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14th of December 2018

Health



Addressing Cultural Bias in Medicine

 “What’s the deal with your people?”

As a second-year South Asian–American Muslim OB/GYN resident in training, I looked up through my scrub mask at the Caucasian female attending physician with whom I was operating as she asked this question.

I had an idea what she was referring to. I had overheard her complain earlier about a laboring patient while she was scrubbing with the other Caucasian attending who was operating in the room next door.

“She acts as if she has never had anything in her vagina, but clearly she has.”

The physician was referring to this recently immigrated South Asian patient, Aisha (name changed to protect patient identity), who was like many women I had been asked to examine: She was meek and, like any other woman in her first labor, she was scared and uncomfortable.

This patient had a small introitus, or opening to the vagina, and had a difficult pelvic exam with an inability to relax her legs during the exam. She had always had pain with intercourse but revealed that she had been told this was normal.

Now, 15 years later, looking back with more knowledge and expertise, I see that this patient clearly had hypertonic pelvic floor muscles secondary to anxiety and fear. This resulted in vaginismus, or a tightening of the muscles of the vagina preventing entry, and it is likely she had a condition called provoked vestibulodynia, or a type of nerve pain at the entry of the vagina when it is touched.

I would encounter many “Aishas” during my residency, and I always felt like the attending physicians involved would begrudgingly take care of “my people.” Yes, their pelvic exams were difficult, and each patient took extra time. But I found many of them did not receive the empathy and cultural sensitivity they needed in their health care delivery.

Many of the patients were from a culture of deference to the physician, so although they may have been uncomfortable, they went along with whatever the doctor said. As a young resident, I never felt comfortable with the stereotype but also did not feel brave enough to say anything to these physicians—who were mostly Caucasian.

Regardless of ethnicity or culture, all physicians need to be aware of their inherent racial and gender-based biases and how these may impact managing women’s sexual health issues and sexual dysfunction. They should also be aware of the cultural stigmas associated with sexual health and practices of their patient base in order to improve health care delivery.

For instance, sexual health topics such as intercourse, infections and even menstruation, are still taboo in certain cultures, such as South Asian communities, Arab communities, native African communities and some conservative religious communities whether they be Muslim, Hindu, Jewish or Christian.

Women are less likely to address these issues of concern given their culture of origin. And even if they were, if a clinician approaches these patients with deep patriarchal perspectives or privileged bias, the patient may be less likely to discuss it with the clinician. In fact, some studies have demonstrated that health care providers’ lack of cultural competence compounded with patients’ beliefs has resulted in some American Muslim women not seeking cervical cancer screening or breast cancer screening at the same rates as other women.

Some physicians have become aware of their own privilege and bias when it comes to both their career advancements and patient care. In a recent article in the Annals of Family Medicine, Max J. Romano, a Caucasian male doctor at the Johns Hopkins Bloomberg School of Public Health, says he had opportunities in his career and advancements he attributes to white privilege. He also discussed how racial stereotypes and bias have interfered in patient care, health care outcomes and life expectancy.

For instance, studies demonstrate that clinicians prescribe less pain medication to African Americans than to their Caucasian counterparts for the same medical conditions.  This is also attributed to racial stereotypes and pain responses of different races.

I take care of many women of color with chronic pelvic and sexual pain conditions. Many tell me they have never felt heard or adequately responded to by other physicians. Serena Williams recently claimed her race was a factor when she almost died due to postpartum complications of a pulmonary embolus (blood clot in her lungs) despite repeatedly explaining her symptoms to her health care team.  

As a brown girl growing up in the South, I was subjected to a significant amount of racism. I always imagined that, once I had attended elite universities, then medical school and started practicing medicine, I would be less likely to see it and would be immune to it.

Working as a Muslim physician in the post-9/11 era, there were many times I would hear blatant racist statements or even subtle ones—such as during Ramadan when fasting—from certain patients and even from attending physicians.

Whether it was a joke about terrorism, discussions about “towelheads” or opinions about female patients, their pelvic exams or their status, these comments were often made with minimal remorse.

It has become apparent that gender biases and sexual harassment are endemic in our culture. Many clinicians are also biased against women who come forward with sexual complaints. As physicians, each of us needs be aware of his or her own biases in order to serve patients with the promise made during the Hippocratic Oath.

I own and operate a gynecology practice in Chicago; one of my specialties is treating patients with sexual dysfunction. “My people” tend to flock to me for their care and management.

Perhaps it is because of my background, cultural competence and experience, but I do know what’s “the deal” is with “my people.” I like to believe that having been brought up with egalitarian principles and a general calling to serve those in need, I am able to deliver unbiased health care equally to my patients. 

This is not indictment of the entire health care system. It is not broken when it comes to equality in health care delivery. But inherent biases impact how physicians perceive patients. Representation matters. Knowing there are like-minded medical professionals is a start. Empathy and goodwill toward all races and socioeconomic backgrounds cannot always be taught to individuals. Being aware of the discrimination and stereotypes is a stepping stone to breaking these barriers in health care.

That way every patient can best be served, regardless if her physician happens to be one of her own people.

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