Dr. Shannon Prince on Racial Justice in Healthcare - Podcast Transcript

The pandemic has cast new light upon healthcare disparities. Vaccine hesitancy in minority communities has led to further discussions of infant mortality and other care disparities. On this episode of SoundPractice, we speak with Shannon Prince, Ph.D., JD, author of the new book, “Tactics for Racial Justice: Building an Antiracist Organization and Community.” Dr. Prince provides both disturbing statistics and practical suggestions to combat healthcare disparities.

This is an important topic that directly impacts millions of Americans. You will find Dr. Prince’s idea thought-provoking on this episode of SoundPractice.

Shannon Prince, Ph.D., JD

Mike Sacopulos:

My guest today is Dr. Shannon Prince. Dr. Prince holds a Ph.D. in African and African American studies from Harvard University. She received a law degree from Yale University and is the author of Tactics for Racial Justice. Dr. Prince, welcome to SoundPractice.

Shannon Prince:

Thank you so much for having me.

Mike Sacopulos:

I'm about to ask you a question about the term anti-racist physician. Can you define that for our discussion today?

Shannon Prince:

Sure. An anti-racist physician is a doctor who recognizes that race can harm one's life and one's health, and consciously works to mitigate those effects.

Mike Sacopulos:

How does one become an anti-racist physician?

Shannon Prince:

The most important thing is to recognize that color blindness can kill. For example, it can be tempting to think of a non-white body as just a white body with more melanin, and that's not the case. The way systemic racism manifests itself results in all sorts of disparities, such as access to healthy food, access to clean air, whether or not we are vulnerable to stressors, such as police harassment. People of different ethnic backgrounds, age differently, they sicken differently. So if you are a physician, you need to be aware that you have to be on the watch for chronic disease in a black patient a decade earlier than you need to for a white patient. You need to recognize that a black woman is at a greater risk for maternal mortality than a white woman is. And then you also have to respect the fact that race, not only determines how we get sick, it determines how we heal.

Although you should never assume that a patient of color is poor, it is important to recognize that in America, we have a wealth gap. White families have exponentially more wealth than families of color. The median white family has 22 times more wealth than the median Latino family. That white family has 41 times more wealth than the median black family. And the average white family has 10 times the net worth of a non-white family.

Why does that matter for medicine? If you're going to tell a patient, "For your health, you need to eat healthy," That that may not take into account the fact that if you're someone from a community of color who is more likely to be poor, you may live in a food desert. You may not have access to healthy food. If you tell a non-white person to exercise, you have to keep in mind that because of poverty, they may not live in a neighborhood where there are sidewalks that are safe to walk or jog on. They may live in an apartment that's too cramped to do cardio in. They may live in a neighborhood that's so polluted that if you go outside and try and exercise, you're going to trigger an asthma attack.

You have to think about how to work through those issues with your patient. So the first step to being an anti-racist physician is not being colored blind. It's seeing color and then treating the effects of color.

Mike Sacopulos:

I would assume that our physicians occasionally encounter explicit racism. How should physicians respond to acts of explicit racism?

Shannon Prince:

The first thing to keep in mind is that the time to decide how to respond to an act of explicit racism is not when it happens. It's not when the patient is there in the hospital bed or sitting on the table and saying, "Well, I don't want a doctor who is Asian or Hispanic or black or Native American," and then everyone trying to decide at the moment what happens. You need to come up with a plan for what you'll do if the situation is an emergency, which, of course, is going to be to stabilize the patient, but also what to do if the situation is not an emergency. You can make a decision as a practice that if you have a family practice or you're a primary care physician and a patient is racist, you just won't treat that patient, but you need to look at all sorts of situations.

What are you going to do if a child comes in with a racist parent? Make that plan before that incident happens; what are you going to do? If a colleague is called a slur? Even if it's an emergency and, at the moment, everyone is focusing on stabilizing that patient, after the incident occurs, don't pretend like nothing happened - debrief about it, comfort that person, understand how to be an active bystander. That way, if you're in a non-emergency situation and a patient says something racist about a colleague, you understand how to handle it.

