Going to the doctor is like going to the car mechanic. It falls right between “trip to DMV” and “post office during the holidays” on the list of errands that we all hate doing. Just like the car mechanic, it can be expensive and even if they don’t fix the problem, you still have to pay. When they do find something wrong, you have to take their word for it and assume that whatever course of treatment they suggest is best. If you try to go against their recommendation they give a condescending stare and then ominously warn, “OK, it’s your life do whatever you want, but it really isn’t safe.”
But at least some people know something about cars that can give some advice. We all have a friend who spends the weekend with their buddies fixing cars. I don’t know anyone who sits around on a Sunday with friends working on each other’s hypertension.
Whether it’s your health or your transportation, it’s disconcerting to have such critical parts of your life in a black box of decision making. You don’t know how physicians are making their decisions. Surely they are thinking about what will make the best health impact, but what else are they considering? Cost? Pharmaceutical advertisements? Convenience? What about race?
In a time where white supremacy is no longer acceptable, a far more insidious form of racism is at play: unconscious bias. Implicit bias and microaggressions are difficult to describe and almost uniformly unintentional, but their impact is tremendous. Because medical decision-making is far more ambiguous than most people realize and involves the evaluation of subjective and incomplete data, it’s particularly prone to unconscious bias.
The CDC estimates that two thirds of adult Americans have either hypertension or pre-hypertension. Deciding the best way to treat this disease impacts over 70 million people. So when the Joint National Committee, a panel of experts on hypertension, released their updated guidelines at the end of 2014, it caused quite a controversy. While the guidelines included a plethora of recommendations, the debate has largely surrounded their recommendation that patients over the age of 60 have a more relaxed blood pressure goal of 150/90 instead of 140/90.
It’s been over a year since the new guidelines were released, but the debate continues. What’s so baffling to me is not that we keep discussing the 150/90 thing, I agree it is important, but that in all this time the most controversial part of the guidelines hasn’t been mentioned in public debate or the media: that physicians should treat black patients and non-black patients differently.
In a nutshell, the new guidelines recommend that certain blood pressure medications, ACE inhibitor medications (ACEs) and angiotensin receptor blockers (ARBs), which are recommended for non-black people as treatment for lowering blood pressure, should not be initially prescribed to black people. Given that, as a society we have accepted race as a social construct as opposed to a biological one, the implications of this recommendation are disturbing.
Guidelines based on shaky research
Guidelines are recommendations that are so strongly supported by research and expert opinion, that everyone should be doing them. This guideline was based solely on one study only, the ALLHAT trial. (Interestingly, if you compare the provided summary of the ALLHAT trial for patients to the one for physicians, the race recommendation was omitted.)
Even from its conception that study failed to make consistent scientific sense: it did not define what it means to be biologically black. In the study the researchers relied upon each patient’s racial self-identification – a social, not biological definition. Many people who are ¾ white and only ¼ black still identify as black because their skin color is still darker and/or they are treated as such by the people around them. But if they are ¾ white, does that make them biologically “more white?” Furthermore, the researchers categorized the groups into black versus white, Asian, other and Native American. How can you on one hand claim there is a biological basis to race and then at the same time decide that Asian, other, and Native American patients are similar enough to belong in the non-black category?
So how did such shaky research make the cut? It’s simple. Physicians and researchers are subject to the same racial biases as the rest of our society. It doesn’t matter how enlightened or non-racist you want to be, a racist society influences all its members. Couple unconscious bias with confirmation bias — the tendency to over-weight facts that support beliefs we already have — and it’s easy to see how this concept made it into the guidelines. We inherently believe that races are different, so we are willing to take any evidence, no matter how flawed, as proof.
Rather than go through the trouble of sorting out cause from correlation, a white-dominated profession finds it much more comfortable to assume that racial differences in health outcomes are due to biology instead of the truth, which is that race is a complex issue that cannot be reduced to one variable. By incorporating such stereotypes into guidelines we cross the line from unconscious bias on an individual level to racism, because now we are implanting that bias systematically.
All of this echoes eerily back to old anthropological “research” that proved white superiority through the measurement of skull size between white and black people. Of course, I’m not saying that these modern researchers are white supremacists; their intentions are certainly nobler. But the same racist pitfall is at play: over attributing observations to race.
Maybe there is an actual genetic polymorphism that causes different blood pressure responses to certain medications, similar to the way sickle cell anemia is a genetic condition more common in black people. However, we would never treat all black people as though they have sickle cell anemia just because it’s more common. We would never treat it without testing for its presence first.
Overemphasizing race is dangerous in medicine
I agree that this is a finding that is worth investigating, but it’s still in its infancy. The research isn’t compelling enough to make it a guideline. By including it in official guidelines, we continue to perpetuate ambiguity over the impact of race on medical outcomes.
At its heart, using race as an identifier is a proxy measure. Researchers like to assume that it has to do with biology but, in reality, the impact that race has on any individual stems from a whole host of things. One study found that black patients and white patients had the same blood pressure responses on an ACE at night while asleep, and that it was only during the day that the black cohort exhibited less benefit. A commenter said, “This finding is difficult to explain.”
Well, I have an explanation: On average, black people encounter more stress when they are awake and out working or living in a white-dominated society, which almost surely raises the blood pressure of many. That’s just my own postulation, but it illustrates the point that while statistics can prove correlation, they do not prove the cause.
Furthermore, ever since the first rumblings of this differential response between black patients and white patients, unconscious bias on the physician level has caused physicians to misapply the guidelines. Though the current guidelines only refer to initial choice of medication for high blood pressure in the setting of no other medical problems, there were reports of doctors all over the country ceasing to prescribe ACEs and ARBs to black patients at all, even when it is absolutely helpful in both races for patients with kidney damage.
Without being explicit about what it is we’re studying when we look at race, it continues to perpetuate a very dangerous concept: that good doctors should take into account skin color when they provide healthcare.
As physicians, we identify as humanitarian scientists. We don’t want to have racial biases. However, given the world we live in, it is impossible to see race and not have it impact us. Not admitting this prevents physicians from actually addressing the problem. Physicians frequently encounter patients who are in denial about their medical issues. We sadly shake our heads and try to explain that denial is only delaying necessary care and that in the meantime things will get worse. But it’s the same for physicians and racial biases, only the stakes are much higher: in this case, the victims of our denial are our patients.