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Diversity in Clinical Trials

While Black and Hispanic patients are consistently underrepresented in clinical trials, there is a reluctance for those underrepresented populations to participate due to a severe lack of trust in the medical profession. This post explores one reason why Black, Hispanic and other people of color avoid clinical trial enrollment.

A 2019 article in JAMA Oncology highlights disparities in race reporting and diversity in clinical trials in the cancer field.

The past several months have pulled back the thin veil of racial hatred that has existed in the United States for centuries. The U.S. medical industry has a long legacy of manipulating and exploiting Blacks and people of color. There are numerous historical records of Blacks and people of color being used for study and medical experimentation without their consent.

Has change occurred yet?

Currently, Blacks and people of color have a consistently higher mortality rate than their White counterparts suffering from the same disease. Some medical professionals believe Blacks and Hispanics have a higher pain tolerance (something I have been told to my face during a medical visit), and prescribed pain medication with lower dosages, if at all. The AMA Journal of Ethics provides a paper exploring the social and psychological factors driving racial bias in medicine and pain treatment, presents evidence that reducing racial biases is possible, and considers medical education’s role in doing so.

There is a constant and tiresome burden of proof for Blacks, Hispanics and other people of color to show they are not criminals, addicts, or troublemakers when visiting an emergency room in order to be treated fairly. Accounts and records of actions and perceptions such as these are too many to list. There should be no surprise that Blacks and people of color do not trust the medical profession, and may avoid signing up for clinical trials.

What can be done?

Dr. Chris T. Pernell has an excellent LinkedIn post to address this question. Dr. Lisa Cooper of the John Hopkins University School of Medicine states “It’s hard to change subconscious attitudes, but we can change how we behave once we are made aware of them,” Cooper says. “Researchers, educators and health professionals need to work together on ways to reduce the negative influences of these attitudes on behaviors in health care.”

Instead of making people feel bad or awkward, people should accept that having biases is part of being human. Unconscious bias cannot be eliminated, but it can be managed. The list below is taken from Institute for Healthcare Improvement:

Strategies to Reduce Implicit Bias

Implicit bias in individual interactions can be addressed and countered if we become aware of our bias and take actions to redirect our responses. Devine and colleagues offer six strategies to reduce implicit bias:

  • Stereotype replacement — Recognizing that a response is based on stereotype and consciously adjusting the response

  • Counter-stereotypic imaging — Imagining the individual as the opposite of the stereotype

  • Individuation — Seeing the person as an individual rather than a stereotype (e.g., learning about their personal history and the context that brought them to the doctor’s office or health center)

  • Perspective taking — “Putting yourself in the other person’s shoes”

  • Increasing opportunities for contact with individuals from different groups — Expanding one’s network of friends and colleagues or attending events where people of other racial and ethnic groups, gender identities, sexual orientation, and other groups may be present

  • Partnership building — Reframing the interaction with the patient as one between collaborating equals, rather than between a high-status person and a low-status person

Similarly, in Seeing Patients: Unconscious Bias in Health Care, Dr. Augustus White offers these practical tips to combat implicit bias in health care:

  • Have a basic understanding of the cultures your patients come from.

  • Don’t stereotype your patients; individuate them.

  • Understand and respect the tremendous power of unconscious bias.

  • Recognize situations that magnify stereotyping and bias.

  • Know the National Culturally and Linguistically Appropriate Services (CLAS) Standards.

  • Do a “Teach Back.” Teach Back is a method to confirm patient understanding of health care instructions that is associated with improved adherence, quality, and patient safety.95

  • Assiduously practice evidence-based medicine.

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