Just Medicine: A Cure for Racial Inequality in American Health Care by Dayna Matthew

Just Medicine: A Cure for Racial Inequality in American Health Care Reviews

• 
  Margaret Adams

  Required reading for healthcare professionals and civil rights lawyers. Dayna Bowen Matthew lays out 1) the realities of implicit racial bias/unconscious racism in the provision of healthcare, 2) the enormous impact that has on health outcomes even after accounting for all other confounders, and 3) her proposal to reduce health disparities with new laws against implicit bias. At once kind and unyielding, Professor Matthew tracks society's progression from explicit to implicit racism and dismisses the current laws against explicit racism as no longer useful. "Laws effectively influence social norms by reflecting underlying social values that exist but about which there is incomplete information or uncertainty," Matthew writes. Making a clear differentiation between socially-maligned explicit racism and unconscious implicit racism, Matthew nonetheless is unwilling to let anyone off the hook, supporting her proposals with studies showing evidence of physicians' ability to correct unconscious racism.
  
  I especially appreciated the way she unpacked how our medical training encourages performing "sorting patterns," the use of familiar patterns and generalizations about people and their maladies to correctly identify, understand, and address illness in relatively short periods of time--an integral part of the differential diagnostic process that also makes us especially susceptible to being swayed by implicit bias.
  
  Very densely written, but worth your time.
• 
  Vivian Ho

  Thoughtful and informative book for those interested in the issue of disparities in healthcare. The author researched the evidence well and provides clear examples of how implicit bias harms minorities seeking healthcare. The solution to address implicit bias through changes in the law is thought provoking. Because I am not a law expert, I understood this part of the book less. But it leaves me wanting to learn more.
• 
  Jane Henningsen

  I picked this up because I wanted to understand racial healthcare inequities, both as a healthcare consultant and a human. I expected this to be a dive into social determinants of health, but it was actually an exploration of the impact of implicit bias throughout the healthcare system. Definitely a valuable read.
  
  Just Medicine explores bias in both sides of the provider-patient relationship and the harm that unfolds when that bias goes unchecked. There are difficult stories in here- providers who chose not to prescribe effective treatments because they doubted patients were capable of adhering to treatment protocols or paying for medications, women with tumors whose pain was initially dismissed by their providers, etc.
  
  On a more subtle level, Matthew explores communication styles and the importance of a collaborative physician/patient relationship in which a patient feels that he or she is a partner in care decisions. White patients with white providers are the most likely feel that they are partners in their own care, Black or Latinx patients with white providers less so. Cultural and language barriers add an additional disconnect for many immigrant patients. This matters - providers who do not fully engage with their patients may miss important information, and patients who feel disconnected from or judged by their providers are less likely to return for crucial follow-up care. It's a tangled web.
  
  Matthew's solutions are legal and policy solutions, which are not my wheelhouse as a healthcare strategy & performance person. I was out of my depth there, but I still picked up valuable knowledge. I would recommend Just Medicine to any healthcare friends on Goodreads!
• 
  Natalia

  This book provides an overview of the racial/ethnic bias in healthcare and resulting differences in quality of care and eventual health disparities. Then, it discusses (briefly) some potential successful interventions to interrupt implicit biases from impacting patient care and finally, concludes with a proposed legal solution to make physicians/hospitals/etc. legally responsible for implicit, in addition to explicit, bias and racism (primarily by revising the language of Title VI of the Civil Rights Act).
  
  I have a few issues with the book. First, it is dense and reads like a re-worked thesis, especially because it is structured in such a way where each chapter walks you through a mechanism in a conceptual model. Second, given the title, I expected more talk about "the cure"- but that really only comes in chapters 7-9. Lastly, and this may be more on me than the author, physician bias is only one very small part of how health disparities result, and I would have liked to see more talk about social determinants of health, health behaviors and all the other non-healthcare ways that health disparities emerge. But again, this is more on me and my training in public health that makes me always aware of the relatively small impact of healthcare on health when comparing it to all other causes.
  
