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Medical Journal’s Inflammatory Comments on Structural Racism Ignites Controversy About Health Care’s Blind Eye to Implicit Biases In Medicine

Medicine is billed as a field guided by extensive research and evidence. But the specter of race reared its head in the field earlier this year when a top editor of the Journal of the American Medical Association posited that structural racism doesn’t exist in health care.

The controversial commentary came during a podcast and led to a shakeup of the journal’s leadership. It also sparked a petition and inspired debate on social media.

It came just over two months after another controversy swarmed over how the health care industry prioritizes people of color.

Susan Moore, a 52-year-old Black internist in Indianapolis, shed a light on the disparate treatment of Black patients in December when she recorded a dying message from a hospital room where she said she was getting inadequate treatment for COVID-19. Moore said she was made to feel like a drug addict when she asked her doctor for medication to ease her “intense pain.” The physician claimed nurses and doctors were ignoring her pleas and tried to discharge her before she was stabilized.

“You have to show proof that you have something wrong with you in order for you to get the medicine,” Moore said in her Dec. 4 video statement. “I put forth and I maintain if I was white, I wouldn’t have to go through that.”

Sixteen days later, she died of COVID in a different hospital. Moore’s plight ignited a national debate on the misconceptions entrenched in the health care industry that endanger Black patients. Many doctors are trained to believe that African-Americans have thicker skin and a higher threshold for pain than whites. Such false beliefs foster a systemwide culture of medical racism, according to a coalition of Black physicians who spoke out about their experiences after Moore’s death.

The JAMA controversy re-awakened those concerns and called into question the credibility of medical journals, which many doctors use as a guidepost.

“Honestly, I’m not surprised,” Dr. Leigh Ann Dooley said of the controversy. “And I feel like we shouldn’t be surprised because we see all the results of systemic racism. So we shouldn’t be surprised to hear that from the people in positions of power and leadership, which are mostly white. Because we see the outcome of the problem on a daily basis.”

Dooley is a board-certified psychiatrist who is affiliated with the Augusta, Georgia, VA health system.

JAMA is a leading peer-reviewed medical journal that publishes original research, reviews and editorials 48 times a year. On Feb. 24, deputy editor Ed Livingston hosted a 16-minute podcast on the JAMA Network, “Structural Racism for Doctors — What Is It?” where he argued that medical racism was no longer an issue. The white doctor took the stance that economics and social class factored more into the kind of care patients receive.

“What you’re talking about isn’t so much racism . . . it isn’t their race, it isn’t their color, it’s their socioeconomic status. Is that a fair statement?” Livingston argued, according to Medscape.

He asserted that racism was outlawed by the civil rights bills of the 1960s and said he grew up in a Jewish family that raised him to be tolerant, Stat News reported.

JAMA Internal Medicine deputy editor Mitchell Katz, who debated with Livingston during the show, insisted that structural racism exists in health care and should be rooted out.

“Structural racism refers to a system in which policies or practices or how we look at people perpetuates racial inequality,” he said.

Dooley pointed to a number of studies that she said debunk Livingston’s notion, showing the realities of racial disparities that exist irrespective of socioeconomic status. The Centers for Disease Control and Prevention in 2019 found that the U.S. maternal mortality rate of Black women is two to three times as high as the rate of white women. (Hispanic women had the lowest maternal mortality rates.)

A December 2014 study published in the World Journal of Psychiatry showed racial disparities in the rate that doctors diagnose psychotic disorders. Blacks and Latinos were disproportionately diagnosed with schizophrenia three to four times the rate of whites over a 24-year period, the study revealed.  

“I think a lot of people in positions of power actually believe that,” Dooley said of Livingston’s podcast comments. “And we can’t actually do anything to address a problem until we acknowledge it. So clearly this person is not just in denial, but not acknowledging the evidence. There are countless studies, at this point, that have shown that racism is a factor in so many different negative outcomes for African-Americans and other brown folks in medicine.”

Beyond the actual debate, many took offense to a tweet that promoted the podcast before it aired.

“No physician is racist, so how can there be structural racism in healthcare? An explanation of the idea by doctors for doctors in this user friendly podcast,” the tweet stated.

The fallout from the podcast and Twitter teaser was swift. JAMA quickly scrubbed the broadcast from its website and Livingston resigned. A cascade of flowery apologies and corporate press statements soon followed from leaders of both JAMA and the American Medical Association, the company that publishes JAMA.

Both entities made a complete about-face. James Madara, head of the American Medical Association, called the comments during the February podcast “inaccurate, offensive, hurtful, and inconsistent with the standards of JAMA.” He espoused AMA’s belief in the existence of medical racism and vowed an investigation.

Howard Bauchner, JAMA’s editor-in-chief, was placed on administrative leave March 25 while AMA’s journal oversight committee investigates the broadcast as well as its promo tweet. Before his suspension, Bauchner hosted a March 16 podcast that focused on structural racism and featured three prominent Black physicians who agreed that it exists.

“Medicine has definitely been weaponized against a lot of different people, but particularly black and brown folks, for a long time,” Dooley said. “To me, the blind spot is just an unwillingness to really accept just how the country was established. It’s that deep, the country was established from a racist point of view, and medicine was established from that.”

She indicated that it’s important for doctors to acknowledge that as a physicians, they’re trained in the racist system and to recognize their education is rooted in the “white power structure.” Everything from the terminologies used or hypotheses posed as medical theories may have racist origins.

STAT News reviewed the 250 top-ranked medical journals from 2002 and 2015 and found that institutional racism was mentioned in just 25 of the the thousands of titles. JAMA did not use the term in any of its abstracts.

“I think the word racism, people feel like acknowledging that word, acknowledging that it exists, means acknowledging that they are racist or have benefitted from it,” Dooley pointed out. “But in reality, we know that that’s actually true. And I feel like we don’t have to put that on someone as a judgment. But we can say the system was set up from a racist point of view.”

The Institute for Antiracism in Medicine, a group founded by three Black female physicians, started a petition last month that called on several changes to JAMA’s leadership and the journal’s message to the medical community.

The American Medical Association met with a coalition of Black physicians April 5 to discuss the organization’s demands, according to Brittani James, a co-founder of the Institute for Antiracism in Medicine. James, a University of Illinois clinical family medicine professor, recapped the meeting in a stream of tweets.

“What we want to see is action. The AMA has the size, resources, and power to really do something. They can move mountains,” James told Medscape.

In January, the American Psychiatric Association issued a public apology letter to Black people that acknowledged structural racism and the organization’s part in “enabling…racist practices in psychiatric treatment” of the past.

Dooley said that was a nice gesture but it’s far from enough to stem the problem. She suggested hospitals begin measuring patients’ outcomes by race to determine if Black patients are receiving substandard treatments. Then use those analytics to find structural racism and root out the mistakes when they are detected.

“We measure everything. I think we find the problem, whether it’s individually or in the practice group,” she said. “It’s literally life or death situations. Let’s do our best to openly acknowledge it, because all of the evidence and data shows that it’s there and that it’s true. So I feel like there should be an overt effort to do that.”

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