- Hey, guys! Welcome to another episode
of the "Wednesday Checkup". John Oliver just did a
hard-hitting piece on medical bias and you asked me to talk
about it, so let's get to it. (smooth hiphop music) I actually like getting these
subjects out in the open 'cause I feel like if we can discuss them honestly, openly, and fairly, we're gonna make the best impact on the healthcare community, starting right here on
this YouTube channel. So when I heard John Oliver
did a piece on medical bias, I knew I had to watch it. But because he talked
about a lot of studies and used a lot of references, I felt like it was in your best interest and my best interest to first
watch the piece on my own, do the research, check out
the studies he referenced, and then watch it again
with you right now. - Men of medicine. - [Announcer] In every US city and town, there is one house that
everybody knows, the doctor. Available here are the services
of the man who, by law, is privileged to practice the most respected of all professions. - In my family medicine
residency training program, we had 21 residents, 18 were
female, three were male. We actually had a little camaraderie that we were the only
three guys in the program. We made running jokes about it. That type of diversity is
really good for medicine. You could even check out my
"Diversity in Medicine" video which I'll link down
below in the description. - Not everyone has the same experience when they visit a doctor. - I think I would've been
treated completely differently if I had been male. - You'll hear doctors and nurses like, oh, they're just exaggerating. - Dramatic. - And not really listening to them because it's a black person,
but if it's a white person, it's just like, oh my
god, this is serious. - It's true. If you are a woman and/or a
person of color in the US, you may well have a very
different relationship to a healthcare system than a white man. - This is difficult for
me to watch as a doctor. Watching patients talk about
getting poor quality of care from my colleagues hurts
because what I wanna do, what I hope all doctors wanna do, is give each and every patient
the best quality of care without distinguishing
between what race they are or what sex they are, what
country they come from, what language they speak. Medicine is not run by robots, it's run by doctors who are humans and humans have biases and
they have other issues, they have stressors. I'm not making excuses for doctors. I just want you to be aware of all the things we're
gonna be talking about throughout this video when it comes to gender discrimination, racial discrimination, the
disparities that exist, why that can happen, and really,
the steps that we're taking as a medical profession to improve that. - Better to talk at you for
20 minutes about this than me, the whitest of white men. (audience laughs) Look, I get a sunburn
watching the Travel Channel. - John Oliver does a really
good job diffusing the situation by using humor here. Oftentimes, I'll tell my students if they have the ability to
insert humor into a situation, respectfully, of course,
and not distastefully, they should do it because
patients love that. I've been on the cancer ward so many times in so
many different hospitals where the second a moment of
lightheartedness comes in, you can see the patient's smile light up, especially in the pediatric population. We love to laugh, we
love to have a good time with our patients and they love it too. - Let's talk about bias in
medicine in two specific areas. First, sex, and then race. And in the words of every
therapist I've ever had, let's start with sex. (audience laughs) Historically, women's bodies
have always been fraught with judgment and misconceptions. - Mom, can I go swimming with
Peggy tomorrow after school? - No, it's not a good idea the first two or three
days of your period. You might get chills and catch cold. - Oh, that's right. (audience giggling) Peggy, of course, I can't go swimming. You know I've got the curse. - Yeah, Peggy! - On one hand, we can look
back at it and laugh and say, oh my god, look at the
things we used to say, how politically incorrect
or how inaccurate is this, but I look back at this and I wanna celebrate the
fact that we've come so far, that we've made strides in medicine. I feel like if I fast forward
100 years into the future and look back at the things I'm doing now, it would be barbaric. It's gonna feel like we're cave people working with rudimentary tools. - Women can still face an uphill battle to get quality healthcare. There are many, many studies showing this. For instance, they found
that women were less likely to be referred for knee
replacements than men. - He's accurate here. There are really good
quality studies that show there are disparities
for women in healthcare. When a disparity occurs, it means something's
happening on unequal terms. Essentially that's a correlation, that we see these two events
happening on unequal terms, but we don't have a causation, meaning we don't have a
reason why that happens. For that knee replacement
study that he talks about where women are less
likely to get a referral to get a joint replacement, that's true. This study does exist, it
was was published in 2011 in a good orthopedic journal. They do such a fantastic job analyzing each part of the system. When the patient
recognizes their symptoms, how long it takes them
to go to the doctor. Once they go see their
primary care doctor, what's the discussion like? How likely are they to get a referral? At what point do they
actually need the referral in terms of the damage that needs to be done to their joints? Once they see the orthopedic surgeon, how likely are there to actually
