Tavis: Dr. Augustus White is a professor of medical education and orthopedic surgery at the Harvard medical school. He is the first African American ever to lead one of the school’s teaching hospitals. Born in segregated Memphis, he also became the first African American to graduate from Stanford medical school and was also awarded the Bronze Star for his service in Vietnam.
His new text is called “Seeing Patients: Unconscious Bias in Healthcare.” Dr. White, an honor, sir, to have you on this program.
Dr. Augustus White: Well, it’s an honor for me, Mr. Smiley, it really is. I’ve watched your program and admired you and your career.
Tavis: You are kind.
White: And I’m really happy to be here.
Tavis: You’re kind. I’m delighted to have you. There’s so much to talk about. I want to get to your life, starting with growing up in Memphis, in just a second. So there’s, again, a lot to cover in this conversation. You’ve distinguished yourself in so many ways.
But I want to start with the book, because what got me the minute that I saw it, aside from that arresting photo on the cover there, was the subtitle: “Unconscious Bias in Healthcare.” So the title is “Seeing Patients: Unconscious Bias in Healthcare.” Why do you think or argue with this subtitle that the bias is unconscious?
White: Well, much of it is unconscious, not all of it. Unfortunately, some of it is conscious and even mean-spirited. But for the most part I think it’s unconscious. I think most people who go into medicine are compassionate people. They care about their fellow human beings and they want to do a good job. But they are still products of a culture that has all kinds of different biases, and I think that’s the reason that explains much of the healthcare disparities.
Not all of it. Some of it, of course, is access. If you don’t have the money to get to the doctor you can’t have disparate care – you can’t have any care. But putting that aside, people who go to doctors end up having disparate care, largely without the doctors even realizing that they’re doing it. If I learn one thing in sort of studying to try to produce the book and get involved and be helpful in healthcare disparities, it’s that our unconscious minds really play tricks on us. A lot of times when we think we’re thinking objectively and reasonably, we’re not.
Our subconscious mind is very alive and well and it can influence the doctor-patient relationship. It can interfere with the communications, even. If a doctor’s communicating with the patient, the doctor may unconsciously filter certain information which doesn’t really come in, doesn’t compute. So that isn’t available as the ultimate decisions are made.
So many of these things are subtle and interactive, but I think they’re quite real. They’re very real, I believe.
Tavis: In this healthcare debate that we had a year ago and quite frankly are still having in some ways, given that there are folk in Congress now who want to overturn what we did last year, but in this debate one of the things that I kept saying, Dr. White, that troubled me so much, and I understood it, I’m not naïve.
But the conversation about health disparities never got on the table. There are all kinds of other issues that were discussed in the writing of this healthcare law, but the very notion that there are healthcare disparities in this country which lead, literally, of themselves, to thousands of deaths a year, just the disparities themselves, that conversation was never raised to the top of the debate, never got on the table. That was my read of it. What was your read of the conversation, or the lack thereof, around this particular issue?
White: Yes, well, as you know it was 2,500 pages, and I can’t say that I read it all, by any means. I am aware, thought, on the positive side of that equation, what I’m aware of is that there’s an institute at NIH now, which is the Institute for Healthcare Disparities.
Originally it was a center; it was called the Center for Comparative Studies of Health Disparities in our Nation. That was elevated to an institute at NIH, which means it has more clout, it has more resources, it has more personnel. Prior to that, it didn’t have enough of those things.
So it’s there to do research responsibility, to try to look at some of these disparities, try to analyze them, try to figure out and do research that will help us to improvement.
I certainly wish that there had been a lot more, no question about that, and we need in our medical schools to spend a lot more time and make stronger institutionalized commitments to educate doctors to get past these issues of healthcare disparities.
So yes, I wish it had been more visible, more there, but this one item I did focus on as valuable in terms of elevating the National Institute of Health’s clout and ability to make a difference in this area.
Tavis: If the lack of culturally competent care is a real issue for people of color in this country, and obviously it is, number one, number two, the numbers of doctors of color still pale in comparison to Caucasian, white, majority doctors, three, if those persons who are doing the teaching are unconscious, to your argument, in their bias for their patients, you put all that together, how then do we ever get over the hurdle of these disparities in the healthcare delivery system?
White: Well, I think it’s a real challenge and I think there are many things in the literature, there are many ways to begin to approach this. But there are two basic areas – one is to have the doctors first realize that in fact it’s an issue that’s alive and well. As you said, race is one of the main elements, but there are other elements.
