Monday, October 27, 2008

Gender and Racial Bias in Medicine

We are far from a homogeneous society. The recent discussion on gay marriage is certainly one example of that. Gene Roddenberry's Star Trek vision of a society where there is no system of currency, no religion, and no racial (or species) or gender bias will never occur in our generation. Even some of the most tolerant people will resort to racial and gender issues when their back is against a wall. I have certainly seen "macho" men, who typically are often critical of women, hire a female divorce attorney to better their odds in court. I have seen more racism in Asia than I have seen in much of the United States. Not only are many Asian countries extremely prejudiced against non-Asians, but equally prejudiced against other Asians of different nationalities. A Chinese-American medical student I once had rotate with me was ostracized by her family for marrying a Vietnamese man (Vietnamese are reportedly at the bottom of the Asian pecking order). I also know an Indian-American resident whose family cut off all contact with him after he married a non-Indian who was not pre-approved by his family. Just look at the way women are treated in Arab countries. America may not be as bad as some would think.

In medicine, gender, age, racial and sexual biases must be put aside. I can never ever remember seeing a patient as anything but a patient. In medicine, we learn to compartmentalize our feelings and emotions. It allows us to be objective and effective. It has to be--at least in emergency medicine. I have heard objectionable conversation in a hospital doctors' lounge only to see the same physicians respond to the pit and and work heroically to save the life someone of color. I have seen doctors cry when one of members of the hospital housekeeping staff (a gay, black male) finally died of the AIDS we all watched him suffer from for two years. I dare you to find a physician or nurse who does not have a bias. These are, for the most part, put away in the treatment room. Health care providers are human. Bias is something learned, usually from parents. Barbara Bush once said, "Bias has to be taught. If you hear your parents downgrading women or people of different backgrounds, why, you are going to do that."

Yet, I just read an article in a journal that detailed the fact that women are not getting as aggressive care as men for STEMI (heart attack). That is ridiculous. While certainly gender and race affect certain aspects of the health care decision making process (e.g., African-American hypertension is treated a little differently than that in whites and men are less likely than women to have endometriosis). Beyond that, there is no excuse for women not going to the cath lab with the same regularity as men. The medical literature contains many articles about racial, age and gender bias in pain control. A study in Atlanta showed that African-Americans were far less likely to get adequate analgesia for the injury (an isolated long-bone fracture) than their white counterparts in an urban emergency department. The same researcher went to Los Angeles and found that Hispanic patients were less likely to receive adequate analgesia for their injury than non-Hispanic whites. Women are less likely to receive adequate analgesia for their chest pain when compared to men. Children and the elderly are vastly undermedicated for pain. I really don't think these biases are overt--just a part of who we are. Yet, they must be changed.

We are all human. We all take risks. Some of us are obese and subsequently suffer from diabetes, hypertension and early death. People who choose to smoke must understand that smoking can shorten your life. Even sexual practices can be harmful when taken to the extreme. In medical school, we had to work at the local STD clinic one day a month. On many of those occasions we saw the same patients--back with another STD. Some were prostitutes (male and female) and some were not. There is nothing sadder than a 21-year-old male prostitute with anal condyloma who will have to wear a diaper for the rest of his life because his "job" has led to fecal incontinence. We all play a role in determining our medical destiny.

Medicine remains both an art and a science. Today, there is more science than art. More of us need to compartmentalize our biases in the clinical arena. Whether you believe health care is a right or a privilege, everybody who seeks health care should be treated equally.

P.S. Just read an article in the Journal of Trauma. Age and insurance status were two major predictors of who ultimately survives trauma. I won't touch that one for a while.

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