go for joint replacement? Now, in almost all these cases, they found women were
getting less care than men. I'm gonna quote the study here: "One factor may be the way
patients describe their symptoms. "Women tend to speak more openly "and personally about their symptoms "and describe them in a narrative style, "when compared to men who
typically present their symptoms "in a business-like or factual manner "and are more reserved in their comments. "Women's narrative presentation
style reportedly contributed "to physicians making
more diagnostic errors." And this study gives so many factors, both from the patient's
side, the doctor's side, the system's side, all of
these things can be addressed. - If they're over 50 and critically ill, they were less likely to receive
lifesaving interventions. - The study itself actually
gave some really good points on what we should be doing to correct this because, again, it didn't specify that this is solely a result of bias. The study talks about the need
for sex or gender analysis after conditions happen, after mortality. We talk about the need for more research to figure out if biases exist and what types of biases exist. And finally, looking at sex disparities that occur between certain conditions. How often do females versus
males have pneumonia? How often do they have
complications of pneumonia? "There may be also plausible
biological explanations "for the differences in mortality "we found between critically
ill older men and women. "Sex has been found "to influence the expression, progression, "and outcome of many
common medical conditions "and can influence pharmacokinetics, "which is how medicine is absorbed, "how it functions, and
responds to therapy." Now, it may seem that I'm trying to find other reasons than
bias as to why this happens. That's true to a degree. I wanna make sure that
we're not missing anything and just jumping to the
conclusion of discrimination because we can then
miss some systemic flaws and biological differences
that had we addressed them, we can do better by our patients. - When going to the ER
with urgent abdominal pain, women were less likely to
receive any pain medicine. - This pain study is actually real. Women were less likely
to get opioid medications than their male counterparts and on average took them longer
to get these medications. But again, the study that
Jon Oliver mentions here, I took a deep dive into it. They do not have a causal
reason for why this happens. They postulate seven reasons. One is maybe doctors are
unaware of women's biology. They're worried about masking specific types of abdominal pain that if they treat the
pain, the patient leaves and then something bad
happens to the patient, they're gonna be doing
the patient a disservice. I think one of the very interesting
points within this study that I like to figure
out an explanation for is that while there
was a gender difference in the prescription of opioid medications for pain between men and women, there was no gender
difference in the receipt of nonopioid analgesia for men and women. If we're postulating that we
have a gender discrimination occurring here between males and females, why isn't it hold true
for nonopioid medications? I don't have the answer to that. That's why I like that
we're talking about this and creating avenues for further research. What I want you to know,
this is for the bright side of this conversation that
Jon Oliver doesn't focus on, 'cause that's not what
his segment is about, but it's that we are aware
of these disparities now. Because of this great research that has been done 10, 15 years ago, we are now talking about this. We have bias education in our classrooms, we have different ways we screen female patients
versus male patients because of their atypical presentations. That's actually one of the next points he's about to get into. - A lot of times, women's
symptoms, especially pain, are attributed to emotional imbalance or women being hysterical or
crying wolf about their pain and that's absolutely wrong. - It's wrong, flat-out wrong. That's not the way we're
trained to practice medicine. I feel like it's almost an archaic way of practicing medicine. And I think this newer
generation of doctors that's been trained
within the last 10 years, I hope, and I am optimistic
that the future studies that are gonna be done on
this will show an improvement. - There was also a systemic problem here where doctors may literally
know less about women's bodies because historically, medicine
has studied men's bodies which here means those
assigned male at birth as a proxy for all bodies. - He is so right in this case. These studies that have
been done 20, 30 years ago on specific ailments have
been so poorly designed when it comes to the patient population that it's just not applicable to everyone. Taking care of a female patient is different than taking
care of a male patient. They way they present is different, the way they talk about
their symptoms is different, their biology is different,
their anatomy is different, their hormones are different, and the way they experience
pain is different. This is not a bad thing, it's just something we need to be aware of and structure our
research around properly. - Take heart attacks. You're conditioned to think of them looking like they do on TV all the time. People grabbing their chest
and then falling over. But for many women, that
is not what they look like. - The reality is we've
studied heart disease as a disease of men. It's not the case. Women have high rates of heart
disease just as much as men, if not more in some cases because it's missed and undertreated. - If you are suffering a heart attack, will you always get a shooting pain down your left arm first?