Disabled people, elderly people, obese people – many other of our biases in our culture are victimized in this particular situation. But if you can have doctors aware of it, doctors willing, if you have a major culture – say your practice has lots of Latino patients in it – then it makes sense to learn something about that culture. You don’t have to be a Ph.D. in anthropology to know everything. But to have some insight, some understanding of that culture is very important.
Also to realize and explore your own biases. This is a recommendation of the Association of American Medical Colleges. They describe various recommendations for educating medical students to help to improve cultural competence, and one of those is to explore one’s own biases and learn if you’re biased against Asian people, if you’re biased against gay people, if you’re biased against obese people.
You should be aware of that, so when you see a patient coming who’s obese, you should see a yellow light and think, okay, I’m aware of this. I realize that I don’t have a great propensity and don’t necessarily warm up to people who are overweight, but I’m going to be on my Ps and Qs and I’m going to make sure I give this fellow human being, this patient the care that they deserve.
That can work, and if you have a good will and you use that mechanism, I think that’s a way to improve.
Tavis: How legitimate is the concern in 2011 that African Americans, other people of color, these persons in various genres you mentioned a moment ago – obese or gay, whatever they may be; Latinos – how legitimate are the concerns of these persons with regard to being suspicious of our healthcare delivery system?
You don’t have to have a Tuskegee experiment every day to make people suspicious of the system, but I find that there are people who are still very suspicious of the healthcare delivery system. Legitimate?
White: Well, yes, and unfortunate, but yes. I think there’s no question that particularly, as you say, you mentioned Tuskegee, particularly among African American patients there is an element of distrust. It makes it harder for them to follow a doctor’s recommendations and things of that nature, but people are intelligent, people are intuitive. Particularly people in minority groups who’ve been discriminated against have savvy and they recognize when things aren’t right.
I encourage them. I think part of the whole program to help this situation is that patients should be trained and educated about these issues, and patients – in the book, I suggest if you have a doctor and you feel like the doctor is disrespecting you or is biased against you, just say, “Doctor, I came here because I was told you were a good doctor and I heard your reputation. I chose to come here, but somehow I’m worried. I’m not sure we’re communicating well. Have you had African American patients before? I just don’t think you’re listening to me, and I’m not understanding what you’re saying.”
Well, if the doctor is offended or blows it off or is hostile then you need a new doctor. But if he says, “Oh, I’m sorry, what is it that I did that you didn’t understand and let’s talk about it,” then I would stay with that doctor. But I think you have to be aware that these things can happen.
I remember seeing patients – I remember very well an African American patient that I took care of who had some serious cervical spine problems. I was a spine surgeon. I couldn’t understand why it hadn’t been diagnosed, that he had been to several doctors, and he was a bit perplexed, too.
Because I saw him, I went through it, and it was very clear what he needed and we were going to move forward. I think this was a situation where this guy just had hit upon two or three doctors that just didn’t pay the kind of attention that they should have to him and he didn’t get the care he needed or he deserved.
So patients should be aware, and not to say that every doctor is biased, every doctor is going to give you lousy care, but it is possible that you can get involved with a doctor who’s prejudiced for whatever reason. I would say confront it and if you don’t like the response, if it doesn’t seem genuine, move on. But if it does, then it’s a good chance that that doctor’s going to try to help you.
Tavis: In your assessment, how open is the profession to hearing the kind of critique you just offered, that a patient should give his or her doctor, if they are feeling some sort of way, shall we say, how open is the profession to receiving that?
White: Well, it could be more open, I think. I’ve not done a survey on that, but I’ve had prominent, respectable physicians I’ve since pushed back. I’m not the only person that’s sort of trying to teach this. But in our medical school, some doctors will say, “Well, I don’t know what you’re talking about. I take good care of my patients, all of my patients.”
And I say, “Well, these statistics are coming from somewhere.” The Institute of Medicine was commissioned by Congress to look at this and they reviewed 600 peer-reviewed journals about these issues that showed all different kinds of health disparities. Thirteen different groups of people experiencing health disparities. So we have to face this.
It might not be pleasant to some doctors, but I think part of that competency as doctors is compromised if they’re not paying attention to cultural competence. In the state of New Jersey, in order to get your license renewed as a doctor or to get your initial license as a doctor you have to demonstrate some training in culturally competent care.
That’s the only state right now that does that. There are other states that try to address this. California, I think, has a requirement – I know it does – for continuing medical education. These are courses that doctors take after they finish medical school, and you sign up for two or three days. All of those courses now in California must include some recognition of culturally competent care education. So these are things that will help us to move forward, I think.
