Episode 60: Eliminating Bias as Part of Professionalism.
Featuring Dr. Augustus White III.
Dr. Augustus White is a pioneering African American physician and Harvard Professor and a leading researcher and writer about unconscious and implicit bias in medicine. Dr. White discusses how bias permeates decision making in healthcare to such an extent that racism, sexism, classism, ageism and other “isms” have a significant and negative impact on the quality of care. His latest publication is a call to action for healthcare providers to redefine their humanity and professionalism in terms of understanding and interrupting bias before it can do harm, and for patients to accept nothing less. With Eileen Bodie. Posted on August 19, 2020.
Eileen: Welcome to the Health Disparities Podcast. A program of the Movement is Life Caucus, where we have conversations about health disparities with people who are working to eliminate them. Good afternoon, I’m Eileen Bodie. I’ve been a member of the Caucus for 10 years, and I am honored today to be hosting today’s conversation with Dr. Augustus White III and talking about humanitarian health care.
Currently, Dr. White is the Helen and Melvin Gordon Distinguished Professor of Medical Education and Professor of Orthopedic Surgery at Harvard University Medical school. Dr. White has extensively researched the phenomenon of unconscious bias and its role in health disparities.
He has also led the way towards racial diversity in medicine as the first African American surgical resident at the Yale New Haven Hospital. Plus, interestingly enough, he has also served in Vietnam as a chaplain in the U. S. Medical Corps earning the Bronze Star. Good afternoon, Dr. White.
Dr. White: Good afternoon.
Eileen: We are honored to have you here today. I’ve been a fan of yours for years. I’d like today to talk about the recent new paper that you wrote with David Shernoff. It’s titled Medical Professionalism and Humanitarianism Healthcare in the American age of -isms. So how about we start with the idea of why did you publish this paper?
Dr. White: Well, I published this because, I was very concerned about the recurrence, the high visibility, the activity in our country, of so many forms of prejudice and -isms. Ageism, sexism, racism, homophobia, all of the inhumane, disrespects that people can perpetuate on one another is very concerning to all of us and particularly, when it occurs in and around issues of medicine, and where physicians are dedicated really in a humanitarian profession and their goal and their training and their proclivity is to treat people with respect and treat them well and be kind to them and to have, so much of these negative things going on in the society, as well as in medicine and in healthcare. And women are disrespected, elderly people are disrespected and it’s really quite common.
So, I was sensitive to, and aware of issues of medical professionalism. And there was a paper that came out maybe, or it’s probably 25 years ago now, but it’s called, “Medical Professionalism in the New Millennium”. And it was a document that was prepared by some medical societies, leading professionals and medical societies in several countries around the world, which included the U.S., and they published this document. The message was really that professionalism in medicine has three major responsibilities, to provide patient welfare, to look out for the welfare of the patient, to support the patient in professional, or at least in the patient’s own autonomy, and to address issues going on in the society that affect the patient’s health. And therein is where I weigh in and support assiduously and respect tremendously this doctrine of medical professionalism, which says not only are we responsible for looking after our patients, but we’re responsible to address as best we can, things going on in the society that are affecting the health of our patients.
Eileen: Medicine is a humanitarian effort, a passion of many professionals. How do these professionals treat patients not humanely?
Dr. White: Well, it’s the reality of our lives, I guess. And, I guess, again, this is one of the reasons we’re hoping that this paper will have some influence in the direction of having us try to move more in the zone of our humanity and empathetic care of our fellow humans, then a propensity in so much of medical realities today, has to do with inconsideration and lack of respect for care of our patients. Basically, are we a humane society? Or are we a society that is functioning too much, according to the law of the jungle? Where the people who have the resources, survive, or they’re not impacted negatively by the social realities that impact their health and therefore can result in their demise really, but certainly in terms of their poor healthcare. And so, we wanted to try to address that, to try to get people to revisit that based mainly on their humanitarian professional training and attitudes and things that do still, impact upon the choice that people make in their profession. I think most doctors are aware that they’re in a humane profession and are humane individuals.
Eileen: Why do you think that this paper is so important at this time? Why are its findings important for people to understand?
Dr. White: Why I think it’s important because the lack of humane respect, is so existent in our society. Frankly, the leadership, in our society, starting at the President’s Office and his behavior is obviously highly disrespectful of women, of elderly people, of immigrants and refugees, and he does not seem to be wanting them to be treated humanely, and this applies also to prisoners. And as I think we mentioned earlier, people who are, gay and lesbian and bisexual and transgender and queer, if you will. These are all people who are very visibly and without much concern being treated with disrespect. And I think that physicians, while they cannot, necessarily, prevent that they certainly can within their own arena within their own spheres of influence, they can make sure that they are being empathetic to patients and treating them in a humane manner. And I think this will be helpful to them and hopefully others will join in, and try to help us be a more humane society, as opposed to just, the law of the jungle.
Eileen: You mentioned in the paper that unequal treatment is often a product of subconscious mental functions, including stereotyping in the neurological interconnections of the brain’s emotional response and cognitive systems. Now that’s very complex, but you also say that people are sort of hard wired, and it’s very difficult to break their behavior and their unconscious bias. So, what can we do, or what can the healthcare community do to unwire this kind of behavior?
