When & Why Women & People Of Color Face Lower Quality Healthcare & Worse Health Outcomes

Sep 16, 2019

Disparities in healthcare quality and outcomes for gender (including people who are transgender) and race are receiving more attention: for example, recent reports show black women have much higher mortality rates during and after pregnancy, and women and people of color receive less medical intervention for pain management and cardiovascular care. We discuss the history, systems, and personal biases that contribute, in a multitude of ways, to these disparities. 

Original air date: September 16, 2019 at 9 a.m. 

GUESTS:

  • Dr. Colene Arnold -  Gynecologist at Inner Balance Pelvic Health & Wellness Center in Newington. She specializes in pelvic pain disorders. She is also the co-founder of Hope on Haven Hill, which provides residential substance use treatment to pregnant women and their newborns.
  • Dr. Keisha Ray - Assistant professor at the McGovern Center for Humanities and Ethics, part of the McGovern Medical School at the University of Texas Health Science Center at Houston. Her work focuses on justice questions related to biomedical enhancement and racial disparities in health care, as well as research ethics and medical humanities. She is an associate editor of the American Journal of Bioethics.  

Transcript:

This transcript is computer-generated and may contain errors. 

Laura Knoy:
I'm Laura Knoy and this is The Exchange.

Bias in medicine is getting a lot more attention recently. For example, thanks to public education campaigns, many Americans now understand that with heart attacks, men and women present very different symptoms and that recognizing those differences can save lives. Still, overall, research suggests that women and minority patients are more likely to receive less effective care than white males. But it's not as simple as personal bias or stereotypes. It's that physicians are still relying on longstanding research, clinical trials and medical training. It's based on the body of your average white guy. So today, in exchange, we look at bias in medicine where it comes from and how addressing it can improve everyone's health.

Joining us by phone from Houston is Dr. Keisha Ray, assistant professor at the McGovern Center for Humanities and Ethics, part of the McGovern Medical School at the University of Texas. She's also an associate editor of the American Journal of Bioethics blog site. And Dr. Ray, really nice to have you. Thank you for being with us. With me in studio, Dr. Colene Arnold, gynecologist at Inner Balance Pelvic Health and Wellness Center in Newington, New Hampshire. She's also co-founder of Hope on Haven Hill, which provides residential substance use treatment to pregnant women and their newborns. And Dr. Arnold, nice to see you. Welcome back to The Exchange. Well, Dr. Arnold, I want to start with you. If you had to explain to somebody who never really thought about this before. Well, you know, bias in medicine, that's still a thing. How would you describe it? How would you explain it to the uninitiated?

Dr. Colene Arnold:
Well, I think one of the things we need to think back to is where does this come up? Where do we have bias? And one of the things is that we look at bias in the workplace, who work at bias in sports, how we raise our children, how we educate our students and just how we interact with one another. And that goes back to how we were raised and how we were educated ourselves. So part of that is the stereotype that you alluded to before in the stereotype that males are tough or females are more emotional. And so that is really deeply ingrained in our brains. And it's really hard to discern that, especially when you're thinking about a doctor taking care of a patient in a short 15 minute visit where we don't recognize that there is a bias that's present. We haven't been educated, that there truly could be a bias there. We're not even thinking about it.

Laura Knoy:
So it's not that doctors and nurses are, you know, terrible people know they don't like women.

Laura Knoy:
And there are plenty of female doctors these days. And certainly a lot of female nurses. So what is the bias then among, you know, good, well-meaning people?

Dr. Colene Arnold:
Right.

Laura Knoy:
So how does it manifest itself?

Dr. Colene Arnold:
If you if you take, for instance, pain, when we think about pain, the bias that I that I just spoke up with men is that they're they're tough, they're macho. And if they actually are showing that they're in pain, then that pain must be above and beyond what they could normally handle. And for women, a little bit different for women. If she's showing her pain, then the bias is that she's emotional, she's anxious, she's over exaggerating. And again, that goes away back to ancient Greece times.

Laura Knoy:
Ancient Greece, meaning go ahead.

Dr. Colene Arnold:
So this is it really interesting. And I found it to be in my in my research. The uterus was thought to be the source of hysteria back in ancient Greek times. And one of the thoughts about the uterus was that it wandered around the body. And if it wandered up to the head, then it manifested itself in hysteria. And since women were the only ones who had a uterus, it was thought that only woman could have the condition of hysteria. And so being overly emotional. Is again ingrained into our upbringing and into this inherent bias that's been around for eons.

Laura Knoy:
Well, and Doctor, I have to say, when I approached this topic, I thought, wow, this still really exists. How would you describe it to someone who says, you know, bias in medicine? That's what you work with. Dr. Ray, what is that?

Dr. Keisha Ray:
So first, I would say that it's first really important to remember that doctors, nurses, anyone else in the health care profession are people just like anyone else. Just because they go through different kinds of training and just because they put on the white coat doesn't mean that their biases in there, they may be better equipped to handle scientific things, things of medicine, things of health care. But ultimately, they have the same biases that we all have. And add on that doctors and nurses that they see patients in the most worse situation that they've been in. Right. They see very ill people. When you're ill, you're grumpy, you're angry, you're tired, you may be frustrated, you're not feeling well.