- It's not always. And in fact, the tricky part about this is men and women feel
heart attacks differently. - Wow!
- The classic symptoms that we see in men is that pressure, the elephant sitting on your chest. They don't often happen to women. They have more substernal
pain, maybe a discomfort, sometimes radiating to the
jaw instead of the arm. - Your jaw? - Yes. - So you could be thinking
it's a toothache-- - Exactly!
- And you're literally having a heart attack?
- Yes. - But here's the good part. Right now in medical school, and even when I trained in
medical school and residency, we're aware of this because of the quality of research he talks about. We're so aware of it that now when a patient
comes into my office, a female patient, and has
some of these symptoms, right away, I recommend to the patient, let's check out your heart and make sure that it's not your heart. Now, this doesn't apply to
the entire medical field because there is doctors
that are practicing that are 67 years old
that weren't taught this. So as time goes on, I think
we're gonna continually improve our identification of
women's heart disease, the way we do research. - The young doctor came
in, very condescending, thought I was just a
drama queen, and he said, "It's not my job to tell
you what's wrong with you, "it's my job to tell you what it's not. "And it's not your heart." - That's obviously an
egregious medical error and horrible treatment of a patient. If you're going into medicine and you're gonna be talking
about patients that way, it's just a failure on
all sides of the equation. Because the goal of a doctor
is to treat the person that's sitting directly or
laying directly in front of them and to come in and say something
like that, it's horrible. And I'm sorry that this
patient had to go through that. I don't wanna poison the
doctor-patient relationship thinking that this is the norm. This is not the norm. - One study found that women who came to the hospital
with heart attack symptoms was seven times more likely
than men to be misdiagnosed and sent home from the
hospital which is terrible. - The tricky part about
recognizing heart attack symptoms in female patients is
that they are often masked and they all often present atypically. Now, we should be on the lookout for this and I do think that if we
repeat these same studies 20 years from now, we're gonna
have much better outcomes because we're learning about this. Actually, the American Heart Association has put forth a ton of effort and money into educating the public
about women's heart health. I actually participated with the American Heart Association Go Red for Women events all the time because we need to not
only educate doctors about keeping their eyes open and being really attuned
to the possibility of these atypical symptoms, but also educate patients themselves. In fact, a Wall Street Journal article that Jon Oliver quotes says this: "Women do bear some of the responsibility "for delays in care themselves. "Women think, 'Yes we'll call the doctor "after we pick up the kids
and finish that report "and put the casserole in the oven.' "But she urges others
to pay more attention "to their bodies and their instincts. "'You know when something is not right. "'That's what I didn't pay
attention to.' says Ms. Thomas. "The acid test, if somebody that you love "is experiencing these
symptoms, what would you do?" This is great advice. The thing that I tell my patients is to be alert but not anxious. You don't wanna be anxious
about your conditions because that can exacerbate
symptoms, make things worse. But if you're alert and you're attuned to what's normal for you, you can then go and talk to your doctor and have a good quality conversation about whether you need to
activate the triage system and go to the ER or you can take the time and go to the urgent care center or your family medicine doctor
appointment a few days later. - We found over 83, 000
excess deaths per year in the African-American community alone. - [Narrator] 83,000
excess deaths each year. That's the equivalent of a major airliner filled with black passengers
falling out of the sky every single day every year. - Okay, that's such a weirdly
specific way to put that. - Jon Oliver's a funny guy. This is interesting. That interview from the
documentary happened in 2008 and it's amazing how much
socioeconomic factors decide whether or not you're gonna have good health outcomes. In fact, it's been said that
social determinants of health, basically your zip code, decides more about your health outcomes, how long you're gonna live, what quality care you're gonna receive, moreso than your actual genetic makeup or your medical history. And that's crazy to think that just because of where you were born, you're gonna have worse health outcomes. But it's true. In 2008, that study was
done and that was the case. I will say, in 2017, which is nine years after
that documentary was done, the CDC released a statement saying that the racial mortality gap is closing. Fast forward to 2019, The
Economist releases an article that states Black men in America are living almost as long as white men. Now, that's a weird headline to hear but it shows that this
