‘We have to do a better job’: How structural racism in medicine harms both doctors and patients

Early in her medical career, physician Rachel Issaka encountered a liver transplant patient who was surprised that she, a Black woman, was one of their treating physicians. All of the other physicians in the same room were white, but none said anything.

Today, Issaka is an assistant professor at the Fred Hutchinson Cancer Research Center and the University of Washington in Seattle, specializing in gastroenterology and hepatology. But even years later, that moment has remained with her. Last week, Issaka wrote an essay in the Journal of the American Medical Association urging all medical professionals to call out and dismantle structural racism in medicine.

Issaka spoke with STAT about her essay and the broader subject of racism in health and health care.

Your experience in that patient’s room was not overt racism. … But as you wrote in your essay, it’s still had an outsized negative impact on you. What were you thinking and feeling at that time?

So in that moment, I had just started my second year of gastroenterology fellowship, and gastroenterology is a highly competitive specialty. And so oftentimes you go through a rigorous application process to get in. I had been chief medical resident at Northwestern University in Chicago. I had had a great year completing hundreds of procedures, having received great reviews from peers and patients. And I was really on this high. And going into that second year, really feeling very competent and reassured in the decision I had made to pursue this specific field in medicine. So that encounter in that patient room really brought me right back down to Earth.

And as I said in the essay, structural racism is really all of the policies and the procedures and the norms that are perpetuated that lead individuals to believe what and who, you know, people should look like. In that moment, that patient had a very specific picture of what her doctor should look like. And that was not what I looked like in that moment. So it really just brought me back down to Earth and brought to my attention how oversized the impact of structural racism is in our country.

How did your understanding of that moment change in the intervening years?

In that moment, I felt as if it was something that I did wrong, and I felt that my inability to respond was my fault. And I remember having this conversation with my family immediately after, feeling really disappointed that I didn’t say something articulate. And I asked them, what would you have said in that moment? And we had this entire brainstorming session and we came up with, you know, why couldn’t they have said, “It’s good for all of us that Dr. Issaka is here?”

And over the years, I’ve really begun to evolve to understand that it wasn’t my failing. It wasn’t, you know, the onus was not on me. And it was really up to the team and especially those who were leading the team to have stood up for me. And now that I am an attending physician who leads teams and lead students and trainees, I step into that role, because I remember instances like the ones I described where those who were leading me did not step up.

So many of the calls for action today around racism and inequality are focused on law enforcement and criminal justice. But you believe medicine also needs its own racial reckoning. What do you think that will require?

I think that has to begin with medicine and the medical profession owning and just accepting their own role in perpetuating structural racism. So, you know, medicine as a profession for years perpetuated this message that Black people did not feel pain, that Black people did not need sleep. A lot of these messages that were perpetuated were used to justify slavery and then later on used to justify denying Black people pain medicines when needed.

So one, medicine must first acknowledge its own kind of role in perpetuating structural racism in medicine by exploiting patients, by excluding individuals. Black people were not allowed initially to practice medicine. And it’s only very recently that, you know, we see Black people in medicine. So one, recognizing their role in exclusion and exploitation. And then once we recognize that, we need to teach that in a very structured and systematic way to those who are entering the profession. So they have that understanding and therefore don’t perpetuate it in their own practice. And once we teach it, then we need to measure if our teaching is working at actually reducing the ways in which new learners and new physicians are interacting with their own colleagues and with their own patients.

In your essay, you cite a statistic that Black Americans represent 13% of the U.S. population, but only 3.6% of full-time medical school faculty are Black. What do medical schools need to do to close that gap?

I think we have to do a better job as far as developing the pipeline of those who are entering medicine. Right now, if institutions want to recruit Black people into medicine, all they have to do is, you know, go in and recruit that individual from an existing institution. It just moves the numbers around, but it doesn’t actually increase representation.

But if medical institutions and health care systems invested money, time, energy into junior high schools, high schools, to help them develop their science curriculum, encourage that those students pursue medicine and continue to follow them throughout their training, by the time those individuals are ready to make a career choice, medicine is going to be at the top of their mind. And then that provides the opportunity and door for them to walk through to join the profession. But right now, what we’re doing as far as just recruiting specific individuals from different institutions to join our own, so that, for instance, one institution can say they have X, Y, Z percent of full time black faculty? That doesn’t really solve the problem. It’s just moving the dominoes around.

So we’ve talked mostly here about structural racism and its impact on Black physicians and physicians of color. But what impact does this have on patients? 

So the ways that this impacts patients is in some of the examples I provided earlier. We know that there are studies in which learners were taught to believe that Black people don’t experience pain. And therefore, when Black people would show up to emergency rooms requesting pain medicines, they would not receive the right pain medicines that they need. When we talk about structural racism, we’re really talking about the policies and the practices that are embedded in our current health system. So as a colon cancer researcher, this is a topic that’s near and dear to my heart. And what we find is that there are multiple ways to get screened for colon cancer.

Oftentimes, individuals who are of underrepresented minority groups, Black, Hispanic, Native Americans, may opt for a noninvasive screening test, a stool-based screening test. Our current government policies state that if somebody chooses that screening test and if that’s stool screening test is abnormal and therefore they need a second, more-invasive procedure, insurance companies don’t have to cover that test. Insurance companies can essentially say that they’ve covered the initial screening, preventative test, and for the follow-up tests, the patient is responsible for paying that.

And that’s an example of a policy that then leads to Black people being less likely to complete colon cancer screening, and as a result, Black men are almost two times more likely to die from colon cancer than white men. So these policies and practices that are in place really, you know, not only harm physicians, but ultimately have really severe and dire consequences for our patients.

What sort of responses have you received to your essay since it was published? 

The response has been overwhelmingly positive. Of all of the institutions that I’ve been affiliated with in the past, several individuals have reached out and have now made the essay required reading for learners and for supervisors. Several of the institutions I’ve been affiliated with are now designing specific programs that will empower those who are in leadership as well as learners to speak up whenever they see bias and in real time when microaggressions happen, whether it’s at the patient bedside or in a meeting or conference. And furthermore, they have proposed to study the impact of those interventions on the long-term outcomes for both leaders and learners.

And so I’m really quite happy that this is the response it’s received. This is what I was hoping for. And as I said in my essay, dismantling structural racism is really a collective effort and everybody needs to play a role. And so the fact that our educational systems are owning this and our health care systems are owning this really does encourage me. And I hope that this current movement will lead to the change that has been long overdue in our country.

This is a lightly edited transcript from a recent episode of STAT’s biotech podcast, “The Readout LOUD.” Like it? Consider subscribing to hear every episode.