For example, you address the comment and not the patient. You say, "Mr. Doe, what you said was racist," as opposed to, "Mr. Doe, you are racist." You're very firm about the fact that you don't tolerate that behavior in your practice. And then you're just mindful of what your colleagues deal with. When a doctor of color walks in the room in his or her scrubs, that doctor may be assumed to be an orderly. You need to know that your colleagues are dealing with that stress. You need to know how to support them in it. Make a plan for how to deal with explicit racism and be clear that if it's not an emergency, you won't tolerate it, you will address it, and then you will check in with your colleague after the fact.

Mike Sacopulos:

For some people, these are difficult or at least uncomfortable discussions. How can physicians discuss and debate racism effectively?

Shannon Prince:

The most important thing about discussing and debating racism effectively is to listen. Listen to what the other person is saying, and then offer a congruent response. In my book, I give the example of being a healthcare provider in a healthcare facility and advocating for more diversity. The person you're in conversation with may have a range of reasons why they don't think the staff needs to be more diverse or don't think that that should be a priority. You want to make sure that you are responding to what their actual concern is. And the way you do that is by saying, "So what I hear you saying is." It's by trying to characterize their beliefs fairly and make sure you get it and then respond to it congruently.

For example, your colleague might say, "Diversity is nice, but diversity doesn't affect patient care." And what you would say is not, "Oh, well, you're a racist." What you say is, "So what I hear you saying is that while diversity is a good thing, it doesn't affect how we treat our patients." And then you give a congruent response. So you can cite the George Mason University study that found that when black newborns are cared for by black doctors, they're three times less likely to die than when cared for by white doctors. And black newborns in America are plagued by infant mortality relative to white newborns.

The study incidentally also found that when a white infant has a black doctor, it's not at a greater likelihood of dying than when it has a white doctor. So you can show that diversity isn't just a frill. It does have a positive effect on the care you give. Or you might say, "So what I hear you saying is that the bottom line is no matter what one's skin color, everybody reads the blood pressure machine the same way." And then you can respond, "Well, yes, that's true. Everybody does read a blood pressure machine the same way, but the reason we should seek to hire more people of color isn't that they have this special cultural technique for reading a blood pressure machine. It's because people of color have been unfairly denied opportunities in our field or at our institution in the past. And just requires that we rectify that." So when you want to debate and discuss effectively, the key is to listen respectfully.

Mike Sacopulos:

That is a good lesson that needs to be learned by all levels of our society, I think. How can physicians unweave systemic racism in the medical field? It seems like these awful statistics that you're able to so easily cite have been around for a while. And our knowledge does not seem to translate to action, which seems to be called for by the very statistics. Can you help me? Can you give me some hope and some ways of moving forward?

Shannon Prince:

One way is to be proactive about continuing your medical education to make sure that you're a doctor who can serve all patients competently. In my book, I describe how most dermatology textbooks only have pictures of what's skin disorders look like on white skin. If you are trying to unweave that systemic racism, you need to be proactive about learning what skin disorders look like on skin that has various levels of melanin. Or for example, we know that when children have sickle cell disease, they're at risk of stroke. And there's a test that's been around for decades that can be given to screen children for this stroke. Because there's so little attention to sickle cell disease and how to treat it, which is not disjunctive from the fact that in America, people who suffer from sickle cell disease are mostly black, physicians don't screen kids, and the results are predicatively devastating. They had these debilitating strokes that could have been prevented. Unweaving systemic racism means understanding what populations of color need to be healthy, and then shaping your medical education so that you are equipped to provide that healthcare.

