Recently, a screenshot of a page in a widely used nursing textbook began making the rounds on social media. The eye-popping passage — which fell under the apparently well-meaning headline “Focus on Diversity” — purported to teach nurses-in-training how to understand their patients’ responses to pain. “Arabs/Muslims,” the authors warn, “May not request pain medicine but instead thank Allah for pain if it is the result of a healing medical procedure.” Native Americans “tolerate a high level of pain without requesting pain medication” — and when they do admit to needing anesthetics, they prefer drugs that have been blessed by shamans. This wasn’t some relic from a used bookstore; Nursing: A Concept-Based Approach to Learning was published in 2014.
The outcry online was predictable and swift. On Twitter, on Facebook, and on Amazon, users condemned the textbook, the publisher, the whole medical Establishment as outdated, offensive, racist. The publisher, Pearson Education, drew comparisons to Nazis. “This is truly *gobsmacking,*” wrote one Twitter user. “How did this happen?” Another called it “medical apartheid.”
Within 24 hours, Pearson had apologized. A chastened spokesperson promised that the offending section would be struck from the e-book and all future print editions. The wave of outrage blew over, and social media moved on.
The generalizations printed by Pearson are so crude that they’re easy to dismiss, but the issue of ethnic stereotyping in medicine merits more than a daylong scandal. The Nursing textbook provided a glimpse into a broader culture in which racial stereotypes are pervasive and have life-and-death consequences.
Nursing students began tweeting equally toxic passages from other textbooks. Textbook of Basic Nursing warns that Asians may not like having their blood drawn, because they consider it to be their body’s life force and doubt that it can be regenerated. Another manual suggests that students focus on communicating nonverbally when their patients are African-American.
Even as doctors on Twitter denounced the textbook, in private, they weren’t so sure. “Spot on,” one surgeon said, after seeing the list. I laughed at the description of my own ethnicity: Jews may “be vocal and demanding of assistance.” It’s the kind of thing, as one Jewish friend pointed out, that Jews might say among ourselves.
But when doctors don’t trust their patients to communicate their own pain levels, instead viewing their symptoms through the lens of ethnicity, it can lead to disparities in health care and treatment. One of the most entrenched— yet least supported — clichés is that African-Americans are unusually resistant to pain. That stereotype has been invoked as far back as the 19th century, when physicians assured slave-owners that black people didn’t really mind the brutal physical ordeals they endured. During World War II, it helped justify the military’s practice of testing chemical weapons on black soldiers. And today, white people are quicker to associate “magical” words — like “ghost” and “paranormal” — with black people, and more likely to believe that a black person could suppress his hunger and thirst or run “beyond the speed of light.”
In a 2016 study from the University of Virginia, a team of psychologists examined doctors’ and nurses’ beliefs about biological differences between races, and explored how those false assumptions contributed to the systematic under-prescription of pain medication to black patients. For the first part of the experiment, the researchers, led by Kelly Hoffman, asked 121 white Americans — without any medical background — to assess a series of false statements about how members of different races responded to pain. Most of them — about 73 percent — endorsed at least one myth. Thirty-nine percent believed that black people’s blood coagulated faster than white people’s; 20 percent said that black people’s nerve endings were less sensitive than whites’; 58 percent believed that blacks had thicker skin.
Next, Hoffman put the same series of questions to 418 medical students and residents. Medical training, it turned out, did go some way toward correcting those biases — the percentage of respondents endorsing false stereotypes dropped with every additional year of education — but it didn’t correct them completely; about half of the med students and residents still agreed with least one false claim. Worryingly, 14 percent of medical residents agreed with the mysterious statement that “blacks age more slowly than whites.”
And Hoffman also demonstrated real-world repercussions: Med students who held more false beliefs also assessed the pain of a theoretical black patient as less severe. In one review of 217 patients who had gone to the emergency room in Atlanta with a broken bone, black and white patients reported similar rates and intensity of pain, but white patients were significantly more likely to be treated for it: 74 percent of white patients, but only 57 percent of black patients, were given painkillers. Even kids aren’t exempt from doctors’ biases: among nearly 1 million children diagnosed with appendicitis, 21 percent of black patients and 43 percent of white patients were prescribed opioids. (The ironic silver lining is that this effect may have helped spare blacks the brunt of the opioid crisis: Unnecessary painkillers are more often prescribed to whites.)
Pearson has promised to review its whole curriculum, but the passage in the textbook was just an example of an endemic problem. Purging blatantly racist passages from medical textbooks is like treating a symptom, rather than the disease.