Just Medicine: A Cure for Racial Inequality in American Health Care

Chapter 6 of Just Medicine starts by referencing the enduring influence of the Hippocratic Oath, which emphasizes compassionate, holistic patient care that includes addressing societal injustice.

The chapter’s opening section discusses “Mechanism 5: Physicians’ Implicit Biases Influence Their Diagnostic and Treatment Decisions.” Despite many doctors denying having such biases, Matthew shows that implicit bias is prevalent and often affects medical care. For instance, some physicians unconsciously adjust their treatment recommendations based on assumptions about a patient’s race or socioeconomic status.

Matthew draws on five key studies that highlight the effect of physicians’ implicit racial biases on their medical decisions. These studies demonstrate how racial stereotypes can lead to unequal treatment, such as physicians being more likely to recommend thrombolysis for white heart disease patients over Black patients, or how pediatricians’ decisions on pain medication vary depending on their level of implicit bias. The studies suggest that the influence of implicit bias is not consistent across all conditions, further complicating the relationship between bias and patient care.

In addition to these studies, research also shows that implicit bias can lead physicians to underestimate BIPOC patients’ adherence to treatment regimens. One study, for instance, found that white physicians were less likely to prescribe effective HIV treatments to Black men, based on discriminatory assumptions about their likelihood to adhere to the regimen rather than accurate data.

Matthew argues that implicit bias contributes to the poorer health outcomes experienced by BIPOC patients, including more surgical errors and complications. This bias also influences referral patterns, with BIPOC patients often struggling to access high-quality care, such as diagnostic imaging.

Matthew points to the fact that, while social science research has its limitations in proving causality, many leading scholars assert that the association between physicians’ implicit biases and BIPOC health disparities is compelling enough to establish a causal relation. Matthew refers to theories proposed by social psychologists that racism, particularly unconscious racism, is a fundamental cause of health disparities. Thus, she notes, racism influences various societal factors, including healthcare, and operates across different diseases and conditions, making it a deeply ingrained issue that simple policy changes cannot easily address.

The following section, titled “Mechanism 6: Implicit Biases Influence Patients’ Satisfaction, Adherence, Compliance, and Follow-Up,” introduces the sixth mechanism of the Biased Care Model, which links physicians’ implicit biases to patients’ health outcomes through the patients’ own decisions after medical encounters. Patients who perceive bias, especially racial or ethnic discrimination, from their healthcare providers are more likely to experience dissatisfaction, mistrust, and avoidance of follow-up care. As Matthew notes, this mechanism is critical because BIPOC patients often report using coping strategies in response to perceived discrimination, but these strategies can negatively affect their health.

One of the key findings in this section is that BIPOC patients, particularly African Americans, Asians, and Hispanics, tend to rate their healthcare experiences lower when they perceive bias or discrimination. This dissatisfaction manifests in various ways, including reduced engagement with providers, lower adherence to treatment plans, and avoidance of future healthcare encounters. For example, patients with limited English proficiency may delay or avoid seeking care due to the frustration of being misunderstood or facing language barriers. Furthermore, Matthew cites research which shows that racial and ethnic BIPOC patients often have less trust in their physicians, leading them to withhold information, ask fewer questions, and exhibit less positive emotional behavior during their visits.

In addition, Matthew cites interviews in which she observed that younger BIPOC patients often act as cultural or language translators for their older relatives, which points to the central role that cultural understanding plays in healthcare. Patients who feel their cultural backgrounds are respected by physicians are more likely to comply with medical advice. However, the majority of physicians in the US do not share the cultural backgrounds of their BIPOC patients, resulting in a disconnect that can reduce the quality of care. As an example, an Indian-American woman describes how her parents’ adherence to medical advice increased when their physician accounted for their dietary habits, something that non-Indian doctors might overlook.

Research also supports the conclusion that patients’ perceptions of discrimination are directly linked to poorer health outcomes. Matthew cites one study in which African American patients who perceived racial discrimination had worse physical and mental health and were less likely to adhere to prescribed treatments. This perception often leads to discontinuities in care, as patients may leave biased providers, seeking alternative care or avoiding the healthcare system altogether.

In the last section of the chapter, titled “Applying the Biased Care Model to Pain Management,” Matthew illustrates how implicit bias leads to disparities in healthcare, especially when related to pain management. Matthew discusses studies that reveal that marginalized racial and ethnic groups often receive inadequate pain treatment. The subjective nature of pain assessments, combined with the risks of prescribing addictive medications, makes pain management especially vulnerable to stereotyping. Physicians tend to rely on racial and ethnic biases when facing uncertainty in patient reports. Thus, doctors may adjust their treatment decisions based on patients’ race and behavior, with Black patients often needing to display assertiveness to receive adequate care. Stereotyping influences physician trust and decision-making, often resulting in unequal treatment.

In Chapter 7 of Just Medicine, Matthew argues that unconscious racial biases in healthcare are controllable and not inevitable. The chapter challenges the complacency surrounding implicit bias, advocating for intervention to prevent such disparities.

In the section titled “Evidence that Implicit Biases Are Malleable,” Matthew presents evidence challenging the idea that such biases are fixed and uncontrollable. She cites research demonstrating that implicit biases can change through deliberate efforts or external influences, much like correcting bad habits. This model replaces the outdated notion of “automaticity,” revealing that stereotypes are flexible and responsive to new information (157). This malleability, as Matthew discusses, allows for interventions that can reduce biased attitudes and their discriminatory impacts, holding individuals and institutions accountable for addressing unconscious racism.

The section titled “Interventions to Transform Biased Care” outlines intervention strategies that can moderate implicit biases in healthcare, structured into three types based on their timing during cognitive processes: Type A, B, and C. Type A interventions occur before stereotypes are subconsciously activated and include distraction methods and “stereotype negation training” (159). This type aims to prevent the activation of negative stereotypes by diverting attention or through proactive training. For example, stereotype negation training helps individuals obstruct automatic stereotypes and replace them with non-prejudiced responses.

Type B interventions focus on promoting counter-stereotypes. These interventions decrease automatic associations with negative stereotypes by exposing individuals to positive examples within the BIPOC group. Matthew cites studies by Nilanjana Dasgupta and Anthony Greenwald, which showed that presenting images of well-regarded Black individuals or women in leadership positions could significantly reduce implicit biases.

Type C interventions focus on leveraging social and self-motivation to inhibit the expression of biases. Matthew uses studies by researchers such as Gretchen Sechrist and Charles Stangor to argue that perceived social consensus could either reinforce or weaken implicit biases, showing that people modify their biases in line with social expectations or to maintain a positive self-image. However, she notes that simply suppressing stereotypes without addressing them has been shown to backfire, increasing bias rather than reducing it.

Matthew emphasizes that these interventions, though backed by strong social science evidence, have not been widely applied in healthcare to address racial and ethnic disparities. She argues that understanding implicit bias as a malleable cognitive process has implications not just for healthcare practice but also for law and policy. Malleability evidence suggests that institutions can and should hold individuals accountable for addressing their implicit biases.

In the last section, titled “Limitations,” Matthew discusses the idea that implicit biases cannot be completely eliminated and notes that their reduction varies across populations. Some interventions lack practical application, and studies have shown mixed results, particularly with counter-stereotype methods. Matthew closes the chapter by arguing that implementing bias-reducing interventions remains difficult due to political and practical obstacles, yet it remains necessary to address persistent racial and ethnic disparities in healthcare.