Blurring the Lines: Distinctions and Distractions in Race and Medicine

I am an insider speaking: a doctor trained in a Los Angeles hospital with its great American ethnic variety, where I learned about wellness, disease, and delivering the highest quality of medical care available to anyone who chose to come, or was brought by an ambulance after a call to 911.

I am an outsider speaking: a Mexican from central California, and not Mexico. Born at the County hospital and raised in the beige government housing development trimmed in 1970sera dark brown.

From both sides of American medicine, I write personal essays and give forensic speeches in hopes of redirecting healthcare toward viable solutions bringing us closer to eliminating healthcare inequality.

The existence of healthcare disparities between American ethnic groups is well-established in the medical literature. No more studies need be done to demonstrate that ethnic minorities do not receive equal healthcare. The overwhelming evidence of inequality is uncontroverted. Despite American medicine’s best intentions, more articles about how Black people wait longer for a smaller dose of pain medication for broken bones than White people with broken bones would be insufficient. We already know.

However, in our current discussions in search of solutions, the medical literature is limited in both depth and breadth. For example, proposed “language access” is a definite step toward closing this gap in healthcare quality between American ethnic groups. Alone, however, this promises to be insufficient because, save a precious few recent immigrants, all Black people in America speak English. Mexican Americans, too, speak English.

The other mainstay of proposed solutions for eliminating healthcare disparities—educate physicians and medical students on “cultural competence”—of course helps our efforts at equality in care. But, this effort can also distract us in our approach to eliminating disparities. Which cultural attribute will explain overt mistreatment of Mexican American people? What seminar on cultural competence would ensure a minority patient receives a diabetic eye exam at the same time as her White American contemporary?

Which keynote speech would work?

No. This is not about culture. This is not about language. Cultural differences, language misinterpretations, health insurance or even access to care, for that matter, do not complete the analysis on healthcare disparities. My mother is Mexican from California. She speaks English. She receives poor healthcare for her asthma and her diabetes. Doctors’ treatment of ethnic minorities in America is in question here. By focusing the discussion of healthcare, disparities on language differences and cultural differences, which are American synonyms for deficiencies, we relocate the locus onto the English-speaking Mexican woman. The Black Southerner. The immigrant’s son. This allows would-be benevolent, fair American medicine to conjure that these are patients’ deficiencies, and not ours.

Healthcare disparities are not a Hmong problem. Rubbing a Thai kid on the head, or giving a Mexican baby the evil eye does not explain the variance in rates of cancer screening, cholesterol screening, cardiac catheterization, or diabetic sequelae between different ethnic groups—independent of economic class. A new delineation of the variance would not help control my mother’s blood glucose, nor correct my friend’s diabetic kidney failure after years of living out of control. American medicine avoids the tough discussion about race: honest concession that biological race doesn’t actually exist; that unequal medical treatment of different ethnic groups throughout American history is the standard; that doctors ourselves, whether overtly or unknowingly, perpetuate differential treatment of different ethnic people, as the data show again and again; that our medical “system” does not consider policy, sanctions, or even rewards in our approach to eliminating disparities in healthcare; that we don’t have the courage to discuss race in medicine because this would require we admit both personal and professional failure.

Race in medicine recapitulates race in society. It would not be intelligent to expect race in medicine to exist independent of race in America. Current solutions addressing other medical quality deficiencies conjoin economics and medicine. Offering cash incentives to improve the quality of medical care, for which Americans already pay more than anyone else on earth, is the latest rage in medical quality schemes. Methods to improve, say, the rate of vaccines for children, screening mammograms for women who need them, or for providing appropriate treatment of simple viral infections are based on cash rewards. Whereas doctors get paid to do the ordinary work of treating patients appropriately, we stand to receive extra payment in the form of Pay-for-Performance (P4P) money when we provide what can then be construed as extraordinary care. In my role as a medical administrator, I find myself explaining how more money can be “earned” for doing the things that should ordinarily be done for patients.

I considered how this P4P approach might address the gap in care between American ethnic groups. If American medicine were to devise a methodology for paying extra cash to doctors and healthcare systems for closing the gap in care between ethnic groups—extraordinary care—then they would earn the cash incentive. Such a primitive Skinnerian approach to changing physician behavior, however, cheapens the cachet of American medicine. But this is not the final blow. Why doctors treat people is in question here. That is, beyond the appearance of inequality is actual inequality: actual flesh in pain; failed kidneys and ensuing blindness; unvaccinated babies; unchecked cancer.

The business case, then, could be made for health insurance companies, or the largest healthcare purchaser, the federal government, to close the gap in healthcare: if ethnic minorities are sicker, then providing them with timely preventive care would save us all money. Cash incentives could be offered to individual doctors, large and small medical groups, and networks of healthcare entities for closing the gap between ethnic groups. This would require that data on “race” be collected, analyzed, adjudicated, and rewarded if successful.

But no one requires—or pays for—any medical entity to decrease the gap in healthcare. Solutions are in order. Perhaps we could continue offering cultural competence and language access education to doctors, nurses, medical groups, and hospitals and their networks? Perhaps we could create a quality sub-committee—a Healthcare Disparities Committee—that would serve as an oversight body monitoring hospitals’, medical groups’, and doctors’ quality scores in closing the gap in care between different ethnic groups? If there is an infectious outbreak in a hospital, quality committees already exist to address—and solve—this problem. No such body exists to solve the perennial outbreak of disparities.

Beyond setting up a committee, of course, would be enforcement. Without the licensing or credentialing agencies in place to enforce this would-be improved equality in care for ethnic groups, medicine is left to its own oversight—which is what got us here in the first place. Fines, financial withholds, or even rewards for achieving the extraordinary effort of treating ethnic

minority groups fairly could all work to close the gap in modern American healthcare inequality.

I do not wish to waste words of ethnic labeling that only serve to direct our attention away from the flesh of the matter. It is no matter whether a Hispanic is a Puerto Rican or a Mexican or a Cuban or a Nicaraguense or a Mexican from California who has never been to Mexico. These are puffs of indecipherable air that render one brown person interchangeable with any other, and disregard his distinct, measurable, reproducible inferior healthcare as one of these brown people, whatever we call him.

My mother, the diabetic, reminded me that she did not take prenatal vitamins when she was pregnant with me in 1963. When I mentioned I was in the process of writing this personal essay, she also informed me that the very first time she saw a doctor during her pregnancy was the night I was born in 1964. I am a Mexican. That’s what I tell people when I’m pressed for an aural version of my face. During my pediatric training, when I was much younger, one of my professors, unprovoked, said, “You look like a Mayan—from a book!”

But I’m not from a book. I am a writer with a degree in medicine, thinking about both professions as means to the highest humanity available. In the end, however, my personal work is silent without the concert of my profession. Whether we invoke P4P, establish a Healthcare Disparities Committee, or plod along as we are, helplessly chipping away at race and medicine, the primordial reasons we all became physicians, those higher human claims, must continue to be our reason for treating people.

Richard S. Garcia, MD, MMM, is a pediatrician and medical administrator. His short story collection, Aztecs at the Guggenheim, continues his examination of identity in America and will be published later this year. He and his wife live in California with their children. Contact him at jazzprose@mac.com.