Dr. Keisha Ray:
And so sometimes when you see people at their very worth, it can reinforce the stereotypes or the biases that you already have. So when people, particularly black Americans, when they're going in to see health care professionals, sometimes the biases that we all have that health care professionals also have can sometimes be used and intercept their care. And so racial biases or racial dumb, very racial disparities in health care are just these different ways that are biases interact with patients. And that's what I study.

Dr. Keisha Ray:
Can you give us a couple anecdotes or stories, Dr. Ray, that you've heard of or that you've written about?

Dr. Keisha Ray:
So, one I can think of that I'm writing about right now is differences in sleep health.

Dr. Keisha Ray:
So sometimes African-Americans will go see doctors and complain that they aren't sleeping. And sometimes there are their worries or their concerns are sort of dismissed because there is these larger problems at play. Right. So racial disparities in health care don't just start in health care. Many times it's because these patients, before they come to the hospital, are already disadvantaged in some way, whether that be not. Would that be having lower income, whether that be less access to quality education in terms of sleep health? Black people in America sleep significantly less than white people. And we see that that is partially least partially due to neighborhood quality where that being noise pollution or air pollution or safety.

Dr. Keisha Ray:
So by the time that they come to see a health care professional when they can mind you because of access issues. But when they finally do, oftentimes their concerns are not really listened to and sometimes they're just given a pill.

Dr. Keisha Ray:
And, you know, health care professionals can only do so much. They can't treat the social issues that are causing someone not to sleep. You also see racial disparities in diabetes care. There are it's more much more likely for a black American to have limb amputations or for a professional to recommend limb amputations that are a result of diabetes complications than it is for a white patient coming in with the same symptoms. And so a lot of times, again, it's partially due to medical racism and racial biases in the health care setting. But it's also due to a lack of access to social goods and to social determinants of health before they reach the clinical setting.

Laura Knoy:
So, Dr. Ray, setting aside the economic disparities and the you know, the neighborhood factors and the income factors and the other things that you mentioned.

Laura Knoy:
But setting aside those economic disparities, what is bias in medicine look like? Are you saying that if someone, you know, a white person, middle income and a black person, middle income, both had the same health care plan, both walked into the same doctor's office with diabetes woods, a black person still be more advised than the white person to lose a limb due to diabetes sometimes?

Dr. Keisha Ray:
Yes, that's exactly what we're seeing. It's exactly what we have a lot of quantitative research to tell us that even when you have the same type of patient with the same type of background, just different races, that they get different care recommendations. We are also seeing similar to when black women are dying disproportionate numbers in during birth and after birth, that even though they have higher incomes than their white counterparts, that they are still subject to racial bias. So it's sometimes it's not even just a matter of education and income, because even when they make more money or they have higher education, they are still subject to these racial disparities in health care.

Laura Knoy:
Wow. So a white woman, lower income, maybe less good health care. Dr. Ray, you're still saying she has a better chance of surviving pregnancy than a black woman?

Dr. Keisha Ray:
Yes. At least in America. Absolutely. In other that the death rates for black women who are. Giving birth or have recently given birth. Still, are there deaths, there's still much higher than white women. Even when does white women have high school education? And these women? Black women have higher degrees such as PhDs, M.D. and JD.

Laura Knoy:
Wow. Okay. So here's a clip from WXIA TV's Atticus Investigates. This is a show in Atlanta about maternal mortality rates in black women. This has been a big issue recently. And we're gonna hear from the husband of Kira Johnson, who died in surgery after giving birth. As you'll hear him describe, waiting hours for a C.T. scan.

News Sound:
I said wait at nights thinking, man, like, maybe I should've grabbed somebody by their car, right? Maybe I should have turned the table, right. Would that have made a difference?

News Sound:
I definitely thought about the whole issue of I didn't want to be seen now as angry, but angry black man. I'm not the smallest guy in the world. And what that would mean and how we would be perceived and how we would be treated as a result of that perception. When this first happened, I would get the question a lot. Well, do you think it was because she was black? You'd think we'd be different if Kira was white with a different color.

News Sound:
And the way I answer that question is the simple fact that you have to ask that question again, that's the husband of Kira Johnson who died in childbirth.

Laura Knoy:
That clip from W. Exile TV in Atlanta. And Dr. Arnold, you were sadly nodding while that clip played. What does that bring up for you?

Dr. Colene Arnold:
Oh, it's just it is very emotional, too, to hear that, too. To have the family recognize that there was something wrong and the patient know that there was something wrong and the medical institution just not recognizing it.

Laura Knoy:
Well, and as a gynecologist, too, so you deal with pregnant women and their babies and you heard him, Dr. Ray, say, I didn't want to sort of go overboard in terms of demanding care because I'm a large African-American man and I didn't want to come across, as as he put it, the angry black man. What do you think, Dr. Ray?

Dr. Keisha Ray:
I think that is so ingrained in just what it means to be a black person in the United States that I sadly could relate to exactly what he was saying. There's, you know, the angry black person trope and particularly the angry black woman trope. And so sometimes you see things are wrong and you see that things could be differently, maybe should be differently, particularly in a life or death setting. But you don't want to have people not listen to you because you maybe raised your voice or maybe because you are very passionate and they take that to mean you're angry and then you don't get the care that you need. And so you're trying very hard to walk this fine line of making noise and making people listen to you, but doing it in a certain kind of way, a kind of way that they can respond to and not be afraid of you.

