Bioethics Forum Essay
TV Show Depicts Racism in Medicine
The television show The Good Doctor has always focused on issues of diversity and inclusion in medicine from its storylines to its casting. This week’s episode “Irresponsible Salad Bar Practices” asked an important question: Is medical practice inherently racist?
The episode opens with a Black female patient, Zara Norton, in medical distress. According to her physician, Dr. Claire Brown, Norton is “loud and messy,” and we quickly learn that she takes medication for high blood pressure and works in the cannabis industry. Brown, who is also Black, has to make a fast choice about how to treat her patient. The protocol she was trained in said that she should assume untreated high blood pressure with an ACE inhibitor—assume this patient is lying about taking her meds. Brown follows her instincts honed by years of training only to have a new resident point out that her actions were nothing less than racial profiling.
It turns out that Dr. Brown misdiagnosed and mistreated the patient who needs surgery to reduce the growth of her heart (hypertrophic cardiomyopathy). Initially Norton is pleased to see that she has an entire team of doctors of color: “My lucky day, three doctors of color taking care of me; doctors who won’t talk down to me, not exactly what I’m used to.” Norton’s surprise is not unusual since only 5% of practicing physicians are Black.
Later Norton learns about Brown’s initial misdiagnosis and treatment and asks for her to be removed from the team. Brown, Norton points out, has changed herself to “make white people more comfortable,” from adjusting her manner of speech and dress to adopting a white, medical way of thinking. Seeing Norton in the ED, Brown is reminded of the “loud and messy” persona that she shed to fit in.
The episode raises the question whether racism is not just part of the infrastructure of medicine, but also in its fundamental knowledge. Did Brown absorb the systemic racism in the hidden curriculum of medicine? Studies have shown medical students having biases against patients who are obese, LGBTQ, and people of color. As Brown learns when she looks at hospital statistics, Black and brown patients are generally undertreated for pain. Part of that is an assumption of higher drug use and part is a history of slavery where slave owners believed their property could not feel pain—a justification for abuse. Even though Norton works in cannabis, she is adamant that she never partakes. However, the team does not believe her until that claim is verified with a blood test. Implicit bias in medicine shows health care workers holding whites in high regard and assuming the worst of their patients of color.
Back when I was a masters student in medical anthropology, a respiratory therapist visited our class to talk about her work in inner city Cleveland. She mentioned that there was a scale for how much air should be forced into the lungs of patients based on their sex and their race. When this room of graduate students pointed out that race was a social, not a biological, construct, the health professional responded, “I don’t know about that. But I know this works.” The biases in the algorithms and decision trees also result in women being underdiagnosed and undertreated for heart conditions and lower the treatment eligibility scores of minority patients with kidney disease. These same decision tools are now making their way into artificial intelligence algorithms that are simply perpetuating and extending the biases of the data and expert opinions they have been programmed with—algorithms that are used to distribute organs, to assign risk of death, and even to schedule operations.
The Good Doctor suggests that racism is embedded in how we train doctors to think, no matter their own experience. While the episode does not offer a solution, it is imperative that we move away from the “I know this works” thinking. Recognizing the racism in medical practice is the least that must be done. Rather than relying on conveniences and workarounds that continue racist thinking and provide inferior care to patients of color, we need to embrace an anti-racist medical curriculum and practice.
Craig Klugman, PhD, is a professor in the health sciences at DePaul University. @CraigKlugman