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

by Dayna Matthew

Offers an innovative plan to eliminate inequalities in American health care and save the lives they endanger

Over 84,000 black and brown lives are needlessly lost each year due to health the unfair, unjust, and avoidable differences between the quality and quantity of health care provided to Americans who are members of racial and ethnic minorities and care provided to whites. Health disparities have remained stubbornly entrenched in the American health care system―and in Just Medicine 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. In a time when the health of the entire nation is at risk, it is essential to confront the issues keeping the health care system from providing equal treatment to all.

Genres: Medicine, Nonfiction, Medical, Social Justice, Race, Health Care, Anti Racist

288 pages, Hardcover

First published December 11, 2015

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.

[Tijana · Rating 3 out of 5]

Readathon book 2!! I only had one chapter then the conclusion to finish but I remember why I put this book down…. You can tell it’s written by a lawyer but they didn’t have to convince me that racism in medicine is an issue, I knew that. I just wish it wasn’t so repetitive and offered some real solutions not just say “we have to fix this.” I’m just the wrong audience I guess

[Carolyn Virginia · Rating 5 out of 5]

WOW! Legal analysis of why there's health disparity and a way to fix it. I took notes in order to keep myself engaged. She notes that the disparity in health care for minorities coccus even when controlling for socioeconomic status. She believes that's caused by the implicit bias that exists by both physicians and their patients. She has developed a Biased Care Model, which describes 6 "mechanisms" of how this occurs. She reports that implicit bias is "malleable;" it can be changed quickly and can be very influenced by social pressure. (I had never heard that before!) She notes that raising consciousness (which has been tried in the past) is not enough. She says "we are "morally compelled" to make changes to eliminate health disparties. Her cure involves reforming Title VI Civil Rights Act to address discrimination due to implicit bias using all the recent social science evidence She explains that clarifying that implicit bias is illegal will bring about changes in health care organizations.

[Vivian Ho · Rating 5 out of 5]

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 · Rating 5 out of 5]

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 · Rating 3 out of 5]

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 · Rating 4 out of 5]

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.

[Shadira · Rating 4 out of 5]

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

[Jacqueline M. · Rating 3 out of 5]

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.

[Elizabeth · Rating 3 out of 5]

Maybe more like a 3.5!

I think this is an important book. We know and have know that implicit biases are common, if not ubiquitous, and that they can have a demonstrable impact on people's actions. The first chapters of this book review the social science literature on these topics and is followed by a detailed methodology on how implicit biases (of both patient and physician) affect healthcare interactions. Where Matthew becomes controversial is when she proposes to legislate the negative effects of these biases.

For some, it might be easy to dismiss this idea offhand as some attempt to regulate thought. But, I think Prof Matthew gives some compelling arguments for why this isn't crazy. I personally think that some of the psychology literature she cites is not robust enough to support some of her conclusions, which prevents me from wholeheartedly endorsing her views, but I went from being very skeptical to open throughout the book. It does get a little wordy and lengthy, possibly because I'm unused to legal writing. I think it also could have benefitted from perspectives on the healthcare systems of other countries with different social and historical backgrounds that the US. Overall I think it's intriguing and that she should publish a second edition once more work into malleability theory and implicit bias psychology more fully reveal the extent to which we can modify implicit biases and to contextualize her work in a changing American healthcare system.

[Anusha Datar · Rating 4 out of 5]

Matthew provides an outline of the legal and medical structures and practice that both reflect and perpetuate racial and structural inequality in the United States. She provides both anecdotal evidence and statistics, and she uses clear graphics and outlines as she builds models for how these systems work. This book feels like something that was obviously written by a lawyer, but there is not too much legal jargon.

A few other reviewers touched on this, but I was also impressed by the way that Matthew considered the inherent tension between the fact that making generalizations about different groups of people and characteristics can make for good medical practice/intuition but also facilitate the formation of (sinister) implicit bias.

While I appreciated her proposed solutions at the end of the book, I did think they did not feel as thought out as I expected them to be. I am not sure how the legislative (and punitive) frameworks she described would work in practice, and I think it's too easy to be skeptical of institutional powers to enforce such provisions without putting outsized pressure on struggling organizations and letting missteps by incumbents slide. That being said, I appreciated that she provided some new ideas!