Laura Knoy:
Then again, that's a story from Charles Johnson, whose wife, Kira Johnson, died. I want to remind our listeners that you can join us. Dr. Arnold and Dr. Ray, you first. Dr. Arnold, please. One of the issues with this bias in medicine seems to come up a lot for women and you alluded to this earlier is pain. So what is it around pain where women's pain seems to be approached differently by the medical community, seems to be diagnosed differently, seems to be treated differently?

Dr. Colene Arnold:
Well, I think one of the things that the main thing is that women are not believed when they come in with complaints of pain, that if a woman appears stoic and she's not showing her pain, she's not believed if she comes in and she shows her pain, then again, she's overly emotional or exaggerating her pain. You know, we all know it's sometimes hard for us to recognize that this actually exists and we need to see proof of that. And one of the things that I think about is so women, again, not being believed when they're in pain and then when we're talking about racial disparities with black women not being believed, there was a study that showed when women presented with pelvic pain, white women were more likely to be correctly diagnosed with endometriosis when they actually had it than black women.

Dr. Colene Arnold:
They were more likely to be diagnosed with pelvic inflammatory disease PID, which is a sexually turn, oftentimes sexually transmitted. And that is it's horrible that that type of bias exists. So say that again, because that's important. Just spell that out for people who aren't as familiar with oh, with white in the large women when they come in with presenting with pelvic pain. In this particular study, they were diagnosed with the correct diagnosis of endometriosis, which is an inflammatory condition within the pelvis itself associated with the menses. And for black women, instead of the correct diagnosis, they were more likely to be assumed to have pelvic inflammatory disease or PID, which is a sexually transmitted association.

Laura Knoy:
Wow. So medical professionals automatically assumed, quote unquote air quotes here, bad behavior was the cause of the black female patient's parent.

Dr. Colene Arnold:
And also just I think what we're seeing, too, with black women is that there is an assumption that they don't know their bodies, that they don't understand, that they're not educated about their bodies. And so there's an assumption that what they're coming and presenting with may not be the correct. Diagnosis.

Laura Knoy:
Wow. That they're just not as up on how their bodies work. Even though, you know, anybody can open a book or Google or find out or talk to someone really interesting. Dr. Ray. What do you think?

Dr. Keisha Ray:
Yeah, I would like, Dr. Arnold said everything perfectly. That's exactly what the research is telling us. Even when we look at patient testimonies, particularly from black women, when they tell us about their clinical experiences, we're seeing that these typical tropes of black women are used, one, that they are hypersexual lies and that if they have some sort of illness or pain, that it's likely self inflicted in a sense that they did something wrong. And that is the cause of it. We're also seeing this strong black woman trope that is sort of prevailing in the black community. I think it's somewhat getting better. But this idea that black women have to be still weak and have to take pain and have to keep going and ignore that pain signal that their bodies are telling them. And so when they come into a clinical setting, they hold on to this stoic attitude and doctors mistake that for not being in pain. So their pain is not treated adequately. They're given ibuprofen or something rather than a recommendation is the especially the recommendation for a stronger pain medication.

Dr. Keisha Ray:
So it's this sort of two fold problem of how healthcare professionals see black women and how black women see themselves and how they interact with their caregivers, which are oftentimes not white.

Dr. Keisha Ray:
So there's this sort of this barrier that naturally happens between black women and they're oftentimes white caregivers.

Laura Knoy:
Interesting. All right. And Steve's calling from Nottingham. Hi, Steve, you're on the air.

Caller:
Good morning. Thank you for this subject. I want to show there is a danger and just see you all as a bias, arguably example.

Caller:
This was at a Martha's Vineyard? My son who was owned, said that I overdosed on my wife's friend's extracts. I called the emergency department at the vineyard and they said, Are you African American? I was insurance. I'm a doctor. What the hell are you asking that question for? Who should know when to slow down? If you were African American, you should come to the emergency department right now. This is these are things you could obstacle for a nuclear crisis, a maelstrom. Okay. So in other words, though, are some differences where men and women are not prejudiced or factors that are biologic.

Laura Knoy:
You know, Steve, I actually really appreciate that point because I've read some research that said that understanding the biases in medicine and understanding the way different ethnicities and men and women interact with different medicines, the different afflictions that they have. I heard it called gender based medicine, but that can actually help everybody if we understand some of these differences. So I really appreciate the call. I'll get our guests thoughts on your call, Steve, after a short break.

Laura Knoy:
And I encourage other people to call with your comments and questions about bias in medicine.

Laura Knoy:
This is The Exchange I'm Laura Knoy today. Bias in medicine. What it is. Why it still exists. And new attention on this issue. With me in studio, Dr. Carlene Arnold. Arnold, Gynecologist, Inner Balance Public Health's Health and Wellness Center in Newington and co-founder of Hope on Haven Hill. And joining us by phone from Houston, Dr. Keisha Ray, assistant professor at the McGovern Center for Humanities and Ethics. That's part of the McGovern Medical School at the University of Texas. Dr. Ray is also associate editor of the American Journal of Bioethics blog site. And Dr. Ray, to first.

Laura Knoy:
But, Dr. Arnold, I want your thoughts too, Dr. Ray, real interesting call from Steve, whose son, who is white, had an issue called into the emergency room. They asked if he was African-American and said if he were, he might be having problems related to sickle cell anemia. So this gets into to I think what bias really is. Is it is it bias? Is it lack of understanding, Dr. Ray, or is it both?

