In defense of not treating everyone the same

As a third-generation Black physician who has experienced firsthand discrimination from health care providers, I wish I could say medicine has changed since my grandparents’ days. But it really hasn’t.

When my grandparents and parents practiced medicine, Black doctors represented only 3% of providers. Today, I am one of the 5% of providers across the U.S. who identify as Black or African American. I’ve spent a large portion of my career being an advocate, educating myself and others, and illuminating the unconscious bias that pervades our health care system. More often than not, I’ve received push back from fellow providers and health care administrators, with many feeling it wasn’t their problem. Instead, it is “my problem.”

Numerous initiatives have been launched to improve health for people historically underserved by the U.S. health care system, most aimed broadly at reducing health disparities. I applaud these efforts and the energy and purpose behind them. But I have begun to ask myself and others, “Are we taking too broad of an approach?” In other words, while the general premise is that everyone should be treated the same, should they really?

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Let me be clear. Health equity is the ultimate goal. It’s been well argued that the Black community should be treated the same as others. That means Black Americans should be prescribed pain medications on par with their white counterparts. Or breast cancer screening guidelines should be the same for all women, despite alarming racial disparities. There are endless reports showing that Black people are not being treated in the same positive manner by providers, and the Covid-19 pandemic has further illuminated issues around access to health care.

Yet just as the scales of justice aim to balance truth and fairness in our justice system, our health care system, too, must find the balance between caring for Black Americans in the same way as everyone else while at the same time providing a tailored approach that, just as importantly, does not. This would represent true health equity.

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This balanced or more inclusive approach must fully acknowledge the unique sociocultural realities and experiences of individual patients and their impact on physical, behavioral, and mental health. Perceived discrimination has proven to be a psychological stressor commonly associated with a range of chronic diseases. Disproportionately poor brain health has even been observed in aging Black Americans who have particularly endured discrimination.

I ask my health care provider peers to ask themselves, “Am I considering these aspects as part of a whole-health care approach with my patients?”

A formidable place to start is where I opened this essay. Health care leaders must insist on a deeper bench of care professionals with the cultural competence necessary to reinforce trust with the Black community. White clinicians are less likely to acknowledge when patients are treated unfairly based on their race, which may promote harmful unconscious bias in racially discordant encounters. A recent study from the National Bureau of Economic Research revealed that Black patients can achieve higher preventive care rates when they receive care from a Black clinician. Yet a recent Yale study found that, while minority patients have a desire for culturally competent physicians, they have little access to them.

The Biden administration’s support for higher-education institutions to recruit more students of color for a more diverse public health workforce is proof of this urgent need. Medical education and provider networks need to rise to the occasion and better train all physicians to interact with patients from various cultures and with different beliefs.

Many Black people today do not feel heard or understood by their health care providers. They do not feel they have relationships with “the system” based on trust. The onus is on health care leaders to provide a safer and welcoming environment, and the first step is admitting there’s a problem. Those of us working as providers and administrators within the health care system must acknowledge unconscious bias in health care and leave any unnecessary patient assumptions in the waiting room.

Until true health equity is achieved, what if a Black patient could experience a health ecosystem that is designed to address her or his individual needs? An ecosystem that has been designed — based on real-world data and input from Black Americans — to solve their needs across access, cultural sensitivities, health challenges and support?

One way to do this is to ensure that the Black community plays an important role in informing and redesigning a health system that has not been designed for them. Taking a page from efforts such as the CDC’s Racial and Ethnic Approaches to Community Health Program (REACH), the Black Innovation Community Coalition, of which I am the executive champion, was launched this fall by virtual care company Included Health (recently rebranded from Grand Rounds Health and Doctor On Demand) in partnership with major employers like Best Buy, Genentech, and Walmart. The coalition will rely on the community to inform a first-of-its-kind virtual care model designed to advance health equity for Black Americans.

Telehealth can also play a role. Some have argued that the rise in telehealth could widen health disparities. I disagree. I believe that virtual care can address the issue of access by offering tailored, quality health care at scale to people in many under-resourced communities. As it expands to become a more integrated tool for chronic care management, virtual care serves as a clearer window into the lives and homes of patients for a deeper understanding of the social, familial, and cultural aspects of their health. It can provide high-quality and more-frequent touch points to collect and measure data in real time to better inform education, care, and positive outcomes so desperately needed in underserved populations today.

Advancing health equity requires everyone to commit to the fact that not all hearts, bodies, backgrounds, living conditions, and social statuses are the same. Do Black Americans like me want to see better? We demand better.

Underserved populations like the Black community need to be treated the same in terms of fairness and respect. Yet it is also essential to ensure that this definition of fairness and respect includes treating people as unique individuals where and when it’s most needed. Can health care providers deliver on this? We can, by pushing the boundaries to raise the standard of care for all. Only then will we achieve true health equity.

Ian Tong is a Black physician and chief medical officer of Included Health.


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