Physician Bias Contributes to Already-Existing Health Inequities in Cardiology, Says Dr Shrilla Banerjee

Shrilla Banerjee, MD, FRCP, consultant cardiologist, Surrey and Sussex Healthcare NHS Trust, highlights some of the key points from her presentation on cardiology care inequities at the European Society of Cardiology Congress 2023.

Transcript

What are some specific cardiology health inequities you discussed in your session?

I was asked to be involved in the JAMA Cardiology session looking at BAME and health inequities, particularly in heart failure but [also] in general populations from the cardiovascular disease perspective. Starting out with introducing the term BAME, BAME is Black and minority ethnic, and it's a term that came about in the UK probably in the COVID-19 era, because we noticed that the first deaths that were occurring in health care workers were predominantly in people of color. So there was a sort of grouping of all the non-White populations in the UK under the umbrella term of BAME. Basically, it highlighted that COVID-19 had uncovered the fact that there is much inequity in health care. The first 11 deaths in health care workers and physicians in particular were all in people of color. It became an issue and there was lots of suggestion that perhaps the pigmentation in the skin [or] the vitamin D levels were all contributing to COVID-19–related mortality. But in fact, it turns out that there's much deeper, more intrinsic causes, which are ingrained in society and ingrained in people that were the causation behind this inequity that had been uncovered by the COVID-19 situation.

When we went through the patient journey, for instance, if you had an out-of-hospital cardiac arrest, when you look at patients in different population groups they tend to live in more concentrated populations of similar people. If you lived in an area where there was a Black majority, the rates of successful resuscitation from cardiac arrest or out-of-hospital cardiac arrest were much lower than if you lived in a White population, and it's similar in Hispanics, in particular in the US. The US data is much more widespread than in the UK because this is something which is perhaps not being concentrated on as much in the UK.

And then going on from there, if you get successfully resuscitated and taken to a hospital, then the issue of appropriate revascularization, opening up the artery, even when it's appropriate and even if you take out health insurance considerations—which obviously is a US feature—there is a significant difference in rates of appropriate revascularization. Then following on from that, if you survive the procedure, then appropriate guideline-directed medical therapy for some reason doesn't seem to be delivered to people of color. And then going on from there, if you need a device, if you have heart failure and you need some sort of defibrillator device, again [you're] less likely to get it even though it's more appropriate. So it just seems to be that across the board there seems to be an inequity, and it's just established and marching on through all the different presentations. It's not 1 particular group of cardiologists, it's across all the practicing physicians who are dealing with our cardiac patients.

So what are the answers? Well, we know about the issues of the social determinants of health. It basically boils down to, if you are richer, you have a better health outlook. If you're richer, you have more stable employment, you have better levels of education, better levels of nutrition, better levels of child health and security, and then going on from there, better access to health care, better living conditions, less-polluted environments, less overcrowding. All of the aspects that contribute to the well-being of a person.

When we talk about it on a more physician-based level, there seems to be some bias as well. There's bias within organizations on a countrywide level. I'm not sure exactly when it was, but in America there was the redlining—basically certain populations were not allowed to live in certain areas or encouraged to live in other areas—and that encouraged more poverty and less chance of improving your social situation by moving to better areas, less pollution, more space. If you look at that, there also seems to be an institutional ignorance towards the social determinants of health and actually making some change to improve outcomes for patients of color. So actually, this needs to be sometimes changed with advocacy, and I think the Americans are actually better than the UK at this. The lobbying from the ACC [American College of Cardiology] in Washington, DC, is so much more effective than in the UK, and we should be advocating and lobbying for our patients generally.

There's also, on a personal level, there's explicit and implicit bias. Explicit bias is obviously completely wrong at all times, there's no way you can justify that, but implicit bias is something that most of us don't even realize that we have. And it's something that we can test for. There is an implicit association test on a website hosted by Harvard where you can actually do a test and it doesn't take long, but you will be surprised how much implicit bias is actually found in people who seem very balanced and reasonable. And I think all of us have some degree of implicit bias, hopefully at a mild or changeable level, but you will never address the problem until you identify the problem, so it's something we really should be encouraged to do.

This transcript has been lightly edited for clarity.