Dr. White: Well, I think the first thing would be to fall back on three words, education, education, education, and I believe that we can go a long way in improving behavior. I think people can be taught to recognize the things that are going on and be more aware of them to know that it can be more rewarding to them as professionals.
This brings us to another point, and that is we are now seeing a rate of as much as 50% burnout in physicians in their practices, and I think that this is in part due to their, somewhat diminution of empathy in their patient care. And I think when physicians are more empathetic, they are more rewarded because they are more humane and they’re more tranquil in their relationships and it’s more gratifying. I think there are other factors that are involved too, in this kind of the resurgence of the inhumanity and the resurgence of examples of less than ideal patient care. This lack of reward when physicians are empathetic, they give better care and they also enjoy their work better. And, I think many of us involved in education and us involved in hospitals and major medical centers around the country, including our medical school, Harvard Medical School, we are addressing the issues of burnout and recognizing that one of the contributors to burnout is this lack of empathy and lack of gratification on the part of physicians.
Eileen: Could the burnout be just because they’re so overloaded with patient load, they don’t have the time to spend with the patients. So therefore, they’re not having that kind of emotional bond, and so, the empathy is not there, not because they don’t want to give it, but because they don’t have time to give it?
Dr. White: Well, I think that’s a part of the reason. Yes, yes, I do. I think that’s part of the reason that there isn’t time. There’s more, stress from that alone, but there’s also more stress on them having to meet certain forms and fill out certain paperwork or the ways of hiring other people to help do that. But this all adds to the stress and the diminution of satisfaction on the part of the physicians. However, again, still, if you are being humane and doing the best you can and being humane, I think it’s more of a reward to the caregiver and tends to provide better care and tends to be more likely to not include burnout on the part of the physician.
Eileen: Do you think there’s more burnout in urban areas versus rural areas in medical care?
Dr. White: I’m not sure I have the knowledge to actually know that. I’m not sure the extent to which that has been studied. There are certainly plenty of reasons for stress and lack of professional gratification in both the urban arena and the rural arena. There’s no question about that. There are different stresses and there are different forces and there are different things that are causing diminution in the quality of work life for physicians. And, yeah, it exists both places and it’s very much alive in both places.
Eileen: What do you think are the key findings of your paper?
Dr. White: We don’t claim any, exclusivity originality, in recognizing any of these problems that is in recognizing the burnout and in recognizing the diminution of empathy on the part of the caregivers, and in recognizing the horrendous, very inhumane prevalence of the -isms that are going on in our country today. And I’m not sure our contributions are so much discovery. In fact, they’re not, but they’re rather recognition and agreement with the recommendations that were made in the professionalism, the medical professionalism. I think that is a wonderful thing for us to continue to encourage our students and all of the people that we are working with to revisit that and to try to work for patient autonomy for patient welfare, and for those activities in the society that are affecting our patient’s health, which would include all these -isms, if you will. And we can’t change all the -isms, but we certainly can stand in support of changing them and wanting to change them. I try to encourage people when I speak to them to recognize that we all have a sphere of influence and that we must act in that sphere of influence to do the right thing. To encourage people by example, and by what we’re actually doing to demonstrate a humane interaction with our patients and with other people with whom we’re working, and I think that has a multiplier effect. I know that has a multiplier effect and many people have recognized that. So, by doing that as much as possible and each little bit contributes pushes back against these, undesirable, inhumane, patterns that have been so, evident in our society these days. And so that is our hope and our expectation and our belief that these small pushbacks can combine, and we can think of them, I guess as Robert F. Kennedy talks about. He talks about small ripples of effect that, each of us do when we can, when we do what we can. And that these ripples of effect add up and can be a very powerful and forceful tsunami in terms of pushback.
So, I think, revisiting and striving to address the humanitarian aspects of medical professionalism will help the patient and will help the physician. It will help the patient get better healthcare. It will help the physician to be less vulnerable to, and to be less impacted by burnout.
Eileen: You said education is the key to really changing all of these -isms. And as a professor, what would you tell other professors who are teaching, medical students, residents, what can they do to be more humane? Can you give us a few examples?
Dr. White: Well, I think one example is, it is a gross generalization and something that my mom tried to teach me, and I think would apply to this, and it’s very, very simple, treat all people with respect. 360 degrees around you, above you, below you, but treat all of your fellow humans with respect. I think that is one step. And I like to when I’m trying to encourage these things and teach, to the physician and to the patient actually. I suggest that the physician humanized the patient when possible do something to have that patient know that you recognize them as a human being and as a person of importance. I think a smile, you can talk about the weather, grandchildren, family, whatever, and it doesn’t take a lot of time, but it’s just letting the patient know that you recognize them, not just as a patient and a problem that you can help to solve, but as another human being. And I think the patients can do that for the doctor if they have time with the doctor say something to recognize the doctor as a human being. I think when that occurs, that greatly facilitates the possibility for good rapport and empathy. And again, there have been studies that actually show that when the physician is empathetic, the patient is more satisfied and the outcome, the medical outcome is better. So, that’s one thing. The other thing is to help the physicians to understand, of course, that practices to address this, are better for the society and better for the patient and better for them because it’s a sort of a win, win, win situation, we believe. So, that’s what we tried to touch on in this, paper.
