Affirmation Bias

2020 has been by any metric, lousy.  It has also been the worst year ever for physicians nagging, and bossing everyone they could reach, often without any objective foundation.

While the head of the National Institute of Allergy and Infectious Diseases has certainly taken the gold in this Olympic year’s “Busybody” event, plenty of others have done stellar work in making this buckling profession a complete and total arm of politics.  This week’s spotlight performer is Johns Hopkins pediatrics professor and developmental-behavioral expert Barbara Howard, MD.  Her front page op-ed “Behavioral Consult” in Family Practice News is a topical favorite, “Racism: Developmental perspective can inform tough conversations.” 

I’ll give Dr. Howard credit, the first sentence gave up any pretense of camouflage:  “Can we help our pediatric patients with the complicated problems of racism, especially if we are privileged (and even white) professionals?”  The deadly dual premise is 1) it is in the purview of physicians to deal with racism their patients may perceive or imagine, and; 2) being “privileged” and “white” are of course drags on our good efforts against which we must take additional guard.

I’m not sure how Howard can quantify “privileged” and we’re sort of stuck with our birth hues.  She describes three levels of racism, “structural or institutional” policies, “personally mediated,” and “the resulting ‘internalization’ of stereotypes into one’s identity, undermining confidence, self-esteem, and mental health.” 

Dr. Howard’s comments are also on her CHADIS site, selling a service touting itself as “The complete pre-visit questionnaire solution …Incorporates patient-generated data.”  So given her resume, I’m not suggesting that she is purely shooting from the hip.  But I do wonder what the objective foundations are for any algorithms which helped her to generate her conclusions.  She tells primary care types that they can “advocate about structural racism and ensure equity within our offices…”  As I pondered this, recalling an infamous Washington Nationals fan of similar mindset, I wondered what in our training qualifies physicians to define, or quantify structural or systemic racism? 

More flags:  “Working to reduce racism thus requires parents (and professionals) to examine their prejudices to be able to convey positive or neutral reactions to people who are different.”  Is this something you need to examine over your morning coffee?

–       “Parents … do well to seek contact and friendships with people from other groups and include their children in these relationships. We can encourage this outreach plus ensure diversity and respectful interactions in our offices.”  Do harried primary care docs really have time to badger parents to go hang out with “other” groups, and what the hell does that even mean?  All office interactions should by definition be respectful, but what exactly connotes “diversity”, and why is it an intrinsic value?

–       “Children need to be told that those being put down or held down – especially those like them – have strengths; have made discoveries; have produced writings, art, and music; have shown military bravery, moral leadership, and resistance to discrimination…”  Does a pediatrician five appointments behind during flu season really want to expend energy first determining if this hectoring is needed, and then delivering it, instead of the parents?

–       “Experiences are insufficient for developing anti-racist attitudes; listening and talking are needed. The first step is to ask children about what they notice, think, and feel about situations reflecting racism, especially as they lack words for these complicated observations.”  This from the same author that earlier in the article worried about internalizing stereotypes.

And finally, “Physicians and nurse practitioners can make a difference by being aware of our privilege and biases, being open, modeling discussion, screening for impact, offering strategies, advocating with schools, and providing resources such as therapy or legal counsel, as for other social determinants of health.”  Legal counsel??  Again, mixed into a thinly beneficent tone are insidious twin assumptions that physicians are supposed to be bothersome social justice warriors, even as they admit they are part of the problem.  We can play the odds that Howard also views gun ownership as a public health question (oh yeah, I went there).

I don’t doubt that Dr. Howard is sitting on a mountain of data, surveys and questionnaires that she feels supports her point of view.  And I also think she applies a smarmy sanctimony to what should be the job of frontline clinicians, caring for patients and their families with decency and respect without being told to, because we already are decent and respectful. 

As I have argued here before, patients are better served by physicians applying their training toward defined problems for which they have applicable expertise.  If I were on a major medical school faculty and selling a data generating/gathering system, fighting against an unquantifiable but politically acceptable threat would be safe moral high ground, even at the risk of ginning up a little angst and acrimony downstream.  The fact that “Family Practice News” would front-page such a piece is likewise a safe take that tempts physicians down dead ends.

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