change their behaviors or fail their courses and vanish from their professors' classrooms.
JUDGING PHYSICIAN CONDUCT: PRIVACY AND THE “HALO EFFECT”
The detection of racially motivated diagnoses and treatments by physicians remains an ineffectual statistical exercise that has been repeated in hundreds of papers in medical journals over the past two decades. The systematic use of diagnostic and treatment protocols by doctors who track outcomes and adjust care is modern medicine's best hope for improving the services it offers patients. But peer-reviewed evidence of racially biased medicine has produced no reforms remotely comparable to what is now being done at many hospitals to improve survival rates among diabetics and preterm infants. Frequent calls for “further research” into the causes of racial health disparities simply defer the possibility of intervention into racially motivated behaviors into the indefinite future.
So the fundamental questions here are: Why has the medical profession never systematically studied how physicians produce racially motivated diagnoses and treatments that can cause medical harm? And how has traditional, and often defamatory, racial folklore been absorbed into medical practice in specific forms that have infiltrated medical specialties from cardiology to obstetrics to psychiatry?
Traditional norms discourage the analysis and assessment of physician conduct or even misconduct. The medical community, like some other professional groups, has been reluctant to discipline its members for unprofessional and even harmful conduct. As one physician-author noted in 1988, “doctors are unwilling to blow the whistle on other doctors. It's somehow bad manners or breaking the faith of the medical profession to report a bad doctor.”23 In this sense, the practice of medicine, like police work, is more of a fraternal order than a scientific community that recognizes and acts upon its responsibility to monitor and correct the deviant and dangerous misconduct of its practitioners.
Another powerful factor that shields doctors from scrutiny is the “halo effect” that wraps physicians in an aura of benevolent power. “Doctors,” a New York Times writer noted in 2009, “have a degree of professional autonomy that is probably unmatched outside of academia. And that is how we like it. We think of our doctors as wise men and women who can combine knowledge and instinct to land on just the right treatment.”24 The combination of benevolent intent and the power to heal has traditionally conferred upon doctors “a degree of professional autonomy” that can make them appear as sages who have earned a status that puts them beyond the judgments of observers who do not belong to the guild.
The physician's authority and autonomy can promote a socially conservative identity that resists both personal self-examination and social reforms. Social conservatives may not see the causal relationship between self-scrutiny and a willingness to promote social change, including the profound social changes that antiracist policies require. Even today, social conservatives (and others) retain the option of preserving the traditional racial hierarchy and its racist folklore inside their heads, while conforming to antiracist public norms that enforce public civility and a degree of racial integration within “disciplined” workplaces such as hospitals and clinics. There can be no doubt that many doctors choose this option, thereby disciplining their social conduct but not their racial imaginations.
Given the degree of autonomy traditionally accorded to doctors, requiring them to examine their own feelings about race, and perhaps change their behaviors, will be regarded by many of them as an invasion of privacy. Whether doctors are entitled to this privacy depends on what privacy may conceal. If it is true that “few people are free of unconscious fantasies about imagined racial characteristics,” as one prescient physician wrote in 1985, then the existence of unconscious fantasies with potential medical consequences challenges the right to privacy of the doctor who harbors them.25 According to the prominent physician and author Sherwin Nuland, “conscious and unconscious prejudice pervades rounds, teaching conferences, and even decision-making.”26 In a word, it can be medically dysfunctional for physicians to preserve and act upon their “private” racist fantasies and beliefs.
Another traditional aspect of physician privacy is the right of doctors to be apolitical and uninvolved in public policy. As two proponents of medical curriculum reform wrote in 1994: “Although organized medicine may occasionally take a stand on matters of public policy and bioethics, such positions are often weakened by medicine's long-standing position that individual physicians cannot be expected to act contrary to their own moral beliefs.”27 While this position appears to defend acts of conscience, some physicians will find it difficult to distinguish between their moral beliefs and their intuitions about racial differences. Those who believe that the traditional Western racial hierarchy is an expression of natural law may well reject the positive (man-made) laws that mandate racial equality. In such cases, how will apolitical and social policy-averse physicians establish relationships with black patients? These patients are, after all, people who require sympathetic racial attitudes on the part of those who treat them.
The racially “conservative” physician thus finds himself in a difficult position, caught between the demands of modern racial etiquette and his own private beliefs about racial traits and differences. It is, therefore, not surprising that the medical school instruction in “cultural competence” that is designed to resolve such conflicts has encountered much resistance for this and other reasons. It is easy, for example, to argue that an already crowded medical curriculum simply has no room for “touchy-feely” instruction in human relations that displaces courses in the “hard” medical sciences. Many doctors who are asked to expand their emotional repertories to include new attitudes toward blacks and other racial groups will reject this as an unreasonable and unrealistic demand on their emotional resources that amounts to a violation of personal privacy.
For this reason the very idea of asking doctors to examine their own feelings for the purpose of better serving their patients already represents radical reform. Integrating the race issue into this process is a further complication that many doctors will interpret as mandated political correctness and unrelated to improving medical treatment. Another factor involved in requiring medical professionals to engage in self-examination is the emotional stress that is often a part of medical practice. The ER doctor Paul Austin has thought deeply about the emotional costs of his medical practice and reached some conclusions that depart from the stereotype of the “caring” and “compassionate” physician. Compassion “isn't an emotion. It's an action. A discipline.” Similarly, “emotional distance may not always indicate a failure of empathy.” Austin recognizes both the practical value and the costs of emotional distance, which can promote emotional survival but also repress feelings in ways that can eventually harm both the physician and his patients.28
Doctors may also find the task of introspection time-consuming and impractical. “Frequently physicians think that dealing with emotions is opening a Pandora's box, that they'll be asked about things they can't do anything about, and that it will take a lot more time—especially if the feelings are about sadness or anger.”29 Inside this Pandora's box lurk the devastating consequences of poverty and family trauma that impact the lives of black patients in a disproportionate way. And it is true that the doctor can do little or nothing in a direct way about social conditions or dysfunctional relationships. What the doctor can do is to study his or her own responses to traumatized people. This process should make it possible to distinguish between the unique identity of the patient and the racial folkloric traits conveyed by the oral tradition described later in this book.
The idea of providing or requiring psychotherapy for racially prejudiced physicians has been heard in the past and has gone nowhere as a way to prevent medical racism. “For psychiatrists who lack the empathy needed for work with all groups of people,” David Levy wrote in 1985, “psychoanalysis has been recommended to erase distorted perspectives concerning race or at least to enable them to become more aware of when their irrational attitudes might impede the treatment process.”30 Two decades later the same proposal appeared in Academic Medicine: “When they are not brought to the level
