Episode 41: The Impact of Racism in Health
Experiencing racism can have both physical and mental effects on the body. Dr. Margaret Seide is here to discuss what those effects are and how the inherent bias that exists in the medical system plays into BIPOC health.
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[1:33] Cassy Price: Hello and thank you for tuning into another episode of Supplementing Health. Often when we talk about how health is a physical aspects, but we don’t always think about the external, cultural influences that impact our health both mental and physical and the healthcare system. Today, I am very excited to have Dr. Margaret Seide joining me to discuss the physical aspect of experiencing racism and how that impacts the body as well as the implicit biases that exist within the medical system.
[2:06] Dr. Seide is a psychiatrist based in NYC who has dedicated her career to destigmatizing mental health in the mainstream media. Dr. Seide is part of the 2% of Black psychiatrists in the United States and prides herself on taking a truly patient-centered approach to her practice, taking the time to listen to and understand her patients’ needs. Welcome Dr. Seide, thank you so much for joining us today.
[2:30] Dr. Margaret Seide: Thank you for having me. I’m really excited to be discussing this topic.
[2:30] Cassy Price: This is such a diverse topic and thought-provoking one as well that I would love to dive right in and get to know when were your eyes first opened to this traumatic impact that racism can have on a person’s health?
[2:50] Dr. Margaret Seide: I really think there is no one moment in which I realized that race can have such a huge impact on your health. I think even after being in medicine for about 20 years, I am still on a daily basis coming to know and understand how race and being a minority of any kind impacts how a person interacts with the healthcare system, how the healthcare system interacts with them, their perception and ideas about health itself and about the relationship they have with their doctor. That’s something that it’s not like one day you know and understand and then like you put it behind you or you incorporate it into how you move forward. It’s something that is ever unfolding with respect to my understanding of that interaction of being a minority class and health status.
[3:53] Cassy Price: Okay, that makes sense. I have heard a lot of stories or read articles of people who are within that BIPOC group who have visited their doctor or maybe ER, only to be treated as if they were trying to play the system or to get meds or a prescription out of the doctor that they don’t need, kind of that discriminatory response. So despite a lack of any indication that this would be the case, these doctors are responding in that way. Are there statistics on how commonly this sort of situation actually occurs?
[4:31] Dr. Margaret Seide: Yeah, there are. And I will say the statics that we have are probably not capturing the entire picture. A lot of the statistics that we have are based on studies and that doesn’t necessarily incorporate the day to day happenings of an average emergency room. Now I will say that prescribing, there are certain algorithms but a doctor, or any prescriber really has a certain amount of discretion with regards to, how am I going to treat this patient and the quantity of medication I’m going to give this patient. But there are certain agreed upon ideas about managing pain.
[5:16] A good example is cancer. When we look at how cancer patients are treated, we see that about, there are certain states of cancer and cancer conditions that are quite painful and of course cancer isn’t something that you can fake or lie about, obviously there are studies and there’ll be documentation of when the patient is interacting with their doctor or showing up to the ER with any particular crisis, and still in fact, those are the best studies because it’s starting with relatively objective data and going forward. And studies show about 35% of minorities are getting appropriate treatment and having their pain managed properly with respect to cancer and 50% of non-minority patients are being treated for pain. Another great example, again, something you cannot fake, something that is not subjective, when someone comes into the emergency room with a fracture of one of their extremities. Which again, shows up on an X-ray, known to be quite painful, about 74% of non-minority patients feel satisfies with their level of pain control, the quantity of pain control that they’re given and actually only 57% of minorities are content with the amount of pain control and the pain medication that they’re given.
[6:57] So this is sort of quantifiable data with respect to conditions that are not debatable, you can’t say, the patient is faking, this sounds suspicious, this is fishy and there’s this objectivity that enters the picture and that part where medicine becomes an art and you’re going on your training and your intuition. Cancer and a broken bone are kind of things that there’s no debate about it and no debate about the fact that those are extremely painful conditions.
[7:28] We see a lot of data, like hard data numbers that shows that there’s a huge difference with prescribing practices. I will say of course that, in recent years, let’s say the last 20ish years where America has really plunged into this crisis, with respect to opioid dependency. And a lot of that is having to do with not necessarily illicit drugs or street drugs, but prescription drugs, like oxycontin for example. Where we see hotbeds of this epidemic are in white areas.
