A 2018 physician roundtable hosted by the California Nurses Association/National Nurses United and the Berkeley Center for Social Medicine caught the attention of thousands of social media users this summer, reinforcing a fact long supported by both anecdotal and empirical research: cardiology is not immune to racial disparities in healthcare.
In the video (around timestamp 1:15:55), a physician explains a patient case in which an African American woman complained of chest pain occurring when she coughed. When the doctor ordered an ECG, found evidence of STEMI, and requested further follow-up while the patient was in the hospital, she was met with reluctance, as the cardiologist only wanted to see the patient in an outpatient setting.
That interaction paints a picture of potential underlying biases that exist across the entire healthcare system, including in cardiology. Even when unintentional, bias can be harmful: The patient had angina, a clear indication for ECG, but there was hesitation to refer her to specialty cardiac care.
Decisions like these, potentially made under the influence of underlying (even if unconscious) prejudice, can ultimately lead to unequal care and worse patient outcomes.
Take coronary heart disease (CHD) for example: According to the American College of Cardiology, African American cardiac patients experience higher rates of CHD mortality (hazard ratios of 2.18 for men and 1.63 for women) than white patients, even though incidences do not vary between the two races overall. Importantly, the risk factors for African Americans are higher, which can make them more likely to have undetected CHD. According to a review in the Journal of Electrocardiology, African Americans can also present differently on ECG, further requiring patient-based assessments inclusive of race and free of bias.
These and other factors demand a closer look into the mechanics and potential effects of racial bias in medicine. Literature related to such disparities is pouring in, with PubMed tracking exponential jumps in papers that include the term "racial bias" since around 2011.
Racial Disparities in Patient Care
The disparities are not just about disease onset, prevalence, and mortality. They also appear within care planning itself.
In situations of percutaneous coronary intervention, being African American makes a patient less likely to receive drug-eluting stents, reports a study in Cardiovascular Revascularization Medicine. Other research in the American Heart Journal found that Hispanic patients have also experienced more conservative and delayed interventions, with longer arrival-to-ECG times, fewer revascularization procedures for non-STEMI acute coronary syndrome, and less availability of exercise counseling and rehab referrals.
These inequities take place even in outpatient settings, as indicated by care plans for matters as simple as cholesterol management. According to a Current Atherosclerosis Reports study, African American patients with dyslipidemia were 15% less likely to report being prescribed cholesterol-controlling drugs than white patients. For Hispanic patients, that number increased to 20%.
Heart failure research in JAMA Network Open has shown how biases may factor into clinical decision making, as African American women were less likely to be offered timely advanced therapies and more likely to be judged by the way they looked and the perception of their support networks.
Checking Inherent Biases with Neutral Tools
These patterns add troubling context to the ongoing dialogue around how to achieve equitable cardiac care without sex-based or racial bias. But reaching parity can be particularly difficult when the underlying factors fueling prejudices are inherent and unintended—as the cardiologist in the viral video may well have been demonstrating.
How can cardiologists check their own biases for the good of their patients? Systemic change starts with small steps and happens in iterations. These are a few strategies that may help:
- Advocate for increased representation of people of color in local and national clinical trials.
- Conduct informal day-to-day bias checks in the spirit of the roundtable video. Diligence can help preempt unintended prejudices before they impact patients.
- Consider self-assessments to identify possible biases that may be at play in your practice. Harvard's Project Implicit is one example of an assessment designed to help individuals discover their own prejudices.
- Adapt your personal Hippocratic oath to be cognizant of the racial disparities in healthcare, as NPR reports many medical students are doing in 2020.
It's also worth reviewing the American Heart Association's indications of ECG as they are, free of potential bias. If patients experience these symptoms, readings are warranted:
- Lasting pain above the waist
- Pressure, tightness, heartburn, or pain in the chest
- A perceived slow or rapid heartbeat
- Severe weakness
- Trouble breathing
- Use of illicit drugs
Stay on top of cardiology trends and best practices by browsing our Diagnostic ECG Clinical Insights Center.
Considerations with COVID-19
In light of COVID-19, patients should also be considered for ECG if certain drugs are administered, such as hydroxychloroquine. Given the present disparities in COVID-19 outcomes among people of color, as discussed by the Mayo Clinic, diligence is essential. However, conducting an ECG involves infection risk for personnel, so ensure proper use of PPE, disinfect machines regularly, and follow other safety protocols, as explained in a recent Heart Rhythm paper.
Keep in mind that diagnostic ECG is a helpful tool in that it can noninvasively and quickly identify cardiac irregularities at the point-of-care, but it still is just a tool. Awareness and behavioral modifications feed into the quality of care just as much as equipment and therapies can. Above all, an assessment of the whole patient is necessary, including but not limited to the increased prevalence of risk factors associated with race.
Bana Jobe is an award-winning freelance medical writer with more than ten years of content experience writing for hospitals, pharma, medical devices, digital health brands, payers, and more.
The opinions, beliefs and viewpoints expressed in this article are solely those of the author and do not necessarily reflect the opinions, beliefs and viewpoints of GE Healthcare. The author is a paid consultant for GE Healthcare and was compensated for creation of this article.