Tavis: How much do you think politics impacts this conversation? I raise that because I don’t have the data in front of me at the moment, but I recall discussing this in the national media when this story came out. You may recall it yourself.
The Bush administration was accused some years ago – the second Bush administration; that is to say, the son was accused in his administration of tinkering with the data. The data suggested that they were not making the kind of progress that they should have been making on the issue of cultural competence where people of color are concerned.
So they started tweaking, playing, redacting some of the data so that when the report came out it would not appear as bad as it really was with regard to the lack of progress they were making.
So I raise that example that comes to my mind right quick to ask whether or not there are politics being played around what we really know about bias in our healthcare system.
White: I’m going to assume that definitely there still is. I don’t think there’s any question about that. There are differences of opinions, there are differences of emphasis. People don’t like to acknowledge that we have 13 groups of people in our society who are experiencing care just because of bias, starting with women – and all women, not just minority women.
Our granddaughters and our daughters and sisters and wives and grandmother and mothers, et cetera. So this isn’t nice, this is not something to be proud of. It’s a definite negative in our current system. So I’m sure politics and attempts to cover it up and so forth may occur and may happen.
There’s kind of a paradox between the Institute of Medicine report in 2003, which documented all of these things – the fact that the AAMC, which is the organization that certifies all medical schools in the United States and keeps them alive, it has two educational directives to try to address this.
So it isn’t a hidden thing, but yet it doesn’t – most people on the street, if you ask someone, don’t know about healthcare disparities, and that’s one of the reasons I wanted to try to get this known to the public. And some doctors don’t really know. Sometimes they’re defensive and say, “What do you mean?” But others actually don’t realize that this is going on. So there’s kind of a paradox there which I really can’t explain. I wish I could.
Tavis: What were you seeing or experiencing in your career that sensitized you to this issue so much that you felt the need to dedicate the rest of your life to it and to offer the text? What were you seeing or experiencing that made you have to do this?
White: Well, I’ve been at my career in academic orthopedic medicine as a spine surgeon, and I’ve played that role. That’s been my primary role in life and I’ve done that as well as I could. But since I was a youngster growing up in Memphis I cared about issues of race, I cared about discrimination. I wanted to make whatever contribution I could to change that, to eliminate that.
So I’ve been concerned about diversity in medical schools and diversity in the profession of orthopedic surgery, et cetera. So I had that kind of background. I was on an airplane traveling back and forth, and I usually try to use that time to study or read, and I don’t engage in conversations much at all.
But there was this young woman, probably 25 years old, very pleasant, relaxed, and somehow I ended up in a conversation with her. We were just chatting a bit and somehow it came up through the conversation that I was a physician. And she paused and she kind of got this forlorn look in her eye and kind of stared into space.
She said, “I hate to go to doctors.” I could just tell that’s something I should follow up. I said, “Well, tell me, why do you say that? Why do you say you hate to go to doctors?” She said, “Well, you can’t see it because of except for my face and my neck and my hands – I have total body tattoos. When I go in to see the doctors and I get examined, they just treat me so badly.”
I could just envision that. I could just see that happening. So I got into it, and then of course obviously all of these racial and other types of groups that suffer these disparities come to the surface, and that’s why I just kind of kept going with it.
Tavis: See, the great thing about doing this show every night is that I ask questions every day and I never know what the answer is going to be. I did not know a tattoo story was going to come at the end of that question. And I’m not making light of her situation
White: I know what you mean, yeah, yeah.
Tavis: I know a lot of kids with tattoos all over their bodies these days who have a hard time getting to the doctor if that’s what holds them back, but I digress on that issue.
You referenced Memphis a moment ago and I know, of course, that you were born and raised in Memphis. You were in Memphis, and I was just there the other day, but you were there and raised in the segregated South.
Tavis: How did being raised in the segregated South impact your life choices, your decisions, particularly where education is concerned? Because you don’t get to where you are without being highly educated. But coming out of the segregated South, connect those dots for me.
White: Well, it’s a little bit of a paradox there, and that is in the Black community in the segregated South, as you know, the vehicle for progress, the vehicle for push-back, the vehicle for survival was education, education, education. So it was not a matter of choosing or thinking about it, it was just that’s what you were told, that’s what you knew, that’s what you understood, and the teachers in the South, I think they viewed their ability to improve issues of race in our country was to make sure that they got every ounce of potential out of every kid that they took care of in those segregated public schools.
So whatever those schools may have lacked in resources or books or Ph.D. teachers or master’s degree teachers or whatever what might be, it was more than made up for by teachers who wanted to motivate them and encourage them and guide them to do their very best.