Dr. Keisha Ray:
I think it's a little bit of both.

Dr. Keisha Ray:
I think sometimes we take the natural biological differences between men and women, and then we use that to make certain claims about how they should be treated. And I think that's where we go wrong, is they usually it turns into you will treat men this way and treat women this way when it's not warranted, when there are biological differences. Sure, then there are calls for different kinds of treatment.

Dr. Keisha Ray:
But sometimes that turns into... You get less care because of this biological difference and you get more care, you get more understanding and more just more, more concern because of these biological differences. And I think that's where the trouble is.

Laura Knoy:
That's interesting. Can you give us an example of what you're talking about there? Like more care or less care based on biological differences?

Dr. Keisha Ray:
Sure. So you see this a lot when we think about having a heart attack. So research tells us that when men have a heart attack in a public setting, say, at a park or at a lecture hall or something like that, something where it's not in their own home, that they are more likely to survive. And that is directly related to bystander intervention, someone Perry's and caused 9 1 1. Someone hurries and maybe started CPR, someone you know, someone helps them out when it's women. Women are less likely to survive a heart attack in public. And that is again, directly because a bystander, a lack of their intervention. Either they don't understand that women are having heart attacks because they don't know what it looks like on women.

Dr. Keisha Ray:
Maybe they're slow to interact. And I think that when you see, yes, there are biological differences and maybe even some differences in how these heart attacks are are portrayed. But that doesn't mean that because they're different, that women should have less bystander intervention. And I think that's again, that's where the issue is, is that we see these differences and that makes us do something different that then endangers their life and their health.

Laura Knoy:
Yeah. And this is an area, I think, Dr. Arnold, where public education, pain campaigns have been pretty robust recently, although the message, you know, needs a while to get through. I love your thoughts, too, on efforts to educate the public about men's and women's heart attacks and what Dr. Ray said about how the public reacts differently.

Dr. Colene Arnold:
Yeah. So that's one of the things we're alluding to is something called precision medicine, where we're really looking at the differences between one sex and another one race in another and catering directly to those those differences. And it absolutely does take a long time to change societal ways also for physicians and other health care practitioners, because some of us who've been out there for a while, we're trained that the standard was the 70 kilogram Caucasian male and 70 kg is a hundred and forty some odd pounds. And that's no longer the average male either. So we can make a difference as well. But we we really so it is important to look at that precision medicine. But then you can't get stuck in that. I really appreciate Dr. Reed's writings. And one of the things that she wrote about was a black woman coming in with hypertension.

Dr. Colene Arnold:
And the practitioner and I should let her talk about this. But what really stuck with me is that the practitioner said, well, we're going to use this the anterior retentive because it works better. Black people. And so she did. The patient came back in again and it wasn't working and she said, well, I don't know why it's not working. It's supposed to work for black people.

Laura Knoy:
On the other hand, and Doctor Ray and I would love your thoughts. And that practitioner was trying to recognize the possible biological differences. Maybe where that practitioner fell down was saying, well, why isn't working? What's wrong with you? But at least that person was trying. Do you think?

Dr. Keisha Ray:
Yes.

Dr. Keisha Ray:
I also want to make it clear that that patient was myself, that, oh, it's okay that that to me, you know, full disclosure. Yeah.

Dr. Keisha Ray:
My experiences mean when I was first diagnosed with hypertension back in college. And I think where the problem is, yes, the doctors and actually multiple doctors did try to help me and they did try different medications that are known to have success in African-Americans. But I think where my doctors failed me is that when it didn't work for me, they kept trying, but they kept trying because they had these other other normative conclusions about myself. They didn't ask the right kinds of questions. They assumed that I was poor. They assumed that I was uneducated. They assumed that I wasn't doing my own research. They assumed that I didn't have doctors and nurses as family and friends at my disposal to help me along this journey. So when they made these diagnoses and he kept saying, you know, we're going to try medication, even though you're your your blood pressure is at stroke level, we're gonna keep trying. Because it should work for you. And I think why they kept doing that was not just based on the biological differences or not just because of their medical findings, because if they were relying just on medical findings, then they would have tried something else because they were relying on tropes about black people and black women.

Laura Knoy:
Interesting. So because if that had happened to me, my guess is they would say, oh, Laura Knoy not working for you. Let's try something else.

Dr. Keisha Ray:
Exactly.

Dr. Keisha Ray:
And that's what we're finding, that it's not necessarily bad. You think about biological differences is unhelpful and downright harmful when we say, OK, let's keep trying these things even though they're not working. You keep relying on these biological differences when the individual in front of you is presenting themselves different than the stereotype or different than what you think of a black person or of a woman.

Laura Knoy:
Well, it's interesting.

And I want to go to another call. But in a few minutes, I do want to ask both of you about the research that undergirds what we're seeing, because as you both mentioned earlier, it's not that doctors and nurses are terrible people who don't like minorities, who don't like women. It's more that there a lot of the research is still based on the experience of your average white male and isn't taking into isn't taking these factors into account. Brenda is calling in from Rye. Hi, Brenda. You're on the air. Welcome.