[Katarina · Rating 4 out of 5]

I think the books is really well done: written and explained. I have described it as the author’s thesis on the problem with disparities in healthcare/medicine and how unconscious racism is the root of that cause and how we can and should address it through law. I really enjoyed the intersectionality of medicine and law and how the author dove into the Social Determinants (or Drivers) of Health (SDoH) and Implicit Bias.

I did have a problem with how the author said that unconscious racism = implicit bias. They are not synonymous. Unconscious racism is ONE TYPE of implicit bias. But implicit (unconscious) bias is not just unconscious racism. Bias comes in many forms. Implicit is the unconscious bias we all have on some level and we are able to become aware, recognize and correct how it manifests. I think explaining that and making the differences between the two would have been helpful for readers outside of public health and those without knowledge on biases and the SDoH.

[Wondimagegn Megersa · Rating 5 out of 5]

I enjoyed reading this wonderful book. The book is about the racial injustices and systemic inequalities in the American health care system and potential ways to reduce such health disparities. The book repetitively mentions that black and brown people in the United States and families with low socio-economic conditions are being disproportionately impacted by the racial injustice and systemic inequalities in the health care system. Some of potential causes of these health disparities include racism, providers' implicit biases, lower socio-economic conditions, lack of health literacy, lack of cultural competency and reduced trust in the health care system due to bad experiences in the past. The book emphasizes that the racial injustices and systemic inequalities in the health care is caused by multifaceted potential factors and require sustainable and comprehensive solutions address all potential causes. I highly recommend this book!

[Kay's Pallet · Rating 4 out of 5]

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 · Rating 4 out of 5]

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 · Rating 4 out of 5]

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.

[Alisha Nordman · Rating 4 out of 5]

Just Medicine: A Cure for Racial Inequality in American Health Care is a very thorough book describing implicit/unconscious biases and its impact on minority groups’ health care. We often hear about social determinants of health like socioeconomic status, job security, access to food, access to health care, and many others, but this book highlights a determinant that is less talked about, perhaps because it is a more sensitive topic or that people are simply unaware, much like the biases analyzed here. One of the most important lessons to take away from this book is that implicit biases that lead to discrimination are not inevitable nor unchangeable.

[Lensa Gudeta · Rating 1 out of 5]

Matthew is a legal scholar writing about healthcare, which automatically makes her medical discussions problematic. Furthermore, a closer look at some of the studies she cites shows that her analysis wildly exaggerates the scientific findings of her colleagues. Finally, she spends over 100 pages complaining about unconscious bias yet never really conclusively demonstrates it's that bad of a problem in the first place. Overall, a poorly written, disorganized book that should be avoided by students interested in the topic.

[André Harris · Rating 5 out of 5]

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 · Rating 5 out of 5]

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.

[Jill M Caldwell · Rating 2 out of 5]

The last chapter (9) is the meat and substance of the book. The rest of the chapters describe what we (in the USA) already know, and I found the author's approach as one of privilege and arrogance. The references were wither not pertinent to the topic or quite dated. The final chapter provides some ways in which to address the injustice in the current health care system.

[Nolan B · Rating 5 out of 5]

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!

[Ben Quon · Rating 3 out of 5]

The intended audience is probably not me. I enjoyed the book but got lost sometimes with the vocabulary used as well as how dense and deep the topic is covered. Overall not a bad book at all, and I learned a lot! It was just dense being more academic/scientific evidence-based than I thought going into it.

[Melanie · Rating 4 out of 5]

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 · Rating 2 out of 5]

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 Larocque · Rating 2 out of 5]

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.

[Marissa Prince · Rating 4 out of 5]

this was really densely written so a slow read but i wanted to read this as a new health care worker, i learned a lot, and it’s such an important topic that i think everyone who works in health care should read this or similar books on the subject

[Hope Zastrow · Rating 4 out of 5]

I enjoyed reading this and challenging myself for my future patients. The reason this isn't 5 stars is because I am not sure how much I truly understood. I worked hard to focus on it but I might not be fully smart enough in law to understand haha

[Lisa Wild · Rating 3 out of 5]

Discusses how implicit racism has negatively impacted the healthcare of individuals of different races. One of the encouraging takeaways, is that efforts to bring awareness to implicit racism actually does help individuals be conscientious and improves care.

[Colleen Yang · Rating 4 out of 5]

good mention of studies and examples, however a little difficult to read and understand