  Overall, if you don't know anything about this topic, I would recommend this book to you because you will definitely be informed after reading!
• 
  Sandhya Avula

  Learned an incredible amount about how dangerous implicit bias is in medicine and how we can use law and policy as a method for improving it. Super detailed book that is a bit tedious - especially the last couple chapters that have a ton of legal jargon - but extremely informative and a must-read for anyone going into healthcare.
• 
  Nadia Hakim

  This book was laid out really well. It’s quite a bit of information and the subject matter is not easy. I really appreciate that she calls out previous researchers on their conclusions that lamely state “more research need to be done” rather than give any possible solutions. Her recommendations are solid and feasible.
• 
  Shadira

  Just Medicine is a must-read for everyone! Weaving together from insights from research in history, sociology, psychology, law, and more, Matthew crushes the argument that racial disparities in health and health care are due to factors like biology and bad behavior. Time and time again, Matthew exposes the role of racial bias and discrimination in disparate outcomes. More so, she offers meaningful and achievable suggestions for resolving these problems. Lets hope those with the most power to create these changes are paying attention to this important scholarly contribution!
  Dayna Bowen Matthew finds that they principally arise from unconscious racial and ethnic biases held by physicians, institutional providers, and their patients. Implicit bias is the single most important determinant of health and health care disparities. Because we have missed this fact, the money we spend on training providers to become culturally competent, expanding wellness education programs and community health centers, and even expanding access to health insurance will have only a modest effect on reducing health disparities. We will continue to utterly fail in the effort to eradicate health disparities unless we enact strong, evidence-based legal remedies that accurately address implicit and unintentional forms of discrimination, to replace the weak, tepid, and largely irrelevant legal remedies currently available. Our continued failure to fashion an effective response that purges the effects of implicit bias from American health care, Matthew argues, is unjust and morally untenable. In this book, she unites medical, neuroscience, psychology, and sociology research on implicit bias and health disparities with her own expertise in civil rights and constitutional law. Just Medicine offers us a new, effective, and innovative plan to regulate implicit biases and eliminate the inequalities they cause, and to save the lives they endanger
• 
  Joanna

  Took me awhile to get through this one! Definitely academic — in a good way. I felt like it was written for healthcare workers, medical school deans, policy makers, and lawyers. Danya Bowen Matthew does an excellent job of demonstrating the mechanisms that cause healthcare disparities between racial and ethnic groups—all operating at different levels, in particular during those crucial patient-provider interactions when implicit bias takes over, all too often because the provider is not allowed to spend enough time with the patient and relies on statistics and preconceived, racist, unhelpful ideas. The outcomes are deadly.
  
  So what can we do about it? I liked how the author walks through the policy history and case law, explaining why it hasn’t reduced disparities to date. In part, it’s because we aren’t addressing poverty and enacting real universal healthcare. Those structural changes would go a long way to closing the gap. It’s also that there’s a long standing belief that if racial bias is unconscious you can’t control it, which is far from the truth. I like how she used the evidence on how laws have been largely successful at preventing and litigating (treating) discrimination in the workplace, so why not in healthcare where again, the question is one of life and death. The book ends with a specific guide to amending Title VI of the 1964 Civil Rights Act and how it would make a difference: 1) prohibit unintentional discrimination, 2) provide for existing disparate impact jurisprudence to continue with the addition of negligence cause of action standard when reviewing a policy or program that does not in fact have anti-discrimination goals, and 3) restore a public-private enforcement model. The author presents a scenario of a case a plaintiff takes forward under the new Title VI provisions she proposes and why it would help. Lastly, she anticipates objections which I found to be a compelling way to convince readers. This book is an ‘appeal to health care providers to begin to act collectively, at systemic and institutional levels, to address the extent to which inequality and racial discrimination diminish the quality of health care in America.’ There is too much evidence in support of policies and programs to address unconscious racism in healthcare (and beyond). Failure is not an option.
• 
  Jacqueline M.

