Vol. 29 No. 1 (January 2019) pp. 4-7JUST MEDICINE: A CURE FOR RACIAL INEQUALITY IN AMERICAN HEALTHCARE, by Dayna Bowen Matthew. New York: New York University Press, 2016. 288pp. Cloth $35.00. ISBN 978-1-4798-9673-8
Reviewed by Leniece Titani-Smith, Department of Political Science, Jackson State University. Email: leniece.t.smith@jsums.edu.
In JUST MEDICINE Dayna Bowen Matthew investigates the sub-optimal health care and healthcare outcomes of people of color in the United States. She offers a descriptive and explanatory account that intersects neuroscience, social science and the law. Her work extends the discourse beyond access and affordability to include a salient but frequently overlooked factor in the poor health outcomes of minority patients: unconscious racism, also known as implicit bias. This book has three overarching goals: (1) highlight and emphasize the reality that unconscious racism “due to implicit biases is hidden, tolerated, and even excused, despite its destructiveness” (p. 54); (2) to demonstrate that unconscious racism is the key mechanism influencing the thinking, behavior, and interactions that produce health disparities in minority populations; and (3) to end and reverse the discriminatory attitudes, beliefs and conduct that cause disproportionate harm to the health of minorities, up to and including policy and legislation. Throughout the book, Matthew puts forth data and evidence, which are generated from interviews with physicians, nurses, and patients, which were part of a snowball convenience sample. The inclusion of national survey data on healthcare experiences would have added weight to the Biased Care Model and provided additional evidence of the disparity gap in treatment. However, the combination of neuroscience, social science, and legal research provides cogent evidence to advance the main arguments.
Matthew examines how implicit bias frames and disrupts the clinical encounter from pre- to post-clinical contact. For instance, implicit biases shape the clinical encounter in many ways, including how close to sit, eye contact, listening to the patient, answering questions, or offering relevant detailed information. Physicians’ implicit biases affect pain management, referrals or recommendations for treatments, tests or procedures, pediatric decisions and diagnoses, and treatment of manageable conditions. Although this book is about unconscious racism, it is not the author’s intent to label all physicians as racists. In fact, she asserts that most doctors are not bigots, nor are they aware of their personal contribution to health disparities among patients of color; further, neither are they aware that they are personally influenced by implicit racial biases. Although none accept the assertion that they might be guilty of implicit bias, research using the Implicit Association Test (IAT), demonstrates that most physicians possess some level of implicit bias toward people of color.
In Chapter 2, “Implicit Bias and Health Disparities,” Matthew reviews neuroscience research on implicit bias. She discusses the distinction between implicit bias and racism and defines implicit bias as the “attitudes, preferences, and beliefs about social groups that operate outside of human awareness or control” (p. 42). She relies on neuroscience research to explain how implicit bias is automatic, unconscious thought without intention and identifies the stages — Store, Identify, Retrieve, Activate, Form and Influence — of implicit bias in the subconscious mind (p. 40). Matthew also offers physiological evidence of how the brain processes implicit biases, and the cognitive processes that lead to bias. Her discussion of the measurement of implicit bias utilizes the IAT, a computer-based test that measures the time a person takes to sort photos of African American and European American faces and combinations of those facial images with selected pairs of positive and negative words. Scores closer to zero demonstrate a neutral preference toward African-Americans or Whites. Harvard Project Implicit researchers reported that they found “a strong implicit preference for white Americans [*5] over black Americans among all test takers including physicians who were white, Asian and Hispanic,” but not African-American (p. 45). Additionally, there is a discussion of heuristics and racial schema, and the useful but possibly destructive role of “sorting patterns” used for solving medical problems and making diagnoses.
This chapter also considers limitations of evidence due to the way social scientists measure disparate treatment and health outcomes. Rather than race or ethnicity as key predictors of disparate health treatment or medical decision-making, explanations favored by social scientists and other researchers focus on socioeconomic status, patient preferences, and clinical necessity. Matthew states that the medical community does not accept the conclusion that unconscious bias and racism contribute to health disparities. That conclusion is rebuffed, in part, because of the lack of data or evidence of unconscious racism, as physicians and other healthcare workers are rarely, if ever, asked about their attitudes and biases. There is also a reflexive aversion to placing blame on physicians for poor health outcomes. Further, institutional effects have not been well studied, and social scientists lack the analytical tools to eliminate all competing explanations.
Chapter 3, “Physicians’ Unconscious Racism,” examines damage resulting from unconscious racism in the medical field. Matthew writes that the medical and scientific “communities have made minimal progress towards understanding, and virtually no progress in addressing, the role that physicians’ unconscious biases play in causing the disparate treatment and health outcomes that racial and ethnic minorities suffer” (p. 74). She details some of the outcomes arising from physician implicit bias in pediatric treatment decisions, their diagnostic decisions, as well as the effect of unconscious biases in treating health issues common to minorities such as heart diseases, renal failure, and cancer. She notes that implicit bias also affects the rate at which doctors provide pain medication to Black people even in the case of children, based on the untrue assumption that African-Americans are more likely to misuse prescription pain medication than Whites (p. 69). This type of implicit stereotyping of Black people limits the ability of doctors to reach unbiased diagnoses, treatment plans, and follow-up care. All of these factors contribute to the healthcare disparity gap between Blacks and Whites. Matthew points out that the ability to address implicit biases in health care is also limited by the fact that few studies have investigated the impact of implicit biases on minority groups other than Blacks and Whites and studies are limited because they do not examine additional traits that may trigger implicit biases such as age, gender, geographic location, and the socioeconomic status of Whites.