racial mortality gap is closing further. Now, we need to keep monitoring this because that can change really quickly depending on the financial
status of the US, how medical care is distributed, insurance status, and all of that, but progress is being made and I think that is the one piece that's missing out of Jon
Oliver's segment here, which, I guess, it's not his
job to give you all of that but it's that we are making progress. - Even just when it comes to contact with the healthcare system, there can be appalling disparities. There are, again, many studies
showing African-Americans have a lower likelihood of receiving recommended
care for everything from pneumonia to hip
fractures to multiple cancers. - This is one of the things I hate hearing about our healthcare system, that just because you
live in a specific area that has a high amount
of African-Americans or even other minorities, you're gonna have worse outcomes in care when it comes to pneumonia,
trauma, all of these issues. We're failing, right? We're failing as a healthcare system, we're failing as a nation. And I actually dove into this article that he's talking about here. "Despite the overall
improvement in outcomes, "the gap in quality of care "between black and white
trauma patients in Pennsylvania "has not narrowed over the last 10 years." This was a study that was done in 2013. "Racial disparities in trauma "are due to the fact that black patients "are more likely to be treated
in lower quality hospitals "compared with whites." Just because of the
lower quality hospital, African-American patients are
suffering more complications, having worse outcomes,
receiving worse care? That's horrible. Is it because these
hospitals are understaffed? Is it because they have
too much patient volume? Meaning too many patients are
coming in at the same time? Is it because they're not
following the standard protocols? Unless we take a hard, firm stance and look at this data that may
be uncomfortable to look at, we won't be able to deliver quality care to all types of patients,
irrespective of where they live. - As a study of med
students and doctors found just three years ago, misinformation about
African-American patients is rampant. - [Reporter] The study
found some doctors believed there are biological differences
between the two races. - The way that this newscaster is presenting the information, it's almost as if she's
saying doctors are wrong to believe that there are
biological differences between the races. There are biological differences and it's actually really
important for healthcare providers to be aware of these differences to deliver better healthcare. - [Reporter] 25% of doctor residents thought blacks have thicker skin. - Holy (bleeps)! You do not expect to hear
that at a medical school. You barely expect to hear
it yelled across a table by a racist grandfather at Thanksgiving! - Again, we have to bring
this back into perspective. This study actually presents 15 points, some of which are true
biological differences between black and white patients and it asked medical
students and residents to rate how true those questions were. It wasn't a yes-or-no question. In taking a test like this,
you're bound to make mistakes. I would have made mistakes on this test. Actually, if we pull up the exam here, some of these questions
can be quite tricky. Question number nine: Blacks, on average, have denser,
stronger bones than whites. Most laypeople and even some
doctors may have trouble. It's true. That is a biological
difference between the races. It changes the rates of certain conditions that can affect our bones
moving forward later in life. The question listed as
number eight in the study says black people's skin has
more collagen, in parentheses, i.e. it's thicker, than
white people's skin. So it didn't just say thicker, it talked about a specific
makeup of the skin, of collagen. It's not crazy to believe that there's differences between collagen. It's just a mistake or
a lapse in knowledge. I don't like that he's
trying to draw a parallel as if it's a racist person
making this assumption. - That is not the only insane
belief that that study found. 14% of second-year med students agreed that black people's nerve endings are less sensitive than whites
which they obviously aren't, and 17% believe that black people's blood coagulates more quickly than whites, which it obviously doesn't! - I don't know how he says
it obvious that there aren't. There are biological differences, and second-year medical students, 10% of them are allowed to
make a mistake on an exam. To point us out and say it's
obvious that they aren't, I would like to see John Oliver,
especially as a layperson, hear the point that blacks have more dense bones than whites, I'm curious to see it's
obvious that's not true. He'll be making a mistake. - Black people, we don't even
get our hands on opioids! (audience laughing) They don't even give 'em to us. White people get opioids
like they Tic Tacs. - First of all, I love Wanda Sykes. I think she's absolutely hilarious. What she's saying is true. The opioid epidemic has
disproportionately affected the white community way more