Eileen: If you had a dream in terms of how they could better teach young medical students, how to be doctors. What would that dream be?
Dr. White: I think it’s the kinds of things that I just said, really, in terms of teaching empathy and ways to express empathy and having the students understand that while it’s humane and important, it’s also in their best interest to engage in this reciprocal privilege. It’s a great privilege. There are not that many places where your work, your day-to-day ordinary work gives you this opportunity to have the gratification that doctors have.
Because of technology and knowledge and experience and so forth they, have enormous leverage and almost powered to be helpful. So, I think emphasizing those things and emphasizing the value that it will have for the patient and for the physician is real. It’s not just, in some hopeful dream, I think it really does occur.
Eileen: Can you give me a few examples of when doctors aren’t humane? What are some of the things that they do that hurt people on an emotional basis and perhaps even on a physical basis?
Dr. White: Well, I think the most common thing is that they don’t show that they’re recognizing the patient or caring about the patient or dealing with a human being. But rather they’re trying to get through the office that they may express their frustration with anything that could be anything. It could be the previous patient. It could be trouble getting a medical record that is needed. But when they respond in a way that leaves the patient out, doesn’t show any concern or respect or interest in the patient, but is very much interested in something else.
Unfortunately, the computer screen provides a very convenient way to do this, to satisfy this unfortunate propensity that some people may have. So, somewhere there in the relationship between the two human beings, one of the things that I think is, again, not to get too philosophical, but it is expressed in so many ways by leading people and that is to try to have us learn, to recognize and address the common humanity, between the physician and the patient. And people who refer to their fellow humans as Dr. Martin Luther King did, as Dr. Cobb did, as Nelson Mandela did, and the Dalai Lama did. Often, when they speak, they start their speech or when they meet a group of people, they refer to them as their fellow humans. I think an attitude and an interest in one another, as fellow humans and recognizing our commonality in being fellow humans. I think it’s 99.5 or 99.9% of our DNA is actually identical. It’s only that very small percentage that’s different. And I think that is a tremendous basis, for us to be able to be humane and more humane as we interact with one another.
But it is interesting how so many of the great leaders in the world, wrote about and utilized at one time or another in their interactions, the Dalai Lama. And, I shouldn’t say more about this without saying the fact that one of my very first mentors, and I’m not putting myself in the league with these people at all, but they did influence me tremendously, and that was Professor Montague Cobb, who was Professor of Medicine at Howard University, and I had the good fortune of having him as a mentor. I invited him to Harvard to lecture, and I invited him to Yale to lecture, when I was at Harvard Medical School and when I was at Yale Medical School and he came, and he was very impressive. When he addressed the audience, he began by saying, good morning, my fellow humans or good afternoon, my fellow humans, and that really inspired me. I understood what he meant. I understood that he was saying, we’re equal, we’re both humans and we should care about each other as humans. And, so I was just very happy to have Dr. Cobb as a mentor.
Eileen: Would you have any final comment in terms about the whole interconnectivity of human beings, sort of a final summation?
Dr. White: What an opportunity. Wow. Well, this common humanity certainly, is very real and very important. And it gets back again to what we’re saying about, are we living by the law of the jungle, or are we living as fellow humans, with responsibilities and opportunities for our interactions? Are we indeed equal and do we indeed have, all of us have certain rights? Right to healthcare, right to freedom and justice. But I think we need to assiduously advocate for this. I think, not only during times when the country, our environment is very disheveled and very much involved with stress and difficulties, but always, we must be careful to address these things.
So, I would say our common humanity is a good theme to recognize, and to do what we can to contribute to that, and recognize that we are always going to need to have some energy and motivation directed to the threats to our common humanity. I sometimes, as a non-historian, naively try to say that the history of the world is really an eternal battle between the good guys and the bad guys, the good girls and the bad girls. And, we have to recognize that, and the good girls and the good guys have to keep fighting. You have to keep fighting no matter if we might be losing the battle or might be losing the scrimmage. We might be losing; we have to keep fighting because ultimately the outcome is going to be a result of that battle. So, we have to stay in within our spheres of influence. And so, we have to try to do the right thing, as best we can with the energy and the ability that we have. So, I guess that would be my message.
Eileen: Dr. White you are truly an inspiration. You’re obviously a very good teacher, excellent teacher, and we have a lot to learn from you. So, we thank you for your time today. It’s an honor to know you.
Dr. White: Thank you. Thank you very much.
Eileen: And I hope all of you listeners out there have learned something from Dr. White today. Thank you today for joining us for this episode of the Health Disparities Podcast. We hope you found it interesting. Please remember to subscribe on iTunes, or you can sign up on our website to receive notification of new episodes. I’m Eileen Bodie on the behalf of Movement is Life. I thank you for tuning in. Good day.
(End of recording)
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