And like many other doctors of the era in the South, he was also a wealthy plantation owner who tried to use science to prove that differences between black people and white people went beyond culture and were more than skin deep, insisting that black bodies were composed and functioned differently than white bodies. They believed that black people had large sex organs and small skulls — which translated to promiscuity and a lack of intelligence — and higher tolerance for heat, as well as immunity to some illnesses and susceptibility to others.
Over the centuries, the two most persistent physiological myths — that black people were impervious to pain and had weak lungs that could be strengthened through hard work — wormed their way into scientific consensus, and they remain rooted in modern-day medical education and practice.
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These misconceptions about pain tolerance, seized upon by pro-slavery advocates, also allowed the physician J. Marion Sims — long celebrated as the father of modern gynecology — to use black women as subjects in experiments that would be unconscionable today, practicing painful operations at a time before anesthesia was in use on enslaved women in Montgomery, Ala. And yet, more than years after the end of slavery, fallacies of black immunity to pain and weakened lung function continue to show up in modern-day medical education and philosophy.
The answer has everything to do with race. To validate his theory about lung inferiority in African-Americans, he became one of the first doctors in the United States to measure pulmonary function with an instrument called a spirometer. Recent data also shows that present-day doctors fail to sufficiently treat the pain of black adults and children for many medical issues. A review of studies examining racial disparities in pain management published in The American Medical Association Journal of Ethics found that black and Hispanic people — from children with appendicitis to elders in hospice care — received inadequate pain management compared with white counterparts.
When asked to imagine how much pain white or black patients experienced in hypothetical situations, the medical students and residents insisted that black people felt less pain. This made the providers less likely to recommend appropriate treatment. A majority of these doctors to be also still believed the lie that Thomas Hamilton tortured John Brown to prove nearly two centuries ago: that black skin is thicker than white skin.
This disconnect allows scientists, doctors and other medical providers — and those training to fill their positions in the future — to ignore their own complicity in health care inequality and gloss over the internalized racism and both conscious and unconscious bias that drive them to go against their very oath to do no harm.
The centuries-old belief in racial differences in physiology has continued to mask the brutal effects of discrimination and structural inequities, instead placing blame on individuals and their communities for statistically poor health outcomes. Rather than conceptualizing race as a risk factor that predicts disease or disability because of a fixed susceptibility conceived on shaky grounds centuries ago, we would do better to understand race as a proxy for bias, disadvantage and ill treatment.
The poor health outcomes of black people, the targets of discrimination over hundreds of years and numerous generations, may be a harbinger for the future health of an increasingly diverse and unequal America.
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Linda Villarosa directs the journalism program at the City College of New York and is a contributing writer for the magazine. By Atul Gawande. Digitization promises to make medical care easier and more efficient; instead, doctors feel trapped behind their screens. On a sunny afternoon in May, , I joined a dozen other surgeons at a downtown Boston office building to begin sixteen hours of mandatory computer training. We sat in three rows, each of us parked behind a desktop computer.
In one month, our daily routines would come to depend upon mastery of Epic, the new medical software system on the screens in front of us. More than ninety per cent of American hospitals have been computerized during the past decade, and more than half of Americans have their health information in the Epic system. Seventy thousand employees of Partners HealthCare—spread across twelve hospitals and hundreds of clinics in New England—were going to have to adopt the new software. I was in the first wave of implementation, along with eighteen thousand other doctors, nurses, pharmacists, lab techs, administrators, and the like.
The surgeons at the training session ranged in age from thirty to seventy, I estimated—about sixty per cent male, and one hundred per cent irritated at having to be there instead of seeing patients. Our trainer looked younger than any of us, maybe a few years out of college, with an early-Justin Bieber wave cut, a blue button-down shirt, and chinos. Gazing out at his sullen audience, he seemed unperturbed. I learned during the next few sessions that each instructor had developed his or her own way of dealing with the hostile rabble. One was encouraging and parental, another unsmiling and efficient.
