Tuesday, October 18, 2016

Health Care's White Guy Problem(s)

The Wall Street Journal reports that women in India aren't benefiting from the spread of smartphones, which are helping men in that country -- where landlines are scarce, especially in rural areas -- perform the same kind of mobile functions most of us take for granted.

Rather than technology leveling gender gaps in India, though, it is exacerbating them.  Some 114 million more men than women have smartphones there, and that gap isn't going away anytime soon, due to gender biases that still dominate.  "Mobile phones are dangerous for women," explained a village elder.

Well, you might say, that's just India.  That sort of thing doesn't happen here, thank goodness.  Maybe you should talk to Tamika Cross, M.D.

Dr. Cross has gained notoriety lately due to an incident on a Delta flight.   There was a medical emergency, and she went into "emergency mode," getting out of her seat to offer her services.  Being young, female, and African-American, though, she evidently didn't fit the flight attendants' mental profile of a physician.  As one of them apparently told her, "Oh, no, sweetie, put [your] hand down.  We're looking for actual physicians or nurses or other type of medical personnel..."

I'm not sure which is more insulting, that she didn't fit their stereotype of any kind of medical professional, much less a doctor, or that they called her "sweetie."

Dr. Cross's experience has struck a chord, promoting #whatadoctorlookslike that has spurred both support and similar accounts, such as Jennifer Adaeze Okwerekwu's account in Stat, Jennifer Conti's story in Slate, or Lilly Workneh's Huffington Post column, plus thousands of sympathetic tweets.

The story is getting attention as an issue for female minority doctors, but the problem is, of course much bigger than that.  It is an issue for minorities and women in medicine generally, and for physicians who have emigrated to this country, to name a few subgroups.

While it is true that, according to the AAMC, women now make up 47% of medical school students, in those medical schools they only make up 38% of full-time faculty, 21% of full professors, and 15% of department chairs.  And nationally women only make up a third of the physician workforce.

Still, that's better than for minorities, who only make up only 20% of the physician workforce yet make up 37% of the population (and are projected to be a majority within a generation).  African-American or Hispanic/Latino physicians each only account for about 4% of total physicians (and, as it turns out, minority physicians play an "outsized role" in providing care to minority and underserved patients).

Clearly, there is a problem.

It's not just from whom we get our care that shows our cultural biases, but also what care we get.  There are well-documented disparities in care by race/ethnicity and by gender.  For example, men and women get treated differently for coronary heart disease, the nation's leading killers for both men and women.  Those differences are neither by design nor are helping women, as their mortality rates for heart disease have not dropped as dramatically as they have for men.

It doesn't help that clinical trials for such care are likely to have twice as many male participants than female, a fact that is true of clinical trials for many diseases.  There are disturbing under-representations in clinical trials for minorities as well.

In perhaps the most obvious example of gender mattering -- or not mattering -- there is the issue of maternal deaths due to childbirth.  The U.S. literally has third world mortality rates in this area, and is one of the few countries who report increasing, not decreasing, rates in the 21st century.  Where is the outrage, where is the urgency to address the problem?  Do most of us even know there is a problem?

Health care shouldn't feel singled out about these kind of biases.  Congress has 20% female Senators and 19% female Representatives, both of which make the private sector look bad: only 4% of Fortune 500 companies have a female CEO.  A recent report on leading New York law firms fond only 19% of partners were female, and only 5% were minorities.

The diversity problem in tech is especially well known.  Women make up less than 20% of tech jobs, and closer to 5% if just counting programmers.  It has been estimated that only 2% of tech workers are African-American and 3% Hispanic.

This matters for numerous reasons, perhaps most importantly due to AI.  AI is one of biggest tech trends, in healthcare and elsewhere, as many see it soon augmenting or even replacing human roles.  Unfortunately, there are concerns that the AI field already suffers from what Kate Crawford, writing in The New York Times, called its "white guy problem," since most of its developers are, in fact, white guys, full of their implicit and explicit biases.

As Professor Crawford said: "We need to be vigilant about how we design and train these machine-learning systems, or we will see ingrained forms of bias built into the artificial intelligence of the future." Your AI doc may not be a white male but may still think like one.

Look, I have nothing against white guys; heck, I am a white guy.  But the fact is that white males are not, and never have been, a majority in this country.  Yet in our health care system you're most likely to get care from a white male, who was most likely trained by white males, and the care you receive is most likely based on what has been found appropriate for white males.

If any of that sounds even remotely right to you, you're probably a white male.

It shouldn't matter the gender, race, ethnicity or, for that matter, sexual orientation, socioeconomic background, or religion of the people giving us care; what should matter is how well they provide that care.  On the other hand, those factors should all factor into the care we receive, to ensure that we receive the most appropriate care for our specific health needs.

We talk a lot about patient-centered care and personalized/precision medicine, but we're a long way away from even recognizing how pervasive our biases are that prevent us from those.  

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