The Whole Physician: Ten Action Items to Combat Peer-to-Peer and Institutional Racial Bias in Medicine

Systemic racial bias is defined in the Cambridge Dictionary as “policies and practices that exist throughout a whole society or organization, and that result in and support a continued unfair advantage to some people and unfair or harmful treatment of others based on race.”¹ In the US health care system, systemic racial bias affects interactions between peers, hospital administration, academic institutions, professional societies, and pharmaceutical and device companies.

Although all professionals of color practicing medicine experience racial bias to varying degrees, Black physicians (see Box) experience racial bias to a greater extent than members of other racial or ethnic groups.² Despite good intentions of physicians and attempts by medical institutions to mitigate bias, significant disparities persist, including underrepresentation of Black individuals and other individuals of color as medical students and in medical school faculty positions.

For change to occur, policies regarding diversity, equity, inclusion, antiracism, and social justice need to be implemented.

We identify 10 actions to combat peer-to-peer and institutional racial bias in medicine (Table), which have been relatively underexplored compared to racial bias in the physician-patient relationship.³

• Action items 1 through 4 are strategies that can be implemented by individuals.
• Action items 5 through 10 are strategies that can be implemented on the organizational or societal level.

1. Be Aware of Your Implicit Bias

Bias formation is a result of a complex interplay of personal interactions and societal acculturation as pertains to race, ethnicity, and other factors. Explicit (conscious) bias refers to stereotypes or preconceived notions of which we are aware, and that shape our decision-making and interactions with others through our words and actions. Implicit (subconscious) bias refers to stereotypes or preconceived notions that influence our thoughts and actions on a subconscious level. Actions that are under the influence of implicit bias include body language, eye contact, and physical proximity. Everyone has implicit bias to varying degrees, and implicit biases do not necessarily align with the stated beliefs of the person harboring them. Recognition of implicit bias may result in embarrassment and defensive posturing, at times resulting in denial of the existence of subconscious bias. Such denial prevents the opportunity for personal growth, which is necessary to dismantle the negative consequences of implicit bias.

Racial bias often manifests as microaggressions, which are brief and commonplace verbal and behavioral cues, intentional or unintentional, that communicate hostile, derogatory, or negative attitudes toward people from marginalized groups. Microaggressions can result in the targeted individual experiencing invalidation, differential treatment, being held to higher standards, receiving fewer resources, and being falsely thought to have lower professional skills by colleagues, medical staff, and executive leadership. Furthermore, microaggressions are correlated with secondary traumatic stress and reductions in quality of life.²

Implicit bias may create a dissociation between what a person consciously believes and wants to do and the hidden influence of negative implicit associations on their thoughts and actions. As an example of how implicit bias might affect conditions in a workplace setting, consider a scenario in which the chief of a department strives to treat everyone equally. In this department, 2 physicians—one White physician and one Black physician—make the same mistake when treating different patients. Both physicians, 6 months apart, failed to implement deep vein thrombosis prophylaxis, and both patients experience a nonfatal pulmonary embolism. The chief’s immediate internal reaction to the White physician is that he made a minor oversight that can commonly occur among physicians, and the chief downplays the incident in his mind.

Six months later, the chief’s immediate internal reaction to learning of the same error made by the Black physician is that the Black physician lacks competence and acted carelessly, which could have proved fatal. In this scenario, the chief is conscious of how implicit bias works, recognizes these biases, and treats both situations and physicians, as objectively as possible. In these types of situations, with leadership less focused on maintaining equitable practices and recognizing the insidious nature of implicit bias, Black physicians may have policies applied to them in a different manner compared with their White counterparts. This can result in higher rates of Black physician resignation, financial challenges, psychologic trauma leading to posttraumatic stress, and/or erroneous or excessive disciplinary action.

On a societal level, the stigmatization and criminalization of Black Americans have been omnipresent in US culture, which has created an implicit bias against Black Americans. When there is a conflict between 2 people and 1 of them is from an underrepresented group, the person from the underrepresented group is often perceived as the aggressor by outside observers. This effect is amplified if one of the people in a disagreement is Black, and even more so if they are male.⁴ Compared with race-blinded scenarios, Black people were more likely to be found at fault when the mediator was aware of the race of the parties involved.⁴ In real-world conflicts, both parties in a conflict should be heard by an impartial outside party, preferably blinded to the race of both parties, and opportunities for reconciliation should be granted in lieu of one-sided punishments. Societal representations of African Americans also cause implicit bias among African Americans. It is erroneous to assume that only those outside of one’s race can develop implicit bias toward members of that race.