When it came to viewing test results, though, things got complicated. In , when I was an eighth grader in Ohio, I built my own four-kilobyte computer from a mail-order kit, learned to program in BASIC , and was soon playing the arcade game Pong on our black-and-white television set. As my Epic training began, I expected my patience to be rewarded in the same way. With Epic, paper lab-order slips, vital-signs charts, and hospital-ward records would disappear.
A study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.
Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. My hospital and clinics reduced the number of admissions and appointment slots for two weeks while the staff navigated the new system.
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For another two weeks, my department doubled the time allocated for appointments and procedures in order to accommodate our learning curve. The software costs were under a hundred million dollars. The bulk of the expenses came from lost patient revenues and all the tech-support personnel and other people needed during the implementation phase.
In the first five weeks, the I. Most were basic how-to questions; a few involved major technical glitches. Printing problems abounded. My hospital had to hire hundreds of moonlighting residents and pharmacists to double-check the medication list for every patient while technicians worked to fix the data-transfer problem. The doctors were used to having all the votes. But Epic had arranged meetings to try to adjudicate these differences.
A simple request might now involve filling out a detailed form that took away precious minutes of time with patients. Rana said that these growing pains were predictable. I saw what he meant. My laptop was available for checking information and tapping in occasional notes; after the consultation, I completed my office report.
Some things were slower than they were with our old system, and some things had improved. From my computer, I could now remotely check the vital signs of my patients recovering from surgery in the hospital.
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With two clicks, I could look up patient results from outside institutions that use Epic, as many now do. For the most part, my clinical routine did not change very much. As a surgeon, though, I spend most of my clinical time in the operating room. I wondered how my more office-bound colleagues were faring. I sought out Susan Sadoughi, whom an internist friend described to me as one of the busiest and most efficient doctors in his group. Sadoughi is a fifty-year-old primary-care physician, originally from Iran, who has worked at our hospital for twenty-four years.
Making time in her work and family schedule to talk to me was revealingly difficult. The only window we found was in the early morning, when we talked by phone during her commute. Sadoughi told me that she has four patient slots per hour. Early on, she recognized that technology could contribute to streamlining care. She joined a committee overseeing updates of a home-built electronic-medical-record system we used to rely on, helping to customize it for the needs of her fellow primary-care physicians.
When she got word of the new system, she was optimistic. Not any longer. She feels that it has made things worse for her and her patients. Before, Sadoughi almost never had to bring tasks home to finish.
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Now she routinely spends an hour or more on the computer after her children have gone to bed. She gave me an example. The list is intended to tell clinicians at a glance what they have to consider when seeing a patient. Sadoughi used to keep the list carefully updated—deleting problems that were no longer relevant, adding details about ones that were. With computers, however, the shortcut is to paste in whole blocks of information—an entire two-page imaging report, say—rather than selecting the relevant details.
The next doctor must hunt through several pages to find what really matters. Before she even sets eyes upon a patient, she is already squeezed for time. And at each step along the way the complexity mounts.
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When I do a Pap smear, I have eleven clicks. Why is it asking me what date, if the patient is in the office today? When do you think this actually happened? It is incredible! She continued rattling off examples like these. The rest came after hours. The pointlessness of it did. Difficulties with computers in the workplace are not unique to medicine.
Matt Spencer is a British anthropologist who studies scientists instead of civilizations. Years before, a graduate student had written a program, called Fluidity, that allowed the research group to run computer simulations of small-scale fluid dynamics—specifically, ones related to the challenge of safely transporting radioactive materials for nuclear reactors.
The program was elegant and powerful, and other researchers were soon applying it to a wide range of other problems. They regularly added new features to it, and, over time, the program expanded to more than a million lines of code, in multiple computer languages. Every small change produced unforeseen bugs. As the software grew more complex, the code became more brittle—more apt to malfunction or to crash.
The I. There is, he said, a predictable progression from a cool program built, say, by a few nerds for a few of their nerd friends to a bigger, less cool program product to deliver the same function to more people, with different computer systems and different levels of ability to an even bigger, very uncool program system for even more people, with many different needs in many kinds of work.
Spencer plotted the human reaction that accompanied this progression. People initially embraced new programs and new capabilities with joy, then came to depend on them, then found themselves subject to a system that controlled their lives.