Caller:
Hello. Good morning. Thank you so much for addressing this big issue. I belong to Hadassah and Women's Health Organization and it's major that we're addressing the discrepancies in care. But what I had happen just two weeks ago in the hospital here after a major surgery for a carotid artery. I couldn't move my head a little. A doctor hospitalist came in the room and stood near the door. I said, excuse me, could you come over here where I can see and hear you? And he turned his back on me and pointed to my son. Professor Stephen Johnston. He said, I will talk to him.

Laura Knoy:
When was this? Brenda?

Caller:
It was on July 24th, about also this year. Just a few weeks ago. I'm still recovering from the surgery, but the. And he came in my room three times while I was there each time. Rude, dismissive. I didn't know what it was. This man whose name was Ahmed.

Laura Knoy:
Well, I do want to put his name on the air because we don't know what was going on with him that day. But go ahead, Dr. Arnold, does this sound typical?

Dr. Colene Arnold:
Well, what I'm hearing is there may be some ageism bias there. That's another type of bias to say I should talk about. Yeah, they're definitely as far as the research with coronary artery bypass, when men have surgery such as that and they complain the pain, they receive pain medication. And studies also show that when women complain of pain, they're more likely to receive sedatives. So that emotional bias that women are overreacting to their pain and they just need to be quieted or sedated for their anxiety and not actually treat the pain that they're complaining of. So there's, again, some inherent bias there.

Laura Knoy:
Is there a reverse bias for male patients if they present with pain? Right. Yes. And you know, you're saying when women present with pain, the assumption is it's emotional or hysteria.

Laura Knoy:
We all know now that our minds and our bodies are linked.

Laura Knoy:
So if a male patient presents with pain and that pain may have a psychological, I want to say direct cause, but his psychology or his emotions play a role in it. Are doctors less likely to catch that?

Dr. Colene Arnold:
Right. And they're more like more likely to actually prescribe pain medication because they're acting in a way that's above and beyond what they normally could handle. And typical male stereotype is that they can handle a lot of pain. They're tough.

Dr. Colene Arnold:
So, you know, my concern for that is that if we are over treating men with pain medication is inadvertently putting them at risk for substance misuse and not perhaps paying attention, listening for cues about underlying, you know, depression, mental health issues, underlying emotional issues that might be causing that physical pain. We underplay that for men.

Dr. Colene Arnold:
Right. And honestly, when you're looking at that 15 minute visit that that physicians and other health care practitioners have with their patients, it's so hard to really comprehend everything that we need to bring into play when we're trying to address a patient's complaint of pain. You know, definitely the the brain is connected to the rest of the body. And I talk to my patients about that all the time, that it may not be the reason. It's not a psychosomatic problem, meaning it's not all in your head, but your head is connected to the rest of your body.

Laura Knoy:
And with men, we might ignore that more. With women, with women, we might overplay it. Right. Wow. So could we save, Dr. Ray, that understanding and appreciating bias in medicine really does help everyone, all races, men, women, everyone?

Dr. Keisha Ray:
Absolutely. And it helps patients and it also helps physicians and nurses. They a they are on the receiving end of biases, too. So when we talk about racial biases and medical racism, we're also talking about the racism that nurses and doctors experience from their colleagues and as well as from patients. That makes it harder for them to do their jobs and be mentally well and also help their patients be healthy as well. So, yes, understanding racial biases helps everyone that is a part of the health care team.

Laura Knoy:
Let's take an e-mail from Jane who says The story of Kira Johnson reminds me of Serena's story after the birth of her daughter. She had a history of pulmonary embolism. She felt pain and symptoms of the pulmonary embolism, as she had previous previously experienced and was dismissed by nurses and doctors. This is a woman with a history of pulmonary embolism, and she is Serena Williams. She had to advocate and advocate to get the imaging required and was subsequently diagnosed again with an embolism. How to eliminate, Jane asks the, quote, inherent bias that exists with race and gender. And that's what we're trying to figure out, Jane. But I wonder what you think about this, Dr. Ray.

Dr. Keisha Ray:
I think the case of Serena Williams is really interesting because it goes to support exactly what I mentioned when we were speaking earlier. And that is that sometimes in calm, sometimes even celebrity status doesn't help black women not be the experiences of racial discrimination in health care that even someone as popular and as well known as Serena Williams still had to fight to be heard. And I think that goes to support that many times. Black women, women in general aren't seen as reliable or trustworthy narrators of their own story that they don't know their bodies, like Dr. Arnold said.

Dr. Keisha Ray:
And I think what what we're trying to do to sort of help this myself and many of my colleagues around the world, around America, excuse me, we're trying to bring more humanities education in medical schools, because I think that's really where we can. Help with the problem is that students. They know the numbers about pain, they know about the biological and physiological representations of pain. But what they don't know is the human side. They don't know how it is expressed in language, how is expressed in behavior. It's how it is expressed in their own thoughts. And I think that's why medical humanities and health humanities educators are really, really trying hard to bring this into medical schools to teach future physicians. This is what it means to be in pain. This is what it means to say their gender and racial disparities in pain.

Laura Knoy:
Wow. So all our humanities supporters out there probably cheering for you, doctor. Right. So literature and history can tell you about another group's experience can help you, especially in the terms of literature, help you get inside somebody else's head and maybe have a little more understanding of what they might be going through or at least help you ask the right questions.