Another thing to do is to conduct a checkup on yourself. For example, a 2016 study showed that white medical trainees believe things such as black people's nerve endings weren't as sensitive. And we see disparities in the amount of pain care that black patients are given versus the care that white patients are given. Black patients are consistently given less. So just ask yourself, when I see a black person purporting to be in pain if I'm more likely to think that that person is a drug seeker, look back at the amount of medication you've given to different patients. Did you give more to similarly situated white patients than you did to black patients? Even though these are individual decisions and individual behaviors, they exist in the context of stereotypes that we have about whole populations, and they result in systemic issues. So be proactive about pursuing your medical education, and then do that checkup on yourself, and reflect on how you practice.

Mike Sacopulos:

Is that a checkup that you think needs to be done with some regularity?

Shannon Prince:

Oh, absolutely. It can be easy to get jaded. You can, for example, go into a hospital in an urban center, very confident and rightfully so in your anti-racist ethos, and then perhaps after you encounter some patients who are drug seekers, you start stereotyping all patients of color as drug seekers, or you become more cynical when someone says that they're in pain, not recognizing that black people don't abuse drugs at higher rates than whites. And that if you were at a white hospital, you would also be encountering a certain amount of drug-seeking patients. Just recognize that people are dynamic, people are fluid.

Mike Sacopulos:

Let's talk about historic racism of the medical field. And I'm sure that we could also talk about historic racism in our profession, the legal profession, but this is a podcast for the medical community. So I'm interested in what advice you would have, Dr. Prince, for physicians that are interested in or need to reckon with the legacy of historic racism in the medical field.

Shannon Prince:

I think it's important to orient yourself to disparities. So for example, in my book, I talk about how cystic fibrosis, which is a genetic disease that primarily affects white Americans, gets three and a half times more research funding from the national institutes of health, and 440 times more funding from national research foundations than sickle cell disease does, even though that's an equally serious genetic illness, but it's an illness that primarily affects black Americans, some Hispanic Americans. And this disparity occurs even though one-third, fewer Americans have cystic fibrosis than have sickle cell disease. So when one disease is getting that much more research dollars than another disease in the past and continue into the present, that means that a cure is that much more proximate for that disease that we're investing in healing than for the disease that we're neglecting.

It's important to look at those past disparities and think about how to rectify them. How can you serve your black patients who have sickle cell disease? What do reparations, for example, look like in the medical context? Should you, as a physician, be advocating for reparations to invest in cures to diseases that affect black people? Think also, for example, about the disparities in amputations. African Americans are three times more likely to undergo diabetic amputations than non-black patients, even though their amputations are often preventable. And if you look at a map of where people are most likely to get amputations, it maps onto which populations were most likely to have been enslaved. We see that the injustices that occurred back in the 19th century still affect disparities and how healthy people are and the treatment that they get.

Be mindful of the fact that the past affects and it infects the present. And then think about how you can rectify that before you amputate that black patient's leg. Is there a solution I could offer? Is there some other treatment I would propose if this were a white patient? Again, check in with yourself, conduct that checkup on yourself but be mindful that what you see today in your operating room, in your practice is a function of what happened in the past.

Mike Sacopulos:

How can physicians make a significant anti-racist impact if she or he doesn't have a formal leadership role at the time?

Shannon Prince:

Once you start doing all this homework, doing checkups on yourself, making a plan for how to handle explicit racism. Continue your medical education so that you can be a doctor equipped to serve all people. Studying history, once you're committed to not being color blind. Don’t be what I call color mute. Talk about color, share the knowledge you're learning, gather your colleagues. And it can be through you giving a CME offering on caring for multicultural populations. You can invite your doctor friends to your practice and just hold casual training. You can create an anti-racist physician reading group. And just regularly, everybody reads an article and a medical journal about a health issue affecting a population of color, and then you all circle up and discuss your findings. You don't have to be the head of a department to initiate these efforts. Anyone can do that, and you can even start these practices while you're in medical school.

Mike Sacopulos:

Do you believe that third-party payers and insurance carriers, for example, have any responsibility or duty to promote anti-racist medicine?

