization often works within communities of color to eliminate barriers to health care access. Some of these communities are on the brink of folding, she says, and she implores organizations to use their energy to fortify the mothers, fathers, and children in those communities.

“We can’t say we need more data. While we’re sitting here having these conversations pretending like we don’t know, there are people across the country that are dying,” she says. “We have really put economics over humanity. We have to go back to the humanity in our society.”

Chambers says the solution requires a multipronged approach. While team-based care has proven to increase patient satisfaction, it won’t matter if folks can’t get access. Historically, she says, policies are the reason health outcomes for people of color are so poor.

So, if policies brought us here, new policies could move health outcomes forward, Chambers says.

“But we have to ask ourselves, are we ready to be bold enough to dismantle the racial and systemic policies in place … that are continuing to perpetuate the inequities that we see play out in health care?”

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