Dr. Keisha Ray:
Yes, it can and I mean, And there's other things, too. I have colleagues that are in music. I have colleagues that are in acting, colleagues that are in history and in English and public health. And we're all trying to do the same thing. Let's try to bring the human experience of pain. So that way when students are in clinical settings and then when they become decisions in medical settings, that they can understand the subtleties of pain and that they can understand that this is what it means to see a person in pain and to feel a person in pain and to have them tell you their story and for you to interact with that story and use that to treat them, not just what you see on the chart, not just the numbers, not just what the diagnostic tests are or are not telling you.

Laura Knoy:
Well, and to Jane's broader point. That is the point we're trying to answer this hour where this bias comes from in both of you've talked a lot about belief systems. What else, Dr. Arnold? You know, old medical textbooks, do medical students even use textbooks, studies that doctors and training nurses in training that are based on poorly weighted populations know populations that are still largely white male. But the research results continue to be used. The research hasn't been updated. Mean what else? besides this inherent bias, lack of understanding, call it whatever you want, but what else is out there in terms of training that is creating this?

Dr. Colene Arnold:
Well, I think that's very interesting. When you speak of the original studies that were made on all of these different medications that we use, say in practice, many of them were performed on Caucasian males. So we have to recognize that a woman's body and a woman's physiology is vastly different from that.

Laura Knoy:
So give us an example.

Dr. Colene Arnold:
So women are premenopausal, they're menopausal, they're postmenopausal. Any given month in a premenopausal woman's cycle, your hormone levels fluctuate from the beginning to the end of that cycle. And so, of course, you have to realize that the way that we metabolize medication, the way that we respond to medication may be different at any given time. And that's partly why women were left out of studies, because it was it was thought to be too costly to integrate women into those studies. It was much easier to do studies on pharmaceuticals and other entities using a male.

Laura Knoy:
Is that still the case? Because, you know, women supposedly, I would guess, make up roughly half the population.

Laura Knoy:
So is that still happening now where research on pharmaceuticals and medical procedures is largely done with a test group of white males?

Dr. Colene Arnold:
That's not that's a longer answer than I have.

Laura Knoy:
Then we will tackle it after a short break. I can't wait to hear what you have to say. And I'll also ask you, Dr. Ray as well. Lots more of your e-mails.

Laura Knoy:
This is The Exchange. I'm Laura Knoy. Today, bias in medicine. What it is, why it persists and how it affects health outcomes. Send us an email exchange at an HP morgue or call 1 800 8 9 2 6 4 7 7. Dr. Colene Arnold is with me in studio, gynecologist at Inner Balance Pelvic Health and Wellness and co-founder of Hope on Haven Hill, which provides substance use treatment to pregnant women and their newborns. From Houston, Dr. Keisha Ray is with us, assistant professor at the McGovern Center for Humanities and Ethics. That's at the University of Texas. She's also associate editor of the American Journal of Bioethics blog site. So both of you, Dr. Arnold, let's tackle that big question that we were starting to jump in to before the break. The studies that medical professionals use, that guide their treatment, that guide their prescribing. You're saying they are still largely based on studies of white men, and I am surprised that that is still the case.

Dr. Colene Arnold:
Well, one of the things that we should think about is that, you know, medications that have been out there for a while, we're not doing new studies on them.

Dr. Colene Arnold:
Typically, they're based on older studies.

Laura Knoy:
I see we're not updating the safety and efficacy studies.

Dr. Colene Arnold:
So, you know, I question that all the time. As a medical doctor, can I feel safe in prescribing some of these types of medicine to the women in my practice that I've been only studied in men? And do I really know that they've only been studied in men? I don't always read those studies on medications to that extent. You know, women are 50 to 75 percent more likely to have an adverse drug reaction than men. And is that because we just don't have enough information on women to be confident about any certain drug? Most of us have heard about of the sleep medication, Ambien. It's prescribed over 40 million Americans each year in 2013, which is just six years ago, the FDA announced that it was requiring the recommended dose of Ambien to be cut in half for women. Over the years, the FDA had received about 4 700 reports of people getting into motor vehicle accidents the morning after taking the drug. Mostly women. Well, new studies found that women take longer to clear the drug from their bodies. And eight hours after taking the sleeping aid. Their levels were high enough to impair their drive. Oh, wow. Sadly, women were included in the studies of Ambien. And when the FDA approved the drug in 1992, the data showed that women's blood levels of the drug were 45 percent higher than men. But it wasn't thought to matter.

Laura Knoy:
How could that not matter?

Dr. Colene Arnold:
That's a good question.

Laura Knoy:
No one wants a woman driving around feeling impaired because of some drug that was mis prescribed.

Dr. Colene Arnold:
So biology does make a difference.

Laura Knoy:
You know, Dr. Ray, I'm guessing it's expensive for drug companies to retest their medical equipment. Certainly they're their prescriptions and so forth. What have you seen in terms of the way prescriptions especially, but we can talk about mental medical equipment are studied and tested and why haven't those studies been refreshed?

Dr. Keisha Ray:
I think one part of it is money. It would be very difficult and very costly to go back and redo these studies on certain medications. It would also be time. I mean, also be costly in terms of time.