  I did really enjoy the middle of this book and I thought the author tackled a really difficult subject with grace and without judgement. That said I can't give it more than 3 stars for the same reasons I rarely give this type of book a high rating.
  
  1. This author is an attorney...and it shows. Conclusion, Reasoning, Analysis, Conclusion. Over and over and over again. Good for legal briefs. Not good for leisure reading. I cannot imagine this being anything other than tedious for anyone who doesn't deal with legal writing on a daily basis. She is representing a cause and she's going to argue her case. She, like all attorneys, assumes that the best and most well crafted argument will win. It usually does in court. It doesn't necessarily do so in the "real world".
  
  2. I really liked her models of how bias affects outcomes and her solutions falling into A/B/C categories.
  
  3. She lost me in the end. Only an attorney would suggest that the solution to all our problems is to increase liability for already struggling healthcare organizations. I cannot support any solution that will increase costs and lead to fraud particularly in an instance when this is literally unintentional/unconscious bias influencing action. The author argues "well if hospitals/providers show that they tried to fight the bias using my (maybe?) proven methods then they will win in court". The problem is that this isn't how lawsuits against hospitals work. Hospitals especially those that are not for profit will have millions tied up fighting lawsuits EVEN IF THEY ARE 100% IN THE RIGHT. Those are millions that could be going to actually helping patients and increasing access to care for marginalized populations. Not to mention expanding cause of action just invites in nefarious 3rd parties looking to collect a check more than they look to true justice. "Justice" shouldn't be a venture capital industry. Therefore I take a solid 4 star down to 3. Not sorry.
• 
  Allara

  Outright racism isn’t necessary to create disparate health outcomes. Our legal system hasn’t kept up with this evolution, argues Dayna Bowen Matthew in Just Medicine. Many of the existing laws written to prevent discrimination, like Title VI, only have teeth when there’s evidence of overt discrimination. Today, racism is often less obvious than that. It can come from people who would claim they don’t have a racist bone in their body, because acts that aren’t racist in intention can still lead to “disproportionately adverse effects”. As it turns out, our implicit biases can influence behavior even more than our explicit viewpoints, so even if you don’t think you’re a racist, beliefs that you hold (especially if you’re a medical professional) could lead to disparate health outcomes.
  
  Just Medicine explores how implicit bias comes to be and moments in the clinical encounter where implicit bias shows up. It seems that implicit bias in medical students gets worse throughout med school. There's evidence that this may happen in the third year when students start shadowing and practicing in the field – Matthew hypothesizes that this is learned by trying to fit in with an existing biased culture. She uses interviews and patient stories to illustrate bias in action and shows how assumptions about a group can prevent providers from treating people as distinct individuals.
  
  Implicit bias from both providers and patients can be impactful. However, evidence has shown that even if both parties have implicit bias, changing the verbal patterns on either side can change the verbal responses on the other side. Physicians are more likely to share more information when patients ask questions and actively engage in the interaction. I thought another interesting takeaway was that “patients in race-concordant relationships with their physicians rated their physicians as significantly more participatory, respectful, and trustworthy”. Even if seeking out a provider of the same race isn’t the solution, it’s still another example of the importance of diversity in medicine (and really, every field).
  
  In a research setting, physicians were able to self-correct when informed that a study was looking at the impact of implicit bias, indicating that if people are made aware of their biases, they can reverse the impact. Because of this, Matthew proposes interventions to reduce implicit bias at a large scale, as well as updates to Title VI to update it for the racism of today – implicit bias rather than outright discrimination.
  
