We often talk about people’s tendency to segregate themselves by race, finance, or nationality. We see it referenced throughout society. But those are only the obvious examples. There’s a more subtle, pervasive version of this in healthcare. And it affects each of us.
We think we’re different, even from other patients with similar medical conditions. This belief affects our day-to-day interactions in healthcare and colors our clinical experiences. It’s a form of self-delusion. We think of our health experience as one steady progression over time, determined by lab results and clinical assessments. In reality, healthcare is an incessantly fluttering wave, oscillating between perception and reaction.
Focus on the changing perceptions of your own health. See how those changes affect how you look at your own clinical conditions. This doesn’t occur in rational, predictable ways, since our thoughts and behaviors are anything but rational. Take, for example, racial disparities in patient outcomes, which originate out of perceptions that form in response to the uncertainties in a patient encounter. W.E.B. Dubois wrote that “racism at a certain point goes beyond rational thought,” and racism in healthcare goes beyond overt discrimination, as most healthcare providers are not outright racists. Yet a persistent disparity in clinical decision-making and patient outcomes exists among African American patients.
Repeated studies have found that Black patients receive fewer pain medications at lesser frequencies than white patients in acute care settings. Hardly any provider would say they decide what medications to prescribe based on a patient’s race. But the data proves conclusively that a difference exists. Perhaps many providers are not honest about their racial tendencies. More likely, racial behavior is inherently complex and manifests both consciously and subconsciously.
Historically, the medical community believed Black patients had higher pain tolerances due to perceived physiological differences, including thicker skin and different lung capacities. The latter misconception continues to permeate clinical medicine and affects every patient who has ever had their lung capacity evaluated using a spirometer. This instrument was first used in the antebellum South to measure the lung capacity of slaves, and even today it has separate settings for Black and white patients. While the use of the spirometer in such a manner is abhorrent and long since discontinued, the data continues to be populated in such a manner, as many spirometers designed today still have separate scales based on race.
The spirometer is an example of healthcare data that gives rise to unforeseen perceptions that go beyond the data itself. If not properly observed, then they reappear in medically harmful ways.
A study analyzing pulse oximeters, devices that measure blood oxygen, found that Black patients had undetected episodes of decreased oxygen concentration, or hypoxemia, three times as frequently as white patients. The study did not attribute any one cause for this, but noted that variations in the data between Black and white patients creates its own risk, since the interpretation of the data is different for Black patients compared to white patients. And those interpretations, largely based on subjective perceptions, adversely affect Black patients.
Past attempts in healthcare to correct for racial disparities tried to develop guidelines that standardized clinical decision-making. These attempts inevitably failed, as trying to regulate healthcare through guidelines is like placing a buoy in the middle of a turbulent ocean and expecting all passing ships to heed its warning. The motion of the ship is affected more by the turbulence in the ocean than by the marker set by the buoy.
In the infamous Tuskegee syphilis experiments, government researchers knowingly infected Black military men with syphilis for four decades to study the disease’s long-term effects without informing the patients in the study. The ensuing distrust that arose within the Black community toward clinical research and the healthcare industry still reverberates today throughout healthcare and plays a significant role in ongoing health disparities.
Those perceptions, more than anything else in healthcare, explain why we see persistently different outcomes for certain patients. We think it has something to do with a particular characteristic of those patients, so we assign labels, we ‘other’ them.
But it’s not any one characteristic that defines a patient. Rather, it’s the oscillating wave of perceptions that creates this confusion. That’s not a ‘them’ problem, it’s an ‘us’ problem.