Implicit biases on the basis of race have been shown to have an adverse effect on patient outcomes. A study performed at Massachusetts General Hospital assessing the presence of implicit racial bias and differences in treatment plans for patients of different races experiencing a myocardial infarction revealed that higher levels of subtle subconscious bias on the part of physicians correlated with a lower likelihood of treating Black patients versus White patients with thrombolysis.⁵ As such, physicians with implicit bias toward Black patients may be likely to have implicit bias toward Black colleagues as well. Tools are available to help individuals become aware of their subconscious bias, including the Implicit Association Test developed by researchers at Harvard University (https://implicit.harvard.edu).⁴

2. Do Not Change Your Identity to Remedy the Implicit Bias of Others

Assimilation is when a minority culture is fully absorbed into the majority culture. It is unidirectional, and only the minority culture changes. In contrast, acculturation occurs when the minority culture changes, but is still able to retain unique cultural markers of language, food, and customs. Acculturation is a bidirectional process in which both cultures change. Society generally accepts diversity as a concept as long as members of minority groups act, talk, and think in familiar ways. As such, society encourages people of color to deemphasize their unique cultural identities to fit the mold of White cultural norms.⁶ As a result, many Black individuals expend substantial energy to “act White” to make White people feel comfortable by only expressing certain aspects of their personality, speech, and physical appearance.

An anecdote provided by one of the authors illustrates how these dynamics present in real-world medical environments. During a physician career coaching session, a psychologist suggested that male physicians of color must act excessively docile to avoid the perception that they are aggressive. In contrast, physicians who are not Black who act assertively are considered strong leaders. The suggestion to a Black physician to act less assertively lest he be perceived as aggressive is inappropriate. As such, acculturation rather than assimilation should occur, and people of color should not feel the need to mute themselves. Instead, others should become more accepting of different cultural identities and expressions despite it potentially making them feel uncomfortable.

3. Speak Up if You Are a Target of Racism

Physicians of color carry a double burden: first, the need to respond to experienced inequity; second, the expectation to fix these dynamics. Speaking out against long-entrenched power dynamics carries risks including retaliation, alienation, and loss of promotion or leadership opportunities. Physicians of color often are reluctant to speak out and thus may remain passive and self-protective. With regard to the second burden, people who are targets of racism cannot be expected to rise to repair racism within institutions. In many instances, Black faculty members are expected to meet clinical and teaching obligations while leading uncompensated diversity efforts without recognition for their work. They are also expected to be involved in diversity initiatives when these may not be areas of passion or interest.

Even comments intended to be complimentary can be problematic in the professional setting. For example, a Black physician comes to work with a new braided hairstyle, and a colleague says “Your hair looks really nice! Is it all yours?” while touching the braids. Several other hospital employees who are unknown to the physician then make similar comments and touch her hair. Inappropriate contact of this nature without consent would not be acceptable in any situation. Another inappropriate comment frequently directed at black men is “You must have played basketball or football.” Although these sports are heavily dominated by black athletes, it is inappropriate to assume that all black men are good at basketball or football. It is best to avoid commenting on the physical appearance of others regardless of race, sex, gender, or age, as even comments meant as compliments can be misperceived in the workplace in the context of different cultural sensitivities, and are inappropriate.

Despite the fact that human resources (HR) departments are required by law to prevent, address, and remediate discrimination, they may fail to address and respond adequately to physicians who experience racism in medical schools, academic institutions, and hospitals. HR departments are tasked with making every effort to guarantee the protection and confidentiality of individuals who report mistreatment, but this is often incongruent with institutional policies that encourage reporting through a chain of command that starts within the department where the offense took place, which can limit objectivity.

As an example, one of the authors of this article was employed at a large hospital system in which a stroke neurologist who had an overt bias against people of color, especially African Americans and Indian Americans, had been appointed head of their group. Over the years, the stroke neurologist had gained the trust and admiration of the administration, while generating significant revenue for the hospital. Complaints to the administration about the toxic work environment and favoritism based on race fell upon deaf ears, ultimately resulting in the resignation of 4 neurologists. It is important in such situations for individuals experiencing such bias to speak up. Retaliation against an employee for cooperating with an investigation or for making a good faith report of harassment is unlawful, and the US Equal Employment Opportunity Commission has the authority to directly investigate charges of discrimination.⁷

4. Be an Ally if You Witness Racism

Physicians may have an intellectual understanding of racism, but the majority have not experienced the emotional and psychological effects of generational and institutional racism. Physicians tend to want to fix things, and make people feel better by providing thoughtful recommendations. This tendency can be counterproductive when trying to empathize with a colleague who has experienced racism. For example, trying to downplay microaggressions by saying specific instances are unrelated to race could leave the recipient feeling manipulated.⁶ Comments like “I am sure they didn’t mean it that way” or “That’s not a big deal” can make the person feel dismissed. Comments such as “I am sorry you feel that way” suggest the issue is in the person’s mind rather than something they are actually experiencing.

