Conversation first step to ending racial bias among physicians

It's a subject most doctors are hesitant to talk about, let alone acknowledge might happen at their practice.

But racial and ethnic discrimination among medical professionals is more common than some might think, said Marcella Nunez-Smith, MD, a researcher and professor of general medicine at Yale University School of Medicine in Connecticut. Discussing prejudice in the workplace is the first step to combating the problem, she said.

It's time "for us as a profession to have what is an overdue conversation about what it means to have diversity in our profession," she said.

In Texas, allegations of racial discrimination against a group of physicians at a medical center have led to a high-profile legal battle.

Cardiologists Ajay Gaalla, MD, Harish Chandna, MD, and Dakshesh Parikh, MD, sued Citizens Medical Center in 2010. The doctors, who are Indian-American, claim that medical center management and others discriminated against them because of their Indian background.

According to the suit, supervisors removed the doctors' staff privileges without good reason and granted the privileges to less-qualified cardiologists. The doctors also were excluded from peer committees and not alerted by staff when their patients presented in the emergency department, the suit said. Emails and memos written by administrators spoke about forcing "The Indians off the reservation," and labeled the center's rival cardiology practices as "the Cowboys" and "the Indians," according to court documents.

One chief executive at the center wrote about "a sense of disgust" as "more of our Middle Eastern-born physicians demand leadership roles and demand influence," according to emails provided by Monte James, attorney for the plaintiffs.

A trial court judge denied a motion by the medical center to dismiss the case for lack of legal standing. The center has appealed. In May, a judge allowed the plaintiffs to further review the email system of the medical center and ordered it not to delete any emails from May 25, 2011, on.

"I have not seen such a level of discrimination, particularly at a large county hospital," James said. "Most people that read these emails are shocked."

Daniel McClure, attorney for Citizens Medical Center, said the hospital acted reasonably and did not violate any constitutional rights of the plaintiff physicians.

"There is no evidence that the actions of this county-owned hospital and its board in adopting a resolution to close the cardiology department was the result of any racial discrimination or was motivated by anything other than a desire to provide quality medical services to the community," McClure said in an email. "The allegations of racial discrimination are simply not true."

The lawsuit is the second attempt by the plaintiffs to sue the medical center. A previous appeals court concluded that the hospital had a rational basis for closing the cardiology department to noncontracted cardiologists. The decision had prevented the plaintiffs from exercising clinical privileges at the hospital. The plaintiffs' lawsuit was later amended and refiled with the more detailed discrimination claims.

The Litigation Center of the American Medical Association and the State Medical Societies, the Texas Medical Assn. and others have spoken in support of the plaintiff doctors. In a court brief, the Litigation Center said evidence shows the center's actions were at least partially motivated by "racial animosity," and violated the physicians' Equal Protection rights.

Culture of silence

The Texas case is unique because the doctors involved voiced their concerns, Dr. Nunez-Smith said. Frequently, physicians who feel racial tension or suspect discrimination stay silent, adding to a general unawareness among organizational leaders that prejudice exists, she said.

A study by Dr. Nunez-Smith, published in the November 2009 Journal of General Internal Medicine, found that a third of physicians nationwide have experienced discrimination at work. The survey showed that 66% of black physicians, 40% of Asian physicians and 30% of Hispanic doctors feel that their race influences relationships with colleagues, compared with 12% of white physicians.

In addition, the survey found that 81% of black doctors, 56% of Asian doctors, and 37% of Hispanic physicians feel that they are under greater scrutiny at work than their peers. Minority doctors also noted a lack of referrals by white physicians and a trend of elusive promotions by administrators.

In an open-ended portion of the survey, Dr. Nunez-Smith said some minority doctors reported more discrimination and racial bias after the terrorist attacks of Sept. 11, 2001.

"It was revealing in many ways," she said. "This group was reporting a lot of workplace discrimination and making the case that things were much worse since 9/11."

Preventing prejudice among medical staff should come from the top down, said Dr. Nunez-Smith. Often, managers make the mistake of asking minority employees to lead the discussion about diversity. This can result in minority physicians feeling further marginalized, she said.

Research shows that physicians who feel discriminated against often find jobs elsewhere. For this reason, conversations about racial bias should happen whether or not a problem has been reported, she said.

"This is a bigger issue for organizations, because physician turnover is extremely costly," she said. "Currently, it's haphazard at best whether these incidents are being reported. These initiatives really need to begin at the top of the leadership."

Administrators should be trained to determine what could be red flags for prejudice among staff, said Ayaz Samadani, MD, a family physician in Beaver Dam, Wis., and former president of the Wisconsin Medical Society Foundation.

Dr. Samadani said he would like to see more efforts by hospital regulatory boards and others to conduct independent reviews of disciplinary decisions against doctors. This could prevent physicians from feeling they have no choice but to sue over lost privileges or what they believe to be unfair treatment, he said.

"The courts should be the last resort," he said.

The AMA Code of Medical Ethics says that no professional endeavor should be denied to a physician based on race, color, ethnic affiliation or national origin. The AMA encourages individuals to report physicians to local medical societies where racial or ethnic discrimination is suspected.

Speaking up

Dr. Samadani encourages minority physicians to talk to each other about experiences they feel might be workplace discrimination. Belonging to a professional medical society is important so doctors have a broader support network, he said.

Dr. Samadani said that in 41 years as a practicing physician, he has never experienced racial discrimination at work. It's usually those who have no experience with people of different races and cultural backgrounds who exhibit prejudice, he said.

Data show that white physicians or those unaffected by prejudice typically feel more comfortable speaking up about racial problems, Dr. Nunez-Smith said. Organizations and health care systems should ask open-ended questions about discrimination and prejudice, she said.

"Nobody wants [discrimination] to be the case. But I think every organization really needs to do a self-assessment," she said. "You demonstrate it's a priority by it coming from the top."