So it was never out of any unique strategy, it was just the environment that I was in. My mother was a teacher, my aunt was a teacher, and so that’s just what I grew up in and I don’t know – I ended up going away to school in the ninth grade, so my education from ninth grade on was not in the segregated South but was in New England and then California.
Tavis: Did the white folks scare you in New England when you first there, coming out of Memphis?
White: Thank heavens, I didn’t know anything about culture shock.
Tavis: That’s a big change. (Laughter)
White: Yeah, well, it was, it was.
Tavis: Memphis to New England is -
White: Well, you’re right.
Tavis: Especially back then.
White: You’re right, you’re right. No, they didn’t. I just did what I had to do. I did what I was supposed to do and I had had almost no contact with white people up until the time I left.
Tavis: I can imagine, yeah, yeah.
White: Very little. I had a little bit. My uncle had a drug store and he rented his drug store from a Jewish family that was right next door. I had a little bit of conversation with the two kids in that family who were roughly my age, but it was not substantive.
Of course I knew about issues of race, though. In fact, one of the shocks – I used to sell newspapers, and I’d gather up the papers and I had kind of a little route in my neighborhood. I’d pick up the papers on the corner once a week. It was the “Pittsburgh Courier,” was what I was selling. I realized after a period of time that I was getting nervous and anxious when I went to pick up the papers to sell. I’d take them around to my different clients, and then if I had a few left over I’d go just walk around the neighborhood, “Extra, extra, read all about it,” what’s the news.
I was afraid subconsciously, and I stopped doing it because I was afraid there’d be a lynching on the front page. That was my exposure, my traumatic exposure, to race, was to sell these papers. So I sort of stopped doing it. But that was my experience.
Tavis: You have been distinguished as an African American first in so many different ways, including a number of firsts you’ve accomplished at Harvard. I don’t want to color the question too much. We live in an era now, believe it or not, where there are still African Americans who are doing things for the first time, including things like being president of the United States.
How have you processed in your life being an African American first at so many different things?
White: A lot of it was circumstance of history. There were doors that were opening up, and I guess I always wanted to do the best I could with what I was doing, and do my best, whether it was in sports or whether it was trying to be the best doctor I could be.
So in that process, as there were opportunities to get through the door when it was open, I went through it. Then due to some of my mentors, one in particular, Dr. Montague Cobb, distinguished African American physician, was a professor at Howard and the chairman of the board of trustees at the NAACP at some point.
I had the good fortune of meeting him when I was young in medicine. He said, “Well, you get through the door but you’ve got to open the door and bring others in.” That was just what I wanted to do.
So when I had an opportunity to get to Yale, the gentleman, Wayne Southwick, was my career mentor who gave me a job at Yale. When I got there I worked with him and talked to him and we encouraged others to come to Yale.
He won the academy diversity award, American Academy of Orthopedic Surgeons’ diversity award for educating the first African American female. She was educated at Yale; she came through after I did. A distinguished physician in Chicago, Carleton West, came through.
But Dr. Cobb said, “When you get through, get in the door, open it up.” So that was what I did and it was just what was natural for me.
Tavis: You’re a Vietnam vet.
Tavis: As I mentioned earlier, we’ve talked in this conversation tonight about all these biases that so many people in our healthcare system are subject to, but I don’t want to close the conversation by asking your thoughts about the way that we treat, consciously or unconsciously, veterans when they come home. One could argue that we still aren’t as good as we ought to be on that issue.
White: I would not disagree with you. I think we’re doing a heck of a lot better than we did with our Vietnam veterans, though, as a society. It was unfortunate, the way our Vietnam veterans were treated. I think we’re working hard on that. As you know, the first lady has interest in that, so we’re more aware of it.
But the problems are formidable. There’s the psychological problems, the tremendous medical problems with the amputees. I know that medical technology and the training for amputees is much better than it was then. There’ve been good medical advances in that regard. So I think we’re doing better, but we should do even better.
Tavis: This healthcare debate in this country, pardon my English, ain’t over yet. We’ll see what comes out of Congress on this issue in the coming weeks and months where this healthcare debate is concerned. But never a conversation more important, to my mind, at least, than talking about the disparities that still exist in this healthcare delivery system in this country.
So the new book is called “Seeing Patients: Unconscious Bias in Healthcare,” written by Augustus A. White III, M.D. out of Harvard. Dr. White, congratulations on the text. Good to have you on the program.
White: Thanks again for letting me be here. I’ve enjoyed it. I’ve enjoyed it.
Tavis: I’m honored. My delight to have you here.
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