Allyship requires trust, support, and accountability among non-marginalized and marginalized groups. Allyship demands speaking out against racism. Non-marginalized individuals must not remain silent when witnessing racist speech or actions. The bystander’s voice aligned with the targeted individual’s voice can form a force to promote change. As an example, consider a scenario in which WM, an older, White male attending neurologist rounding at an inner city hospital, often says “those people” when referring to the majority Latino patient population. One day, WM says to a group of Black residents, “You people know how those people behave, right?” After this encounter, one of the residents mentions this comment to the chair of the department, who downplays the event by saying, “You know how WM is.” A White resident who is present says, “His comments were not even directed toward me, and I find them offensive.” At that point, the chair of the department is more likely to take the complaint seriously, and meet with WM to address his inappropriate behavior.

When employers commit acts of racial prejudice, individuals targeted by such prejudice may feel powerless to prove that racial discrimination occurred. As a result, some physicians who experience discrimination end up resigning to escape a toxic environment. If complaints of racial prejudice are received frequently, institutional leadership may perceive this uptick as a result of false reporting, which may trigger defensive posturing or passive “railroading” by the employer to persuade the employee to resign. Approximately 45% of the nearly 90,000 discrimination complaints made to the US Equal Employment Opportunity Commission in 2015 involved a charge of retaliation against the employee by management, including responding to a complaint by ostracizing the person or even demotion.⁶

These dynamics can occur within the framework of an HR paradox: HR departments and policies at times undermine the HR department’s mission of mitigating workplace issues including those involving bias and racism. In such situations, HR departments may protect institutions over individuals, resulting in physicians who experience racial bias feeling ostracized to the point of resigning, and potential allies feeling pressured to remain silent. Furthermore, colleagues, regardless of race, may be reluctant to step forward when witnessing racial bias for reasons including self-preservation and a feeling of powerlessness against large, well-resourced organizations. Established grievance protocols may lead people to become more complacent with non-action, trusting that the policies in an organization with unrealized instituational bias will ensure fairness for all.⁸ If an institution’s grievance system is ineffective, employees may become less likely to speak up, which ultimately undercuts the goals of grievance protocols.

5. Support Diversity Initiatives and Avoid Tokenism

Diversity programs that are set up to address racial disparities in health care have sometimes failed to achieve their goals for multiple reasons. Some programs have official or unofficial quotas, which result in accepting a limited number of African Americans to meet metrics, with an abrupt drop in acceptance rates for qualified applicants of color once the quota has been filled.

Organizations with and without diversity programs at times practice tokenism, which occurs when a limited number of people—perhaps as few as 1 or 2—are granted positions to give the appearance of racial equity within the organization. These efforts are ultimately hollow, as people are typically placed in low-level positions without any meaningful opportunities for promotion, to influence recruitment, or to play a role in shaping policy.

In addition, programs that are intended to recruit African Americans who have been historically disadvantaged because of institutional and structural racism over generations may end up recruiting newly immigrated and first or second-generation Black Americans from Africa, the Caribbean, South America, and Central America, who are considered for quota purposes to be African American.

Such disconnects continue to deny African American physicians the benefits of policies designed to mitigate the discrimination they have faced for centuries while giving the appearance of effectiveness.⁹ Lack of diversity is not limited to hospital administration and medical organizations. In the pharmaceutical and device industries, qualified African American physicians are at times granted entry-level opportunities to serve as a speaker and/or on an advisory board, but not afforded the opportunity to progress to higher-level opportunities.

6. Clear Pathways for Promotion

Studies have demonstrated that underrepresented in medicine (UIM) faculty, especially Black and Latino faculty, receive promotions at lower rates than White faculty.^10,11 Comprising only 2.6% of physicians in academia,¹² Black and Latino physicians are less likely to attain senior academic rank, especially the rank of full professor, compared with White faculty in US medical schools.¹³ Black and Latino physicians in the United States have seen declining representation in full professorships from 1990 to 2016 in 16 medical specialties, including neurology.¹⁴ There are also fewer African American academic faculty than non–African American Black faculty, which further skews the underrepresentation of African Americans in academic medicine.