than it has the black community which is a result of the overprescription of opioids to the white community. - One recent analysis
found that black patients were 34% less likely to be
prescribed opioids for pain than white patients
with similar conditions. And while there are a lot of good reasons to prescribe fewer opioids, my patients are black
is just not one of them! - We have to figure
out how that bias forms and where these patients are
more likely to be treated. As I mentioned earlier
in some of the segments, that unfortunately, the African community attends lower quality hospitals. In lower quality hospitals, doctors are generally
faced with more patients, less resources, and
they're facing patients that may be facing homelessness, they may have substance abuse issues at a higher rate than the white community, so they may be more reluctant to prescribe opioid medications. I think we need to do a better job at formulating our research to not only find out
that, A, this happens, but to try and figure
out where this happens. Is it happening in isolated centers? And then we can focus on these centers and figure out what's going on, why these biases are occurring or these disparities are occurring. - If you consistently have bad
experiences with healthcare, you might be less inclined to seek help that you need in the future. - This is important to
note in both directions, that if you consistently have
bad experiences with doctors, you're less likely to trust them and less likely to seek help. John Oliver's absolutely right. That's the human condition. Now, I also wanna bring forward a topic that's not as much discussed in that doctors, throughout their day, are constantly seeing
drug-seeking patients, are seeing patients who are
selling their medications, are seeing patients who are not compliant and the doctors may be genuinely worried about the abuse of these medications. That can not only trigger doctors to prescribe less of those medications but also have a genuine concern
as to if they prescribe it, are they doing a disservice. I'm not excusing the fact that doctors are
prescribing 34% less opiates to black patients than
they are to white patients. I'm just merely saying that we should really take a look at this and figure out why this disparity occurs. I'd like to speak up for
the medical community because I know doctors, in some of these low
socioeconomic communities, are dealing with less resources,
less time per patient, dealing with very difficult patients, and patients that maybe
have incomplete insurance or poor health coverage and the only thing they can prescribe and that the patients
can afford is ibuprofen and that's horrible to say! In talking about all this, it may seem that I'm ignoring the bias or discrimination that can occur. This absolutely occurs. And I've heard anecdotally
from some of my patients where this has happened and it sickens me and we need to talk about
that, put that in the open, but now put an over focus on that where we miss systemic flaws
like socioeconomic factors, quality of hospitals, the quality of insurance
that patients have, because unless we address all of these things simultaneously, we're gonna make progress in
one area but fail in another. I wanna help patients as much as I can and not get short-sighted and focus on only the
most inflammatory factor. - It was just this belief
that I was making things up, that what I was saying wasn't real, that I must be seeking
drugs or selling the drugs or some such thing. - That's what you were getting
in the doctor's office? - Oh yeah, absolutely! - See, this is horrible. But what I will say is now
we're establishing guidelines that will allow us to avoid
these awkward interactions. For example, we're creating pain contracts where if we're establishing with a patient that we're gonna be giving
them controlled substances, we create a contract. This is how it's gonna work. We're gonna give you X number of pills. If you lose your pills,
this is the plan of action. If you are traveling, you have to take your
medications with you. And there's all these
guidelines that are set so that the patient knows what to expect, the doctor knows what to expect, and there's no surprises and
no feelings of discrimination. - And there's perhaps no stocky expression of where sex and race can negatively impact healthcare outcomes than maternal mortality. Currently, The United
States has the highest rate of maternal mortality
in the developed world. - This statistic receives
a lot of publicity and there's a few interesting
theories that people have. First of all, the maternal
age in The United States who are having babies later in life, we're the most obese we've ever been, which obviously lends to
a lot of complications when it comes to pregnancy
and post-pregnancy, but then I found a really
interesting article that suggested this theory. Scientific American showed the statistic that the maternal mortality
rate from 1999 to 2002 was about 9.8 per 100,000 live births. And then if we fast forward 10
years later to 2010 to 2013, it jumped to 20.8 per 100,000 live births. What they say here is really
the most interesting part. The numbers in the latter
period may have been affected by a small change in the forms that are filled out when a person dies. Until relatively recently, most states relied on a
