Further homework: White privilege and patient care (the conversation continued)

A US study found that when cared for by white doctors, black babies are about three times more likely to die in the hospital than white newborns, but that this disparity halves when black babies are cared for by black doctors (1). Is the ultimate white privilege then to be a newborn white baby where “the race of their doctor makes little chances to their survival”(2)?

Of course as paediatricians, we set out to look after all of our patients. It would be difficult to find someone who would knowingly give a different level of care to a child based on some individual characteristic. This particular study is not UK-based and could be argued to look at associations rather than cause (although I need the statistics explaining to me!) but can we still argue that the finding is not relevant here? Although we do not have an equivalent UK study, we know that there are variations in the number of infant deaths in the UK according to race (3).

There are many variables which are likely to account for differences in outcomes for paediatric patients based on race: Greenwood et al highlight that black newborns are twice as likely to die in their first year as white newborns in the US (1,090 versus 490 deaths per 100, 000 live births respectively) and comment that “the reasons behind these disparities range from increased rates of eclampsia and preeclampsia during pregnancy to preterm delivery, to social determinants like socioeconomic inequality and racial bias”(1). These are factors which are also relevant in the UK (4,5). This specific study examines in closer detail how the race of a paediatrician might influence outcome for newborns born in hospital and call for more research into racial concordance in addressing health disparities. (Note the phrase ‘disparity’ is used rather more than ‘inequality’: a not unusual difference between UK and US literature looking at differences in health outcomes). But they are careful not to call for physician-patient matching by race: they comment that from a practical point of view, there are not enough Black physicians to serve the population in question, and that physician performance varies among physicians of both races. Furthermore, matching physicians to patients based on race would not resolve any underlying cause for such differences. So what are the underlying reasons for such differences in outcome in this study?

Given that Black infants experienced inferior health outcomes regardless of who was treating them and the effects were found to be more pronounced at hospitals that deliver more Black newborns, it is likely that the answer is complex but several factors are mentioned as plausible contributors. Some of these factors are highlighted below: we might consider how they could potentially apply to our own patient care here in the UK and I have asked some questions for us to consider.

Spontaneous or implicit bias and stereotyping

“Indeed, a growing body of literature explores the

question of whether actors exhibit different levels of bias toward

both children and adults. Wolf et al. (27), for example, examine

whether adults’ spontaneous racial bias toward children differs

from their spontaneous racial bias toward adults, finding that

people have significantly greater favorability toward their ingroup.

Strikingly, this bias was exhibited equally toward adults

and children. It is therefore possible that such an effect might

manifest exclusively as a function of spontaneous bias”

“Black newborns may have different needs and be more medically

challenging to treat due to social risk factors and cumulative

racial and socioeconomic disadvantages of Black pregnant

women (29)”.

“Physicians of a social outgroup are more likely to be aware of the challenges and issues that arise when treating their group, it stand to reason that these physicians may be more equipped to treat patients with complex needs”

Does implicit bias affect how we care for our patients?

Health system, access to health system and social factors

“Uninsured neonates, for example, experience 333 more fatalities per 100,000

births than insured neonates (729 fatalities per 100,000 for uninsured

and 396 fatalities per 100,000 for insured) (37). Furthermore,

Black newborns experience an additional 187 fatalities per 100,000

births due to low birth weight in general (38). However, both of

these social factors are dwarfed by the increase of ∼18,000 deaths

per 100,000 for newborns weighing less than 2,500 g, compared with

newborns weighing more than 3,500 g (39)”.

“there may be selection on the part

of patients, whereby the mothers of Black newborns are having

difficulty accessing the optimal physician (or are choosing their

pediatrician using an inefficient selection criterion)”.

Access to healthcare because of lack of health insurance does not apply in the UK but what other barriers might there be to accessing healthcare in the UK for certain groups?

How does socioeconomic status in relation to race affect outcomes in the UK?

Care of the mother/parent

“Consistent with prior work, we see a penalty for Black birthing

mothers in general, although the base mortality rates are an order

of magnitude lower than for infants. In the cross-tabs (column 1),

among birthing mothers cared for by White physicians, Black

mothers experience an additional 14 deaths per 100,000 births,

tripling White mothers’ mortality rate of 7 per 100,000 births.

There is no difference in mortality rates based on physician race.

However, while the interaction of patient and physician race is

directionally consistent with concordance benefits for Black mothers,

the estimate is never significantly different from zero”.

We know that studies such as MBRRACE-UK have shown that in the UK, Black women are five times more likely and Asian women twice as likely to die in childbirth. How does the care of our parents affect care of our paediatric patients?

Communication

“to the extent that newborns cannot verbally communicate with their physician,

we are able to observe the effects of concordance without trust

or communication issues affecting the patient–physician relationship.

Inasmuch as prior research has struggled to disentangle the mechanisms

behind concordance’s effect (10, 26), the setting allows us to

explore concordance in the absence of one invoked mechanism—

communication. Thus, if concordance effects manifest, we are able to

rule out communication as the exclusive mechanism”.

This study ruled out communication as a confounding factor given that babies cannot speak! But does communication have an influence over other aspects of care? How might we improve communication with our families and children?

The effect of physician training

“On the other hand, it is possible that training regarding the challenges

faced by Black newborns is lacking (the prototypical patient

being White). Robustness checks in the supplement suggest patient

predicted mortality is not significantly correlated with

physician race, nor is there heterogeneous physician availability

based on practice and arrival times”.

How has the way we have been educated shape what we see in our patients? Perhaps “Mind the Gap: a handbook of clinical signs in black and brown skin” might be a place to start.

The homework-over to you

Finally, Greenwood et al call for us to look at what actions can be taken by policy makers, administrators and physicians to ensure that all newborns receive optimal care as well as the importance of “raising awareness among physicians, nurses and hospital administrators about the prevalence of racial and ethnic disparities, their effects, furthering diversity initiatives and revisiting organizational routines in low-performing hospitals”.

With that, I’ll hand over to you all for your thoughts and ideas

References

1. Greenwood BN, Hardeman RR, Huang L, Sojourner A. Physician-patient racial concordance and disparities in birthing mortality for newborns. Proceedings of the National Academy of Sciences of the United States of America 2020 117 (35): 21194-21200.

2. Lakhani N. Black babies more likely to survive when cared for by Black doctors-US study. Guardian online Monday 17th August 2020. Available at: https://www.theguardian.com/world/2020/aug/17/black-babies-survival-black-doctors-study

3. Kroll ME, Quigley MA, Kurinczuk JJ, et al. Ethnic variation in unexplained deaths in infancy, including sudden infant death syndrome (SIDS), England and Wales 2006–2012: national birth cohort study using routine data. Journal of Epidemiolgy and Community Health 2018;72:911–918.

4. Khan O. The colour of money. How racial inequalities obstruct a fair and resilient economy. Runnymede Trust 2020. Available at: https://www.runnymedetrust.org/uploads/publications/pdfs/2020%20reports/The%20Colour%20of%20Money%20Report.pdf

5. McKenzie G. MBRRACE and the disproportionate number of BAME deaths. Aims journal 2019 31(2). Available at: https://www.aims.org.uk/journal/item/mbrrace-bame