Dr. Keisha Ray:
And I think people sort of say, you know, we have this. It works. We have the data. Let's move on and analyze. It is analyzing of the data who is involved in a clinical trial? It is just it's just not a concern. And so when you see stories and you see there the data such as what Dr. Arnold was saying about Ambien, it becomes less important. You say, hey, we have the research that tells us it works. Let's move on to the next thing. And I think that's a great disservice to women and I think a great disservice to the general public, because women who get in these cars and drive are not just hating other women. They're hitting other people as well. So it's really a great disservice to everyone, not just women. But I think it's it's not just prescriptions, too. It's also medical devices like like hip replacements. That is a well known area.

Dr. Keisha Ray:
And where the difference is in hip replacements for men and women. The research is done on men. So hip replacements are studied. It tells us how they're they're made to sit men's bodies, how they move, how they walk, those kinds of things, how they participate in activities. So women are reporting a greater dissatisfaction with their hip replacements. And this is particularly after sex, because hip replacements for women do not.

Dr. Keisha Ray:
It doesn't fit their body the way they move in, the way that they move, particularly during sex. So they are reporting is greater dissatisfaction with their life after a hip replacement. And it's basically because this medical device was not tested on women and it was it's not designed for their bodies.

Laura Knoy:
Ok, Doctor, I find that shocking because we all know that men and women's hips are quite different. Anyone, you know, speaking as a longtime athlete, I can assure you that, you know, my particularly hip structure is different from men's hip structures. And sometimes that leads to, you know, different types of athletic injuries that women tend to get versus men. We're just balanced differently. Dr. Ray. I am absolutely shocked that hip replacements were not tested on men and women.

Dr. Keisha Ray:
Yeah, I mean, I am shocked as well. And after a hip replacement, when you go through the checklist of how satisfied are you with life now that you have your hip replacements, one of the things that people always say can make their life better or worse is how happy they are with their sexual life. And if hip replacements don't allow women to enjoy their sexual activities, then they're going to have a greater dissatisfaction with life. So it's really a bigger issue that this medical device is not tested on women because it also makes them greater dissatisfied with their overall life, not just with their hip replacement. And why women are not why these devices are not tested by women's bodies, why they aren't a part of the research.

Dr. Keisha Ray:
You got me there. It seems obvious exactly what you said. It seems shocking that it's not, but indeed it's not.

Laura Knoy:
Let's take another call. And this is Rosaline in Manchester. Hi, Roslyn. You're on the air. Welcome. Thanks for calling in.

Caller:
Thanks for having me.

Caller:
So my question is is how does the medical bias fit in with transgender health as a transgender woman myself? I've had the luxury of going to a doctor and having myself basically not being diagnosed with anything, just being like, oh, you're just imagining it and then being kicked out of.

Laura Knoy:
Wow, that doesn't sound very helpful, does it, Rosaline? So thank you for the call and Dr. Ray, have you written about this in your work in bioethics?

Dr. Keisha Ray:
I have transgender health has some of the same biases that we see in gender and gender disparities and gender biases and health, but they also change gender, health and transgender individuals also have their own unique experiences and their own unique biases. Some of the similarities, I would say, is being ignored. As the caller pointed out, that happens. That's one of the things that is an overlap between women and men going into a clinical setting. And transgender individuals going into a clinical setting. But there are also some things, unique, certain biases about what gender means and how we assign gender that is unique to the transgender experience. And I don't want to take away from that and say that it's the same as all because it's really not.

Laura Knoy:
Here's an e-mail from Carol who says, Laura, would you ask your guests about the time constraints on physicians dictated by the institution they work for or the insurance companies? Makes it pretty tough to get to know your patients under such limits. And, Carol, you're so right. And you talked about this earlier, Dr. Arnold, but just address that issue again.

Dr. Colene Arnold:
Oh, my goodness. Thanks for the question. Yes. So when my pet peeves and institutionalized medicine is the RVU. It stands for revenue valued unit. And that's basically what patients are brought down to their considered RV use. And a clinician is they look at how many RVUs they see in a day. And you have to meet certain criteria to maintain your salary and potentially even maintain your job. And 15 to 20 minutes with a patient, a new patient and somebody with pain, a diagnosis that may be really difficult to make because you can't see it. It's just it's so troublesome. I honestly, I've worked with chronic pelvic pain patients and I take an hour to 90 minutes with my patients because it takes an hour just to get their story so I can not see a patient in 20 minutes. And I can do this because I'm in a private practice. But if I worked for an institution for a hospital, I couldn't do that.

Laura Knoy:
Boy, when we talk about pain especially, it takes a long time to figure out pain.

Dr. Colene Arnold:
So on average, the patients who come to see me have seen seven to eight different doctors over already. Aid's worth of time. How? Because they've been dismissed. So they're in bad shape by the time they come to you. So, yeah, I mean, they're there. Their process has caused their pain has progressed significantly when if only a doctor had taken the time to work with that patient. And and even if they didn't know what the diagnosis was, find somebody who could help them. And don't just stop with that patient.

Dr. Colene Arnold:
When you click off on their note,.

Laura Knoy:
You know, I'd love to as we talk about pain and taking the time to dig into, you know, what it's really about, what it's coming from, how to find the best treatment. I'd like your thoughts to Dr. Ray and what we talked about earlier in terms of women's pain is often dismissed as a, you know, an emotional problem, men's pop, men's pain. Perhaps we don't pay enough attention to the emotional side of that. That seems to play into our emails. Comment about the 15 minutes. And I wonder if you think Dr. Ray.