  I think, at the end of the day, my takeaway was that most of us will have some form of implicit bias – it’s part of being human. But we’re lucky, because implicit bias is malleable. We need to be aware of those biases and work to educate ourselves and correct them so that we can be part of the solution instead of worsening the problem. And laws to hold large (healthcare) institutions accountable for addressing health disparities certainly can’t hurt.
• 
  Kay's Pallet

  This book is about the important topic of conscious and unconscious racial discriminations in the medical field. This book has so much potential to spread a lot of information and awareness to yet another injustice in our society. However, this is so dense and repetitive, it's hard to get that information out. In my opinion, this book was difficult to get through due to writing style (page long paragraphs, repetitive phrasing, fact after fact without much backing it up (at some point she even says that she doesn't have evidence backing up a claim because the experiment was bad)). I'm really not a fan of this writing style, however, I think this topic is important and the take away is informative, which is why I rated it 4 stars instead of my wanted 3 stars.
• 
  brandon

  due to the rigorous selection process that underlies medical school applications, our society is filled with physicians who are compassionate and truly look to enter this profession due to a desire to genuinely care for others. furthermore, despite the turbulence that exists outside of medicine, it is difficult to say that there are many physicians who practice and exhibit explicit racism in the modern day. more often, it is the implicit bias that drives clinical decisions which unfortunately will result in worse health outcomes for patients of color. as we continue to puzzle over how to best navigate this cognitive challenge, it is imperative that we acknowledge that after so many years, medicine will not simply reform itself.
• 
  Nuzhat

  Really enjoyed the first chapters of the book discussing all the health studies and their implications in how outcomes are affected. Her Bias Care Model was insightful along with the interview snippets of practitioners and patients of the different aspects of the model. Her interventions disrupting the aspects based on timing of the interaction were also helpful in telling the story that the inequities we have in health care today are due to racism.
  When the author uses the last chapters to discuss law and legally impacting the situation, I can recognize that it's necessary, but I was a bit less interested.
• 
  André Harris

  I randomly found this gem at Howard University’s bookstore, while on a tour. When I saw the title, it immediately grabbed my attention. I read half of the book and couldn’t put it down for two days, then I got lazy and stopped reading.
  
  This was the first book that I’ve read that it felt as if I wrote it myself! Matthew masterfully articulates the sentiments of my heart! I believe anyone involved in public health and healthcare in any juncture should make this part of their required reading.
• 
  Valerie O'loughlin

  excellent, insightful read about racial/ethnic disparities in healthcare, and a well-thought out plan to address these inequities. Dayna Matthew provides a brilliant model to explain the circular/positive feedback loop that facilitates racial inequities in health care, and backs up her theories with solid scientific evidence. Her legal arguments about how Title VI should be revised to address these concerns of implicit/unconscious bias are impeccable. a must read for all.
• 
  Nolan B

  It’s frustrating that many people try to invalidate disparities, simply because they have not personally experienced them. Dayna Bowen Matthew brilliantly explains issues that have been ignored for many years. Major reform is needed, and I am forever grateful for the people fighting for that change! Excellent book!
• 
  Melanie

  While I think that the author's ideas and theories are interesting, I am not 100% convinced of her conclusions. It was an interesting read that lead to a lot of great discussion in our book reading group.
• 
  Blandinus

  its a good glance into how implicate racism can have longing and damaging impact on patients and the power structure of the health care system. However, its very liberal in its solutions to fixing those problem when a radical change is really needed.
• 
  Lorraine Carter-Larocque

  Unfortunately listened as an audiobook, so could not follow a lot of the detailed legal and medical explanations, plus mentions of tables where one cannot see them made for a frustrating experience. Very dense. Do not listen as an audiobook. Perhaps actual reading would be best.
• 
  Yuliya

  This is an important book and it proposes an intriguing possibility for dealing with health disparities. It was a hard read for me, a bit too lawyerly, but worth the effort.
• 
  Stephanie

  4.5, rounding up.
• 
  Rachael

  Everyone should read this, the first 2 chapters are a little rambling but it has ideas and perspectives invaluable to health care equity.
• 
  Zoha Qureshi

  A must read for everyone working in healthcare!
• 
  Alec Marentic

  Important for everyone to read and consider.
• 
  Larry Garcia

  Overall good read. Posits on the idea of implicit bias as a major component of health disparities. It could have included other relevant factors (i.e social, economic, culture)