Shannon Prince:

Absolutely. And I think that one way they can do so is through the use of metrics. For example, if the insurance companies looked at how many black people whom they insure get amputations versus how many white people they insure get amputations, or how many white patients get an alternative treatment to amputation, as opposed to black people, they could see where there might be some disparate factors. Because they have the data, they know what they're paying for. They could use that data. They could make it publicly available, for example, with patient data redacted. They could make it available to medical schools. They could publish an article in a medical journal. They could share those findings in Congress so that we could see that not everyone is getting the same treatment. And third-party payers are in a wonderful position to make that information available because they have the data.

Mike Sacopulos:

As we talk today, our country certainly, in pockets, continues to battle COVID-19. Do you believe that the pandemic has focused a light upon racial disparities in healthcare?

Shannon Prince:

Absolutely. We see that different racial groups have different likelihoods of getting COVID and of dying from COVID. And that's for a range of public health reasons. We know, for example, that people of color are more likely to be essential workers, which means that they're more likely to come in contact with the disease. We know, for example, that if you are someone on the Navajo reservation, you may not have running water. And so, when you're being told, "Wash your for 20 seconds throughout the day," that's very hard to do when you don't have running water. And so, doctors just need to be mindful of the fact that you can't be color blind. Different patients are at different risks. They need different levels of care. Also, that different patients are carrying different allostatic loads. When a person who already, because of racial disparities, had a lower baseline of health gets COVID, that COVID is going to manifest very differently in someone who had a higher baseline of health. Thinking about how all these public health factors affect your patients, makes you more sensitive as you treat them.

Mike Sacopulos:

We've seen an increase in telemedicine as a result of the pandemic. Do you believe that telemedicine has created any increased sensitivity of physicians regarding their patients’ daily lives?

Shannon Prince:

I think that it's important to recognize that telemedicine is not a panacea, but it does offer some wonderful resources for doctors. First, it can make doctors accessible to patients who otherwise would not be able to reach them for or a range of reasons, lack of transportation, lack of childcare, or just a geographic gap between where the patient is and where the doctor is. Also, it allows you to look into somebody's home. You may be looking at them over Zoom and see the mold growing on the wall behind them, and that affects your diagnosis. But it's also important to recognize that telemedicine is not available to everyone, and it's disproportionately unavailable to racial minorities. So for example, a large chunk of Native American children live in homes that don't have access to the internet. I think that while telemedicine can be a great resource, it's important to recognize that some patients aren't able to take advantage of it at all.

Mike Sacopulos:

Could give our audience some suggestions of ways that they can go about promoting anti-racism in the medical field, in their daily routines.

Shannon Prince:

Sure. Anti-racism is often about the little things. You have to get the paper towels in your clinic from somewhere. When the lights go out, you have to hire an electrician. If you are going to have magazines on your waiting room table, they have to come from somewhere. Create a racial justice budget and support non-white vendors by purchasing goods and services from them. Get those paper towels from a black-owned company, hire a Hispanic electrician, order a black enterprise magazine, or a Jet magazine, or Ebony magazine, and have that on the waiting room table. The way you do this is to try and make your racial justice budget reflect population parity. If you live in a town where Hispanic people are X percent of the population, try and make sure you're spending your outgoing dollars with population parity. And then, hold yourself accountable. Just as you make sure that you don't go over budget in your spending, make sure that you're not going under budget in your diversity efforts.

When you're going to engage a white vendor, engage the ones that support diversity. The way you can find them is by looking at their EEO-1 report, which is a report that many businesses are required by the government to fill out that discloses their racial and gender demographic data for different job categories. Other companies that aren't required to fill this out still often do so just to be transparent, so seek those companies out too. Think about your waiting room. Why not put these wonderful graphic novels that are coming out about the civil rights movement on that waiting room table? Why not put a coloring book about the civil rights movement there for the kids in your pediatrician's office to play with. Just make those small decisions that help promote anti-racism, and just make that a daily part of running your practice.

Mike Sacopulos:

Great advice. Dr. Prince, thank you so much for being on SoundPractice.

Listen to the full episode on SoundPractice.com .