[8:09] I believe and studies bear out that this is because of the prescribing practices with respect to white patients, that there is this liberal, candy store buffet almost, approach to prescribing practices that has led to the state of a lot of people suffering from substance dependence when it comes to prescribed medications. And I’ll also throw in other substances such at stimulants and benzodiazepine where we’re not seeing the same epidemic blossom and be such an issue in minority communities and that is because of the relationship between the prescription pad and the white patient that has really ignited a lot of the epidemic that we’re seeing.
[9:02] Cassy Price: But doctors take an oath to treat all patients equally but obviously that isn’t the case. So, why are we seeing certain groups of patients getting different care, in your opinion?
[9:16] Dr. Margaret Seide: So, yes there is an oath, but doctors are human. And by that I mean, prior to you walking into the hospital that day, prior to you even starting medical school, you’re a human being. And you are subject to the discussion that your family is having at the dinner table, the media that is incredibly biased and points us in a direction, the news stories that show and feature much more prominently, Black people, the idea of a Black person as an addict, as a poor person, an indigent person. The idea of white being frail, needing help, the damsel in distress which I think goes back to the shampoo commercial with a blonde woman.
[10:17] White, Black, or any doctor, is absorbing these messages, all their life and I don’t believe, and I’ll give the benefit of the doubt, that’s generous, giving the benefit of the doubt, I don’t believe a doctor approaches a patient in general saying, this is a Black person, what can I do to disenfranchise this person, to give bad treatment to make sure this person is still suffering when they walk away from the care. I’m going to go out on a limb and say your average practitioner is treating patients with that in mind, but I believe the average practitioner brings to there, all of their life experiences, all of the media, the messages, all of that is absorbed and then culminates in the decision that they’re making, because like I said, there is this objectivity.
[11:16] You’re the trained person, you’re the professional. What do you think a patient needs at this moment and how much of it does this patient need at the moment. And I think all the implicit, explicit racism that this person is exposed to sort of shows up and modifies the decision that they’re making. So even though yes, there is an oath in the background, that you want to believe that the doctor is practicing from, it is not outside this person’s culture and the messages they’ve been exposed to their entire life.
[11:55] Cassy Price: Okay, and so as you’ve mentioned, racism is all over our society. It’s in the media, just the way people are portrayed in shows or that kind of thing, and in some cases, depending on where you live, you see it in your streets and in your, you know, your stores and things like that. So I guess what I’m wondering is how does experiencing that racism not only in your healthcare treatment, but in your day to day, impact a person’s mental and physical health?
[12:30] Dr. Margaret Seide: So with respect to physical health, we know that there are studies that demonstrate, the term that is used a lot in the medical literature is weathering phenomenon. And another term for it is the sojourner’s syndrome. So this describes the biological differences that we see in, when we compare Black individuals and I’ll say Black Americans, but this study has been duplicated in places where there is known racism, where Black people are a minority. I mean other countries in Europe, Australia and South Africa in addition to America. And the same studies and statistics don’t bear out where Black people are the majority and there may be other issues but racism isn’t among the primary issues in that culture.
[13:30] So what we see, when we compare, and I, this is including other minorities, such as Hispanic, and also Indigenous people are really known to be suffering from a lot of the ailments that are known to be a product, a by-product of racism. So we see these differences such as higher blood pressure on average, higher cortisol which is one of our stress, inflammatory hormones, higher A1C which sort of looks at how our blood glucose has been doing over the past couple months and the past couple years. These are all inflammatory markers that really dictate how a person’s overall health is going and that we generally put under the umbrella and the term allostatic load is used.
[14:25] There is such a difference between Blacks and whites in this country with respect to those markers that the weathering syndrome implies the fact that a Black body is weathered. So literally, a Black person at the age of 40 and a white person at the age of 40, that Black person can show an average of up to 15 years of a higher allostatic load. More years, more weathering. As if that person’s body were older than their non-minority counterpart.