Research and publications are core elements of any curriculum vitae when seeking promotion in academic institutions. Furthermore, securing funding from the National Institutes of Health and other agencies is critical for executing large-scale research initiatives. Black scientists are less likely than White scientists to receive National Institutes of Health funding after controlling for an applicant’s educational background, country of origin, training, previous research awards, publication record, and employer characteristics.¹⁵

In addition to a dearth of funding opportunities, a lack of mentorship among Black faculty can serve as a barrier to promotion and advancement. Protected time should be offered for both mentors and mentees, with an increased emphasis for UIM relationships.

Any strategy to improve UIM faculty promotion should include the creation of pipeline programs to increase the number of medical students from UIM groups as well as the systemic adoption of culture change initiatives, including invitations for UIM faculty to take on leadership roles, consult on recruitment, opine on faculty promotions, and serve as adjudicators in disputes, especially when race is involved.^16,17

Co-Promotion

The best leaders establish trusting relationships and involve others. Senior Black faculty and other leaders should not be focused on self-preservation and the accompanying concern that helping others will negatively affect their own career trajectory. Many people who are afforded positions of power lead passively, because they do not have the same life experiences or are no longer experiencing racial bias to the same extent as those who are facing hardships, even though they may be of the same race and at the same institution. In addition, Black physicians may experience imposter syndrome (ie, harboring self-doubt about one’s abilities or accomplishments) to a greater degree than most physicians, as they may be among only a few UIM physicians or the only UIM physician in leadership positions at a given institution. Co-promotion should involve a leadership development team, transformative leadership strategies, and approaches to enhance the careers of members of populations that have been marginalized and subjected to biases in medicine.

7. Expand Democratic Processes Within Medical Societies

Medical societies play an important role in promoting patient care, education, research, and advocacy. Society meetings are places where like-minded clinicians, scientists, and industry partners can network, which can result in collaborations on a national or international scale. However, the leadership of these societies often do not reflect the evolving demographic makeup of the membership or the patients they serve, which can be attributable to a number of causes.

In some medical societies, leadership positions are lifetime appointments, and opportunities for leadership only occur when there is a vacancy of a position or expansion of the board. At times, founding members of these societies, even when they retire from clinical practice, teaching, or research, or when they move out of the geographic confines of regional societies, refuse to relinquish their leadership positions.

For societies with leadership term limits, the voting membership is able to vote for certain positions, but other positions are decided by internal committees. In addition, some societies have nominations committees, who decide which candidates can appear on an election slate. This practice can result in well-qualified candidates not appearing on the slate of candidates in favor of friends and mentees of members of the nominations committee. Allowing candidates who meet predefined criteria to appear on a ballot rather than requiring a nominations committee to select a limited number of candidates is critical to realizing the needs and desires of the medical organization’s voting membership. As an example of how these issues can affect nomination practices, one of the authors of this article, as well as people senior to the author were not added to the nomination slate during multiple election cycles at the discretion of the nominations committee, while former trainees and junior members with connections to nominations committee members appeared on the slate.

Lifetime appointments, a lack of consecutive term limits, not allowing members to vote for certain leadership positions, and nominations committees preventing qualified candidates from appearing on an elections slate can prevent younger, female, and/or UIM physicians from gaining opportunities in physician society leadership. It also limits these members from exercising their right to have their vote count towards selecting their preferred leadership.

8. Implement Term Limits and Transparency Within Hospitals, Academic Medical Centers, and Other Clinical Settings

Similar to physician societies, hospitals, academic medical centers, and other clinical institutions should implement policies that promote rotations in leadership. Institutions should identify and develop leadership skills in internal, young candidates, with a focus on diversity, who may have limited access to mentorship and may have not otherwise considered taking on a leadership position. As American demographics change, it is important that clinical leadership correspondingly becomes more diverse.

Some institutions, such as the Mayo Clinic, impose term limits on department chairs, section chiefs, and graduate medical education program directors. In such institutions there is an internal call for applicants every 7 to 10 years. Once an applicant pool has been generated, members of the department provide feedback regarding the applicants. This is followed by the formation of a selection committee, comprised of physicians both within and outside that specific department, which ultimately makes the final decision. Deliberately promoting such transparency conveys that everyone’s voice counts and the process is fair.