Dr. Keisha Ray:
Yes, I think I think the 15 minutes is a big problem. I think also, though, one way to sort of help get more of their patients story is to make better use of our medical students. Right now, I teach at a medical school, so I interact with medical students. And many times they will attempt to make us establish a connection with the patient, get more information that they can then relate to the attending or to the resident that is primarily seeing the patient. I think that's one way to sort of make use of this 15 minutes.

Dr. Keisha Ray:
But I do think that there when we talk about gender disparities, particularly in pain, that we do have to think about how we treat men in this and that sometimes men are there. They're very emotional. State is dismissed. And I think we can't ignore the emotional part of pain, particularly when they've been in pain for so long or they've been trying for so long to get proper care and proper management for their pain. But it's a two way street. When we talk about gender disparities, there's some for men and and some for women.

Laura Knoy:
Here's an email from Michael who says, Is this a problem without a solution? I used to think that technology held the answer. But even though technology, specifically artificial intelligence, has been shown to aid in providing better outcomes, we know that there is bias in technology either in the programmers or in the data to inform the A.I.. Is there a role? Michael asks. In technical for technology, in reducing biases in medicine and Michael, thank you for the e-mail, Dr. Ray, what do you think?

Dr. Keisha Ray:
You know, I'm not sure, because when we look at some of the data, it tells us that racial disparities exist even when the diagnostic tests that are that technology gives us tell us and show us indicators for pain, that even when this machine or this technology says this person is probably in pain, we still then have humans that are interpreting that data and then making the decision about what to do. So I don't think that the answer is just in technology. I think it's in the human interaction.

Dr. Keisha Ray:
And I think that's where education and I think that's where medical and health humanities in medical schools and in pre medical schools as well, pre medical programs. That's really where the solution is. I don't think there is that this is a problem with no solution. I just think we have to examine the possible solutions and then make the efforts to to start there.

Laura Knoy:
How much would having more diversity in the medical field help with medical bias? What do you think? DR I wanna hear from you too, Dr. Arnold, but go ahead, Dr. Ray.

Dr. Keisha Ray:
I think that would help a lot. I think many times our patients, particularly our black patients, are seeing decisions that are not black themselves, are not people of color. And I think that there is a lack of understanding about how the experience of being a black person in America also affects health and how it affects our interactions with the healthcare professionals. So I do think that that would help a lot. I think it will also help colleagues. I myself have been in that position where another colleague, a white colleague, has an issue that is related to a student of color. And I'm called in for assistance.

Dr. Keisha Ray:
And I think having those colleagues who you can also rely on for help is also really important. But if those physicians and nurses and other practitioners of color aren't there, then they aren't there to see those patients. They aren't there to be a helping hand for their colleagues. And so I think that that would actually it would help a lot. And I think that starts in making sure we have more diversity in our pre medical programs and undergraduate education and making sure that we have more diversity in our medical schools.

Laura Knoy:
So, Dr. Arnold, Dr. Ray has talked about the importance of the humanities and ethical studies, also the importance of having a more diverse medical field. What else might help address this issue of bias in medicine when it comes to treating men, women, people of all races?

Dr. Colene Arnold:
I think we have to start with the assumption that we should be believing our patients and not that they're coming with another agenda or that they don't know what they're talking about. I think it's very important that we believe that when a patient presents, that they're in pain, that they're in pain. And I know that at times in healthcare, we are very we're very cautious about when somebody comes in pain. Are they just trying to get an opioid? Are they trying to get disability? You know, we we we confront them with a sense of mistrust where I think it's very important to make that first interaction that you believe that that patient is presenting with what they're actually presenting.

Laura Knoy:
It's easy to understand why doctors these days will absolutely be, you know, looking out for people who are seeking opioids, given the ravages of the opiate epidemic on the state of New Hampshire.

Dr. Colene Arnold:
Yeah. And I can tell you just with my own practice, that working with patients with chronic pelvic pain in the last couple of years, I've not had a single person ask for an opioid and I've not prescribed it either. What else do you think would help Dr. Arnold? So besides the humanities, which I think is huge, I didn't get any humanities in my pre education or in medical school or in my residency, I think it's huge and it's important to really look at every every body part as you're going through the process of showing that, say, gender or racial bias exists. You have to do it in cardiology after due to nephrology. You have to do it in gynecology. It can't just be one class for one. And then you also have to address every physician, physician, assistant and nurse practitioner. That's already out there. Who's practicing? Who didn't get this training? So you have to integrate that into continuing education as well.

Laura Knoy:
Continue education and also. And I don't know who would do this, but busting open some of those studies that you and Dr. Ray mentioned, where the population studied for the efficacy of a certain medication or as Dr. Ray said, hip replacement surgery. We're all done on men. I don't know who's gonna bust open those days and pay for them to be redone, but that seems like another avenue that both of you have talked about. And to our guests, Dr. Ray, thank you very much for being with us today and taking the time out. We appreciate it. Of course. Thank you. As Dr. Keisha Ray, assistant professor at the McGovern Center for Humanities and Ethics at the McGovern Medical School at the University of Texas, also associate editor of the American Journal of Bioethics blog site. And Dr. Arnold, it was nice to see you. Thank you for coming in. Thank you. That's Dr. Colene Arnold, gynecologist at Inter Balanced Pelvic Health and Wellness Center in Newington and co-founder of Hope on Haven Hill. This is The Exchange on New Hampshire Public Radio.