[14:59] Another issue is, how long do you live which is of course one of the biggest markers of health. And we see that the difference between – so women in general live longer than men – so when we compare the two biggest categories that are farthest apart with respect to life span is white women and black men. And that average is 15 years. So that’s 15 years of life and that’s not even speaking to what the quality of your life is in the last five to 10 years which we know can take a hit and might not be counted with mortality.
[15:42] There is a huge physical difference when it comes to what is it like to grow up, be raised, be exposed to racism when you are a minority. And again I just want to go back to this isn’t a biological difference, how Black bodies are different from white bodies, because when we look at countries where racism is not prominent, not dominant, these numbers don’t bear out these numbers, they disappear. And what we’re expecting out of the health of a white person of a given certain age is equally true for, with respect to a Black person.
[16:25] And, the other part of your question, mental health, not that’s an ongoing issue that is hard to quantify, because it’s not like I can look at your blood pressure, your weight, your abdominal girth, things that I can, again, chart and document. But mental health is definitely impacted by racism because a person is growing up in a world where their culture is off brand, their skin colour, their hair, everything, all of those things are basically just the subliminal messages of those things not being accepted, not being beautiful, that takes a toll. With respect to depression, anxiety, sleep disturbances. And a picture that we – under the umbrella of a diagnostic statistical manual which sort of documents psychiatric diseases – what we’re seeing looks a lot like post-traumatic stress disorder. Where the person is repeatedly, chronically traumatized by their experience of being Black in America or being a minority in America.
[17:50] I personally see it in lots of ways, one thing, when my recent experience has been in outpatient medicine. I’m interacting with people coming to me based on a need that they think they have and I’m interacting with them and I’m trying to be supportive and helpful, and when I have minority patients versus non-minority patients, I notice that my minority patients will be more likely to be sheepish about what they need. They’ll see me and even though I’m very available to my patients, I’ll say here’s my email, here’s my cell phone number, let me know how you’re doing, if something’s bothering you, if you need a refill, anything like that. I’ll have my non-minority patients reach out, be engaged in their care, requesting things and want my attention which is fine. I want to give them my attention.
[18:54] But when it comes to minority patients, I’m so much more likely to have the experience of, they come to their next visit and they’re like oh, by the way, I ran out of medication two weeks ago, but I didn’t want to bother you. Or actually, I’ve been having this side effect, but I was just waiting for my visit. I didn’t want to bother you. There’s this sheepishness, and this like I’m not wanting to take up space and demand anything of you or want your attention, or make myself know or make my needs verbalized because I’m just trying to be in the background. And I should say that my practice is in the Wall Street financial district of Manhattan so these are people who are really accomplished, educated, have a certain standing in society, but still when it comes to what do you need and how can I help you, there’s always this hesitation which I believe is due to the impact of being Black in America. I don’t take up too much space, don’t make too much noise, don’t ruffle any feathers and sort of walk this fine line that shows up in the healthcare system.
[20:10] And, that’s not great because it’s not great for me to see a patient and they’re like, I ran out of meds two weeks ago. And it’s also not great because we know that in medicine that the healthcare system, insurance, all that is extremely flawed, so you have to be ready to advocate for yourself and advocate for your family members. And if you have this built-in system of sort of not wanting to speak above a whisper and show up and make requests and ask questions like hey doctor, did you forget this and I need that, that’s going to show up as compromised care.
[20:44] Cassy Price: No, that makes sense for sure. And I think when you’ve grown up being told, sit down, shut up, stay in your place, it makes it that much harder to have that confidence to advocate for yourself and even knowing how to navigate that process of how to advocate for yourself as well. That makes me think the bias and racism within the system isn’t necessarily just toward the patient. I’m sure you as yourself as a Black practitioner have experienced it when you’re trying to navigate that professional side of the system, I assume. So, in your opinion does that systemic issue within the healthcare system, or experiencing it as a practitioner, does it play into how you navigate that landscape?
[21:40] Dr. Margaret Seide: So, for the practitioner side, there is a lot of racism in medicine and in academia. And I don’t know any Black, female doctors who haven’t suffered and struggled so much. It is really hard. I mean, ss much as you might think that medicine is progressive and it’s a bunch of people who want to help people, I think the statistics as far as treatment, promotion, again things that are quantifiable. Like how many Black people, Black women or women period, are making it to full professor. Or pay, on average, a Black female doctor makes 50 cents for every dollar that a white male doctor makes. So again, those are the things you can quantify and put a number on.