9. Form Coalitions

Coalitions are groups of people and organizations that coordinate strategy through communication and collaboration to achieve a common goal.¹⁸ Coalition formation is an essential step in promoting diversity and inclusion. Coalitions can leverage mainstream and social media to communicate common themes. Social media in particular can be a powerful tool when used appropriately to respond quickly to a rapidly changing landscape, and does not include editorial barriers that limit dissemination of a spectrum of viewpoints, including those of UIM physicians who may not otherwise have a platform.^19,20 Social media allows UIM groups to create online communities, report when they experience or witness bias, react in real time to transgressions, and disseminate research without needing an invitation.³ Expressed viewpoints can represent majority opinions of physicians that are not shared through official channels, as they may be contrary to the leadership of the institution or organization.

For example, physicians and patients may agree that new patient appointments should be 60 minutes in duration and follow-up appointments should be 30 minutes in duration, but hospital administration may suppress this viewpoint, citing that it may negatively affect revenues. Through coalition formation with patient advocacy groups and community leaders, hospital administration may revisit this issue, and encourage insurance companies to reimburse services provided at a higher level as part of a pilot program designed to demonstrate better care delivery and cost savings with longer appointment times and more diverse faculty who mirror the diverse patient populations they serve.

When forming coalitions, physicians, patients, professional societies, and patient advocacy groups should practice inclusion for advocacy goals to be achieved. Given the financial and political sway they carry, insurance companies, hospital systems, pharmaceutical companies, and device companies can play a powerful role in coalition formation.

10. Eliminate “Grandfathering”and Hold All Physicians to the Same Board Recertification Standards

The term “grandfathering” has racist origins from the 1870s. After the passage of the 15th Amendment to the US Constitution, which prohibited racial discrimination in voting, numerous states, particularly in the South, instituted voting requirements such as literacy tests, poll taxes, and constitutional quizzes to prevent African Americans (ie, newly freed slaves) from voting. Such tactics backfired when poor, White potential voters could not pass these tests or otherwise qualify. This resulted in the creation of the “grandfather clause,” which granted men voting eligibility if they had previously voted or if they were the lineal descendants of voters (ie, their grandfathers had been eligible to vote).²¹ Use of the term “grandfathering” should be avoided due to its racist origins.

One modern practice of such legacy policies can be appreciated in physician board recertification. In the 1990s, the American Board of Medical Specialties (ABMS) and its 24 member boards, including the American Board of Psychiatry and Neurology (ABPN), stopped issuing lifetime certifications in favor of time-limited certificates that were valid for 10 years. Physicians who were board-certified before these arbitrary dates held certificates without expiration dates that were honored without any further requirements, and were “grandfathered” into lifetime certification. These physicians are older, approximately 80% White, and approximately 70% male.²² As such, the practice of grandfathering in regards to board certification is discriminatory, because a group of physicians who are older, mostly White, and mostly male are granted elite status with no further requirements to maintain their board certification, while younger physicians, which includes a larger percentage of women and people of color, are required to pay and participate in Maintenance of Certification (MOC) programs.

MOC programs are expensive, time-consuming, unproven in terms of improving patient care, and include content which is often irrelevant to the physician’s specialty or practice. Mandatory MOC compliance reduces patient access to health care, increases the cost of health care delivery, and contributes to physician burnout.²¹ Lifetime certificate holders are permitted to practice after passing an initial ABMS or ABPN certification examination, completing relevant continuing medical education (CME) (requirements vary by state), and holding an active license to practice medicine. These are the same criteria required by the National Board of Physicians and Surgeons (NBPAS.org) for board recertification.²³ Those who do not hold lifetime certificates should be afforded the choice to recertify by participating in ABMS/ABPN MOC programs, American Osteopathic Association (AOA) programs, or CME based recertification with the National Board of Physicians and Surgeons that is tailored to the physician’s specialty or practice-specific educational needs.

Conclusion

Deep-seated systemic racial bias against marginalized groups has been inherent to American society since its inception, with African Americans experiencing generations of discrimination and inequity in the US health care system. This article, written by physicians of color from different backgrounds, demonstrates the importance of allyship and taking action at individual, institutional, and societal levels to effect change to help mitigate racial bias. This treatise is by no means exhaustive, but by focusing on these 10 action items, medical professionals can begin to establish a framework to improve the health care system for everyone.