By Adia Harvey Wingfield, author of Flatlining: Race, Work, and Health Care in the New Economy
At this point, it is safe to say that the coronavirus has laid bare foundational inequalities in American life–in access to education, work, housing, and perhaps most visibly, health and health care. Black Americans bear much of the brunt of these inequalities. They are more likely to be employed in “essential” jobs that cannot be done from home, more likely to have other health conditions that exacerbate the effects of COVID-19, and make up a disproportionate number of those infected with the virus. Black health care workers, however, may also be uniquely impacted by the demands their profession is currently taking. In my recent book Flatlining: Race, Work, and Health Care in the New Economy, I show that Black health care professionals are often dismayed and disillusioned by observations that their white coworkers treat Black patients with disdain and condescension, particularly when these patients are low income and/or uninsured. The below excerpt from Flatlining indicates how, in the current conditions of the pandemic, these experiences may be more pronounced than usual.
Because of their shared racial status and commitment to the public sector, black health care workers usually feel a sense of kinship and solidarity with black patients. This does not appear to be true for their white peers. To the same degree that black health care workers feel personally obligated to treat black patients with kindness and respect, they note that many of their white coworkers apply racial stereotypes to the patients they serve. Given black health care professionals’ commitment to caring for these populations (even at their own financial expense), seeing white coworkers dismiss or shame black patients becomes extremely frustrating. It also illuminates the ways racial outsourcing requires black professionals to do the equity work of assuming an outsize role helping organizations meet their stated goal of providing care for racially diverse populations.
In many cases, equity work is done subtly and without a lot of fanfare. Ella, for instance, makes it a point to stand close to and even touch some of her patients when she completes her rounds at the hospital. She is especially likely to do this for patients that she expects will not receive the same level of care and concern from her white colleagues. In one case, we had to deliver some very bad news to a young black woman patient. Before going in, Ella explained the patient’s history to me, and said, “She’s going to take this hard. It’s not an easy situation to be in and there’s really no right answer as to what she should do.” When we entered the room, Ella greeted her patient warmly, stood next to her bed while explaining the situation, and touched her arm reassuringly as she shared what would need to happen next.
At the end of the day, I talked with Ella a little bit more about this patient. When I asked her if she thought her manner was common among other physicians, she laughed outright and replied, “Girl, please.” Comparing her own approach to patients to her colleagues, Ella notes how her own attitude about treating patients evolved when she transferred to a hospital that served a poorer population:
“In my old practice, I served patients who are on Medicaid, but a lot of my patients were really kind of middle-class or affluent suburban patients. And so, if you were late, they penalized you. Right, I could still see you, but you were going to be seen after every other single on time patient before you.
“Here, I don’t do that anymore. Patients sometimes have to catch two buses to get to me, or they have to get their kid to school and then get here. If they don’t have transportation, they got a ride. I mean, the social situations are so complex that I will see you whenever you get there, because I realize that the average patient goes through a lot.”
Yet Ella continues on to point out that most of her colleagues do not share this sentiment about patient interactions. Instead, they are likely to assume ill intent:
“A lot of [my coworkers] don’t see that, and they’re just like, ‘These patients are always late. They have no respect for time.’ Or, we admit patients who are pregnant, a lot of a lot of times not because admission changes anything, but because they are so high risk that a bad thing could happen at any moment and we just want to be there to catch it. But for the young mom who is single and has 5 kids, who’s going to take care of her kids? Yet, when she decides to leave, we make her sign paperwork that says she’s leaving against medical advice. And it’s, ‘I can’t believe this woman would go home with this condition, and she is willing to kill her baby. And I advised her that all these bad things could happen, including death.’ All true. But, I mean, we’d also say she was a bad person if her five kids who are under the age of 10 are at home by themselves. So, [it’s easy for them to] forget the human aspect and the complex situations that our patients have and just operate as if our patients have the same lives we do. Which is unfair.”
While Ella takes pains to be cognizant of the social context in which her patients make decisions about health care, compliance, and treatment, her observations indicate that these efforts are not necessarily as common from her coworkers. Her perception is borne out by some interactions I witnessed between white practitioners and patients of color. During another visit to her hospital, I was heading back to the room where doctors and nurses convened for their morning meetings when I heard someone speaking loudly. Coming further down the hall, I noted that it was a young white woman nurse in conversation with an older black male patient who appeared to be in his seventies. I hesitated long enough to discern that the gist of the conversation involved the nurse’s frustration with the patient for failing to follow her medical advice. Before I ducked into the central room, I overheard her angrily ask, “Why are you standing?!?! I have told you so many times that standing is not good for your lungs or your abdominal muscles! You do not listen!” The patient simply hung his head and bore this scolding silently.
I did not say anything to Ella or any of the other doctors about what I overheard, but I did note that the tone and approach this nurse used was starkly different from the ways I heard black practitioners talk to black patients. To be sure, black health care workers sometimes expressed frustration with the patients they treat. They noted that some patients use the ER for routine care rather than emergencies, or they described feelings of irritation with patients who ignore their professional advice and refuse to vaccinate their children. However, I never heard black practitioners express these feelings directly to patients. They were exacting and careful about treating all patients, but particularly black poor ones, with the utmost respect, and often did so in ways that offered a sharp contrast to the interactions I witnessed between white practitioners and black patients in public care facilities.
Akinyele, the anesthesiologist mentioned earlier, argues that some of these differences are rooted in white practitioners’ racial stereotypes of poor black patients:
“Here’s the deal on the care. When a patient walks through the door, they’re there for help. Now, there are people who do take advantage. Or attempt to take advantage or try to get the most out of their visit, but the bottom line is we are there as service providers. The detractors say, ‘This person has no insurance, this person’s a frequent flier, this person only wants narcotic medication, they don’t really have a problem.’ But that notwithstanding, it shouldn’t determine or shape your care for them. You should care for them the same. There were many times when I saw patients shunned simply because of their skin color and what problems they presented with which may or not be prevalent in our communities, but that our community can’t help. But tell that over many years of time we began to change our own lifestyles. But that’s not something that can change tomorrow. So having a physician, if you want to use a lack of a better term, taking it out on the patient because of who they are or what environment they’re from, I thought was very unfair. Without considering that maybe it’s not the fact that they’re black or that they’re poor or–maybe they just don’t know. Maybe they don’t have education. And from my colleagues’ perspectives I’ve seen where they administer care and hopefully they administer it in the best way possible, regardless of how the patient looks or sounds, but there’s all sorts of anecdotal conversation about ‘I know how these people are when you give them medication’ or ‘I see this all the time with this population.’ Where is that research? Where is that evidence?”
Akinyele is careful to note that he hopes and believes his colleagues still administer the best care they are able to offer. But his comments also highlight that seeing white practitioners stereotype and denigrate black patients makes it all the more important for him both to monitor colleagues’ actions and to offer care that is thoughtful and considerate in contrast. This racial outsourcing has multiple consequences. It leads to equity work for Akinyele, as he watches coworkers to ensure that they are in fact treating black patients the same as others. This then creates dissension, frustration, and social distance from white coworkers who seem comfortable viewing black patients through derogatory racial stereotypes.