End the pain: Start with antiracism
Authors: Tolulope O. Rosanwo, Leslie S. Kean, Natasha M. Archer
Journal: American Journal of Hematology (2020)

A young, black man with sickle cell disease (SCD) presents to a New York City emergency department with severe leg pain, having fallen days previously. He waits to be seen by a physician… Implicit bias defines the attitudes that impact our actions and decisions about people or things in an unconscious manner.1 In recent years, implicit bias training in higher education has provided a space for many clinicians to evaluate their own personal attitudes towards both patients and coworkers. Implicit biases are the often defined "hidden biases of good people".2 As this understanding of implicit bias has taken root in our collective consciousness from the late 20th century to the present, the goal to confront bias in medicine has become an institutional value. Nonetheless, tangible improvement in minority health has been slow moving. The current Covid-19 pandemic exposes these deficiencies acutely.3 Although more and more clinicians are developing an intellectual understanding of implicit bias, this awareness has failed to eradicate racism in healthcare.4 A key deficiency of the current understanding of implicit bias, is that it allows us to view our behaviors as impersonal entities—good people involuntarily producing biased actions. Racism is a personal moral failing that is not solely a belief of personal superiority over another person due to race, but also describes the support of impersonal structures wired to adversely impact groups of people on the basis of race. Ibram X. Kendi defines a racist as "one who is supporting a racist policy through their actions or inaction or expressing a racist idea."5 On the other hand, an antiracist is a person who supports "antiracist policy through their actions or expression of an antiracist idea."5 Antiracism implies action always and dismantles passivity. In Kendi's view, this means that being a racist or antiracist is not a fixed identity. It is dependent on one's actions at a point in time, from moment-to-moment. In addition, the tenets of antiracism hold that as long as we continue to concentrate on the fact that we are "good" we will never truly be convinced to fundamentally change our behaviors. "You're not too jaundiced." "If you want, we can do labs to see if you are in crisis." "We're only going to give two scripts. No more after that." "I understand, Miss, but it's like, this is what happens all the time, too. The first thing out of your mouth was 'I'm sending you home' … I feel, honestly, Miss, I'm trying to hold tears back now." So, SCD is a congenital disorder that primarily impacts black patients, people who already face racism in every facet of American society. Although often debilitating, SCD has not evoked the same empathy from health providers as other diseases impacting other racial groups.7, 8 Many believe this lack of empathy and understanding is influenced by the race of the population who are predominately affected by the disease. A documentary is a careful construction of reality portrayed as truth, and while this doctor-patient interaction was authentic, it illuminates common misunderstandings of the disease. For we who care for patients with SCD, this was a troubling encounter. The impacts of portraying SCD in this manner could be damaging to patients, physicians, and viewers unfamiliar with this disease. The first misconception created by this encounter is that drug-dependence and addiction are one and the same. Yet 90% of patients with SCD do not suffer from opioid addiction. Equating SCD with drug-seeking behavior feeds into misguided, non-evidence-based thinking.9 It also crafts a perception of patients with SCD as delinquents, criminals, and immoral people who should not be trusted. Rather, SCD is a genetic disorder that results in dysmorphic red cells occluding vasculature. So, SCD does not cause dependence on pain medication. It causes pain, organ failure, and early death. In the absence of adequate disease-modifying treatment for over a century and lack of a universally safe cure, front-line physicians rely on opioids to treat pain. It is a medical error to view patients with SCD as addicts when the vast majority is seeking medical treatment for a pain syndrome that arises from firmly established pathophysiologic consequences of their sickling disorder. The second misconception is that SCD pain is not real. Nearly 70% of patients with SCD avoid seeking medical help during vaso-occlusive crisis despite its incapacitating nature.10 Many patients with SCD are reluctant to access care for the key reason that they fear poor treatment and dismissal of their experience, a scenario poignantly depicted in the Lenox Hill episode. If you are a patient with SCD, it is exceedingly difficult to approach a physician if you are unsure that the physician will believe your pain and act as your ally. From over-policing to under-treating pain, our society has demonstrated to black people that their lives matter less, and that those in power do not seem to care. Moreover, prescribing a medication when we do not believe a patient's pain is real is doing them a disservice. Patients should never feel defeated before presenting at the hospital. Our duty and privilege as physicians is to provide hope and compassionate care—not mistrust. Lastly, another common and potentially lethal issue that patients with SCD face is the lack of a thorough work-up of a patient's pain symptoms. A SCD crisis is a clinical diagnosis of exclusion. It cannot be diagnosed with labs or any other diagnostic test. It is imperative to rule out other causes of pain such as acute fracture, osteonecrosis, or other clinical catalysts of pain, such as infection especially in the instance of atypical pain. Drawing a conclusion (that appears to us to be compounded by bias) inhibits the physician from further investigating the etiology of a patient's illness. Antiracism calls for us to continuously reflect on how our behavior in a patient encounter could be racist and how we can actively mitigate those behaviors. It calls for us to be courageous in facing these behaviors, and to fight against the fragility that leads to lack of introspection and change. It challenges us to be rigorous with our thoughts and actions, and to radically counteract the impacts of racism in medicine. Racism makes patients sick, and contributes to sub-standard care. Therefore, antiracism is a key component of preventative medicine. We propose that central to the antiracist work of the physician is the acknowledgement that racism is a social disease that affects ("infects") us all. Eradicating racism in healthcare should be the physician's duty, and we will not succeed until healthcare providers understand that their passivity contributes to this societal scourge. This task does not fall on the few who wish to champion it. The moral imperative lies with all of us who wish to do no harm and end the pain. Implicit bias trainings are part of the answer but are not enough. If we are to change our behavior, we must begin by accepting that we have the power to do so if we have the will. In our careers, we will all likely make a medical error or miss a diagnosis. While horrible in the moment, those experiences can be instructive and constructive for us as clinicians. Let this be an opportunity to reflect on your interactions with patients with SCD and to ensure that future behavior does not support racist ideas. A black man with SCD presents in the emergency department with a chief complaint of leg pain. The antiracist physician grapples with their biases and by doing so is able to treat this man with dignity and an evidence-based medicine. We can and should all be antiracists. Thank you to Dr. Daniel Promislow for his thoughtful feedback on the manuscript. The authors declare no conflict of interest. Contribution: Tolulope O. Rosanwo wrote the manuscript. Leslie S. Kean and Natasha M. Archer edited and revised the manuscript. No data was generated for the expressed publication of this article. All data discussed from other studies can be found in the cited literature within the references.