[22:40] The other things, the day to day lived experience of being a Black physician in academia or in a predominantly white hospital, I’ll use the word horrifying. It is something akin to a nightmare and it’s particularly hard because becoming a doctor is you know, so hard. It’s taxing, you give up everything, you go into the deep six figures in debt, it’s four years of college, four years of medical school, maybe a year or two of research, five or six years of residency. And that’s longer than a lot of marriages last. That’s like the equivalent of the investment you make in 18 years of raising a child. And then you cross over the finish line. You become an attending physician which is the ultimate goal and you’re still being treated badly. You’re still being kicked around. You’re still not invited to the party. It’s incredibly hurtful. So of course, that affects how you interact with patients.
[23:46] Exactly how, I think it’s hard to detail and to put a number on it. I have certainly had my colleagues doubt me, question me, be passed up for opportunities that should have been mine. Pay was not what it could have been, or should have been, and had a lot of patients doubt me, want a second opinion. Maybe even, visibly and actively shake the hands of my non-minority colleagues and actively not shake my hand. I’ve had that experience a lot. Now I would like to think it actually makes me more compassionate when I’m interacting with patients that are other, of any kind. Anyone with mental illness is sort of part of a stigmatized, marginalized population.
[24:40] And so those are the people that I’m interacting with and working with and I’m more aware that this is how the world operates. I know you’re not getting a fair break and a fair shake because you struggle with addiction or LGBTQ issues. I’ve worked a lot in eating disorders, so I’ve worked with patients who are 100 lbs., 200 lbs. overweight so I know those are people who are walking around this world in a body or in an experience that makes it so that people are looking at them. From their boss to the person siting next to them on the bus, their co-workers, that they’re having this other experience. And I share in that. And I know that. And I, just because I’m a physician, it’s like, oh but you’re comfortable or you’re educated, or you have a decent income so therefore you must not be able to relate to my experience. And that is really false. The way medicine works, it never lets you escape and feel like oh, I’m up here and all the rest are people down here. I’m always feeling and reminded of – and maybe that’s a good thing – that I am in the trenches and with patients and identifying with patients that are marginalized in any way.
[26:00] Cassy Price: What is being done from an education standpoint, to address these inequalities, if anything?
[26:08] Dr. Margaret Seide: So I know that there are a few programs, in particular I’ll spotlight the Sophie Davis Program in New York City because I’m somewhat familiar and have interacted and worked with and helped train some of those patients. Sophie Davis is a medical program where students are training to become physicians. And that program is very progressive and they make it part of their curriculum that they’re including cultural competency, that they’re having these open, frank conversations about healthcare disparities, about treatment. Going over it and incorporating it into their education some of the numbers that I’ve told you about like when a patient comes into the emergency room.
[27:02] Their skin colour really directs the treatment that they’re going to give, to get. So that is like a newer, more progressive program which from what I’m hearing about the experience of the patients, is really amazing and really impressive. I will say for myself, in my training, and I went to school from 2000-2004, I received zero education about cultural competency or about how race shows up and impacts the decisions of healthcare providers. Not one iota, not one lecture. Nothing, nothing whatsoever. And that was also true of my residency and even in my training, when we’re assigned reading or continuing our education even as a professional, none of that has been incorporated and no attention has been given to any of that. Even when we’re having these courses that are annual or every other year that are just mandatory where we’re just checking a box to say that we had some sort of conversation about cultural competency. I mean those things are a joke. They’re so superficial, so fake, so neat and polite and make sure not to step on anyone’s toes. It’s clearly designed to be, let’s not to this, but be able to say that we did do this.
[28:33] That’s what my experience with any sort of cultural competency training has been with respect to hospitals. So overall, it’s not been great. There are a few programs that are featuring this and making this part of their education, but I’d say that’s relatively new. As an attending I’ve had very little exposure and you know, space for discussion of this topic. I know that for myself when I was teaching residents and medical students, I tried to incorporate it into the curriculum. But that was me, with like extra space for what do you want to teach for this lecture and me saying I want to introduce these discussions about racial inequity, racial equity and healthcare disparities. But it was not like part of the curriculum or anyone telling me, can you design several hours of lecture time, educating our residents and our medical students about this issue.