Chapter 4, “From Impressions to Inequality,” introduces readers to the Biased Care Model (BCM) which is a conceptual model that diagrams and explains the connection between bias and inequality. Matthew asserts that the BCM addresses questions about the mechanism that links implicit bias to health disparities, and it is used “to identify target areas where future researchers and policy-makers might quantify and reduce the effects of implicit biases” (p. 75). Matthew puts forth the six mechanisms that constitute the BCM.
To highlight, mechanisms 1 (Physician’s Biased Perception of Patients) and 2 (Physician’s Biased Statistical Interpretations) have an impact on health outcomes before the patient and doctor even meet, as biased perceptions of a patient’s minority group membership influence physicians’ expectations of the patient prior to the patient encounter. Physicians’ erroneous statistical interpretations and use of data about a patient’s racial or ethnic group, whether that data applies to the patient or not, affects perceptions of patients ahead of the clinical encounter. Mechanisms 3 (Physician’s Biased Conduct and Communication) and 4 (Patient’s Biased Conduct and Communication) interact reciprocally to influence doctor-patient communication during the clinical encounter. Mechanisms 5 (Physician’s Disparate Diagnostic and Treatment Decision-making) and 6 (Patient’s Biased Post-Clinical Decisions) [*6] influence diagnoses and treatment decision, patients’ decisions about compliance and adherence with treatment, and follow-up care post-clinical encounter.
Chapter 5, “Implicit Bias during the Clinical Encounter,” is focused on explaining Mechanisms 3 and 4 by illustrating how implicit biases impact physician conduct and communication during the clinical encounter. Utilizing evidence from social science research, the author demonstrates that physician communication affects patients’ health outcomes both positively and negatively. For example, research shows that when addressing minority patients, doctors with high implicit bias scores were more verbally dominant during the clinical encounter — asking fewer questions, disbelieving patient’s pain assessment — in addition to lacking eye contact, spending less time with the patient, and providing less information on treatments, outcomes, and side-effects. In general, these physicians were less patient-centered. These behaviors contribute to negative health outcomes, drive down patients’ trust in doctors, and reduce patient cooperation. Matthew also addressed the bias and biased communication that some patients have toward their doctor, particularly if the doctor is African-American.
Chapter 6, “From Inequity to Intervention,” challenges the belief that because unconscious racism operates without conscious control, it is “unavoidable, intractable and beyond conscious control” (p. 155). Matthew cites studies demonstrating that implicit bias is “malleable.” She emphasizes evidence that unconscious implicit attitudes are responsive to deliberate, individual-level choices, even if the individual is not aware of experiencing racial bias. And that implicit bias is “not impervious to relatively short-term change,” although it stems from social knowledge and learning that is slowly acquired over time (p. 156). Malleability describes “an ongoing learning process in which people with old, objectionable implicit biases learn to respond to newer, more appropriate attitudes and beliefs. Put another way, longstanding and unconscious thinking can change” (p. 156). Matthew cites the “connectionist model” of implicit bias, which argues that implicit associations are not static and inaccessibly fixed. “Biases can be revised depending upon current informational inputs gathered and weighed with each new encounter. This flexible view of stereotyping replaces an outdated rigid one and allows for the evidence that individuals can constantly update their stored group knowledge that generates implicit biases” (p. 156). Hence, this chapter details interventions that can transform biased care by inhibiting expression of implicit biases and prejudices after they are formed.
In Chapter 8, “A Structural Solution, Matthew,” Matthew utilizes Frieden’s Health Impact Pyramid to describe the varying levels of impact that public health interventions can have on health outcomes. At the bottom of the pyramid are interventions that have the broadest positive impact on improving public health outcomes. Interventions at the top of the pyramid have limited effects on improving public health. In this chapter, the author indicates that the fight to end health disparities has been stalled, and in some areas is worsening. The “cure” that Matthew prescribes to end disparities in healthcare and health outcomes is to “have the courage to make unconscious racism illegal” (p. 190). She argues that in addition to interventions, the law, which would reframe social norms about justice, fairness, and quality in healthcare, must be brought to bear. She argues that it is not enough to simply rely on interventions; to realize a full solution, there must be a paradigm shift in addition to a stick or carrot to move towards a health care system that values the lives of all patients.
In the concluding chapters 9 and 10, Matthew offers legal solutions including reforming Title VI of the Civil Rights Act to prohibit policy and practices that disparately impact minority health, incentivizing federally funded entities to create institutional interventions that reduce discrimination, permitting litigation of civil rights claims against entities that allow physician implicit bias, restoring the private cause of action for disparate impact claims, and creating a new disparate care claim based on a negligence standard of care. Lastly, Matthew [*7] discusses positive changes arising from The Affordable Care Act that resulted in successful claims of gender and sexual orientation discrimination. However, she points out that the Affordable Care Act has not been as beneficial in racial discrimination claims.
This dense, scholarly, and informative text offers a treatise on reforming the provision of minority healthcare in the United States. It provides a conceptual and theoretical model that should be utilized for empirical tests of implicit bias in healthcare. This text would be of interest to healthcare administrators, policymakers, advocates, researchers, graduate students, attorneys, healthcare workers, and physicians in all fields.
© Copyright 2019 by author, Leniece Titani-Smith.