death certificate form that was created in 1989. A newer version of the
form released in 2003 added a dedicated question asking whether the person who died was currently or recently pregnant, effectively creating a flag for capturing maternal mortality. The addition of this question means that the apparent increase in
maternal mortality in The US is quote, "'Almost certainly
not a real increase. "'It's better detection
from new certificates.' "says Robert Anderson, "chief of the Mortality Statistics Branch "of the CDC's National Center
for Health Statistics." The CDC is saying we're
not actually seeing more maternal mortality in our country. What we're actually seeing is better representation
of that mortality. - If you're a woman of
color in this country, especially if you're black, your odds of dying in childbirth are three to four times higher
on average in our country. - Why? 'Cause you're not talking
about access to healthcare. You're not talking about
money or education. - No, and this is gonna be hard to hear. We believe black women less when they express concerns about the symptoms they're having, particularly around pain. - These racial disparities
exist even when you control for socioeconomic factors like education or insurance status. We are literally disbelieving
black women to death and that is appalling and often-- - That is appalling! There's no doubt that this happens and it needs to be addressed
on a systemic level. I don't wanna get caught up and believe that's the
only thing that's happening because researchers have found
other contributing factors like the researchers in New York who found that up to
half of this disparity can be as a result of black patients attending lower quality hospitals, but then even then, we need to figure out why those lower quality hospitals are contributing to this
increase in maternal mortality. Is it genetic? Is it because they're
predisposed to illness? Is it because there's lack
of preventive care options? And until we have this
difficult discussion, we're never gonna figure
out how to close that gap. I wanna come in from the
optimistic side again and let you know that there's
actually millions of dollars that are being dedicated to looking at all of these gender issues, race issues, maternal
mortality issues from Congress to figure out what's happening,
to conduct proper research, to improve our screening methods. And again, I wanna hammer this point home that a lot of these studies
were done 10, 20 years ago and that already we're seeing improvements in the way that we treat female patients, in the way that we identify our bias, in the way that we understand that we need more diversity in medicine, that we're trying to create
funnels from different cultures to come into the field of medicine through scholarship
programs and all of that. In fact, I work with the STFM, the Society of Teachers
of Family Medicine, who have scholarship for minorities that I've actually donated
to and partnered with through my foundation Limitless Tomorrow. And the more we can do that, the more we can get onboard
with this type of diversity and bias training and acknowledgement that our system is failing
certain minority groups, we can all do better. We'll all improve as a result. This is obviously quite
a controversial topic. Uncomfortable for me to watch, uncomfortable for my colleagues to watch, but I think it stimulated some really good conversation among us. If you have any outstanding
comments or questions or even experiences
that you care to share, drop 'em down below in the comments. I'm all about stimulating
happy and healthy conversation, especially if it means we're gonna improve the healthcare field. And definitely click on this video. And as always, stay happy and healthy. (smooth hiphop music)
Wow!! I am seriously impressed. I thought for sure this was gonna be a rebuttal video, like after that WWE wrestling episode. But this guy deserves serious props... he actually seemed sincere in his fact checking and was willing to concede the parts that were completely true but also correct portions that needed a little more interpretation. Seems like a real decent human being and a responsible doctor.
Man, that rebuttal for that study of pregnant-colored women having a higher death rate was really profound. I wrote that shit down cause it really make you think what other statistics could be misleading.
This video okay...but I looked at his twitter following and the only political person he seems to follow and tweet (favorably) at is.....Ben Shapiro.
The only part I have issue with is him talking the studies not finding a causal link for or against bias discrimination. I mean, bias is internal, which means it's objectively difficult maybe even impossible to measure, so the studies not drawing that conclusion is an expected outcome. It doesn't mean it's not bias, or that bias doesn't play a large factor. How do you determine bias among a statistically large set. One can only go by trends at that point and trends make the interpretation far more complex, as this doctor shows.
Otherwise, loved this video!!
Anyone got the tldr. Or tldw version