[29:36] Cassy Price: Okay. Do we see a lot more or do you see a lot more BIPOC providers coming up through the system and do you thing having more diversity in the race of providers available will give more quality care to the patients?
[29:58] Dr. Margaret Seide: So, I’ll answer the second part first. Yes, statistics show that is when there is a significant difference. When a Black patient is cared for by a Black physician there are differences. And to back to what we can really count which is the health of mothers who are giving birth and the likelihood of fetal demise, we know that there’s a huge difference between Black and whites in this country, or minorities and non-minorities and that gap closes only where there is a Black physician in charge of the case. And certain other populations when there are clinics, let’s say there’s a Spanish speaking clinic or a clinic that is designed for a population that is non-gender conformative and there are people who have a passion for or an interest in this population who gravitate and work and give out care from those clinics, that’s when the difference is made.
[31:23] And so yes, there is a huge difference where there is a provider who looks like you, feels like you. How that difference shows up, is it that a Black provider cares more, is it that the Black patient feels more cared for and better able or more willing to verbalize what they need, say that they’re in pain, that their wishes and requests will be responded to. That they won’t be looked at like they’re drug seeking or complaining too much. We know that those things make a difference.
[32:04] Now, yes, if you were to compare the big picture like 30ish years ago to present times, there are more BICOP providers. However, the interesting thing is that that increase has slowed and is even on the decrease. And I think one of the major reasons is that there used to be a certain amount, I guess I’ll call it affirmative action, that was applied to looking at medical school applications, with several programs wanting to level the playing field and saying, we want our class of physicians to be more representative of the city that they live in, the country and even the patient population. Of course, once you’re in medical school, the work is all the same for everyone but there have been certain programs in certain schools that have applied that in years past. However, a couple of years ago, with respect to the cases that have been filed, lawsuits, by non-minority students, particularly in Texas, who have sued schools saying, you gave my spot to a person of colour who, our transcripts, here’s how we compare.
[33:37] The only difference was race so I’m suing you. So, because certain schools do not want to be included in that and do not want to be part of that and the unfortunate success that some of those cases have had, that is changing. And obviously I’m not going to say that minority students are less capable but because of all the factors in our society, from the quality of schools in certain neighborhoods, the likelihood of things like AP classes, after school programs, all of those things changing so that by the time you show up with your transcript ready to get into medical school as a minority person, you might have as good of a brain, as good of a work ethic, or better than your white counterpart but your transcript might not reflect that. So nowadays, more recent years, that approach of lets’ see what we can do to make sure our class looks more reflective of what America looks like. That is on the decline. And so the number of minority physicians and providers is stagnant, isn’t continuing to increase and will even be falling because of the changes that I mentioned.
[34:59] Cassy Price: That’s actually really disappointing to hear because of how much more awareness, especially in the last year to two years has come up and how many more discussions are happening you would think that the action and the change would be the natural next step, that people would start to want to be more inclusive and want to improve the equality. I’m super disappointed to hear that especially since it does mean a greater quality of life all around, right? If you become a doctor, it’s because you want to help people, generally speaking, and you want to be giving your patients that quality of care and in turn helping them improve their quality of life because your health is wealth, right? You can’t enjoy a healthy lifestyle you’re not going to be able to maximize all the other experiences that come with life. So, I mean this is such a vast topic and unfortunately, we’ve only just scratched the surface in this conversation. But I do appreciate you talking the time to help impart your wisdom and your experiences and your knowledge on me and our listeners because I do think it’s such an important topic to really bring to the forefront and get out there. So, thank you so much for taking the time to chat with me today.
[36:18] Dr. Margaret Seide: Thank you very, very much for having me and giving me a chance to talk about something I’m so passionate about and a topic that really needs more and more discussion.
[36:32] Cassy Price: Since this is such a broad topic we will have to have you back again to discuss other aspects of racism in health such as the influence of economic standing and some steps that individuals and institutions can take to start moving the needle in the right direction when it comes to equality in the healthcare system. Like we both said, this is a really big topic and a really important one and I think it’s a great opportunity to help educate people on what’s going on around them that maybe kind of happens behind closed doors. So once again, thank you so much.
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