Cardiologist Albert Hicks, MD, MPH, who works with Hip Hop Public Health, said Black men face barriers at multiple points in the cardiovascular care system, from preventive testing to referrals for specialized treatment.
Even when genetic conditions put Black men at higher risk for heart disease, they may be less likely to receive recommended genetic testing. And when they develop heart failure, they may be less likely to receive specialty care.
“If you’re Black and you have heart failure, you’re less likely to be referred to see a cardiologist,” Dr. Hicks said. “Even if you get admitted to the hospital, you’re less likely to be put on a cardiac service.”
That referral gap can have serious consequences. For Black patients with heart failure, disparities can begin before treatment decisions are even made. As the disease becomes more advanced, Black patients are also less likely to receive a heart transplant or other advanced therapies.
Dr. Hicks said those differences have to be viewed within the broader history of inequities in American medicine.
Research further reveals the gap. In one study of more than 100,000 heart failure patients treated in intensive care units, white patients were 42 percent more likely than Black patients to receive primary care from a cardiologist. Black patients were also 55 percent less likely to receive life-saving interventions such as heart transplantation.
For Dr. Hicks, the issue isn’t simply whether Black patients eventually receive care. It’s the series of decisions along the way: who gets referred, who gets evaluated by a specialist, and who gets considered for advanced treatment in the first place.
These disparities do not necessarily mean an individual physician consciously discriminates against Black patients. Rather, Dr. Hicks argued that subjective judgments can accumulate throughout the healthcare system, influencing who receives specialty care and who is considered for treatment.
Research has repeatedly documented racial disparities in cardiovascular care, but identifying the precise reasons for those disparities is more complicated.
Social determinants of health can affect both cardiovascular risk and access to treatment. Dr. Hicks doesn’t dismiss those factors, but argues that focusing exclusively on them can make the problem seem so enormous that individual healthcare providers feel powerless to address it.
Physicians cannot change a patient’s neighborhood or undo decades of structural inequality, but they can examine the decisions they make in the exam room.
“I’m a practicing doctor myself,” Dr. Hicks said. “You can look at your internal biases to see if you have a problem with lower referral rates for patients of color compared to others.”
That kind of self-examination, he said, used to be more common in medicine. “We were doing that work, but the pendulum has shifted,” he said, with providers and institutions less likely to examine that type of information.
Some of the most striking evidence of implicit bias comes from experiments in which physicians are presented with essentially identical patients.
Dr. Hicks described research in which physicians watched videos of a Black patient and a white patient describing the same heart attack symptoms. The patients were matched on characteristics including age and sex and followed the same script.
Physicians were more likely to refer the white patient for cardiac catheterization, an invasive procedure used to identify blockages in the heart’s arteries. The Black patient was more likely to receive conservative management.
Dr. Hicks said researchers found similar patterns in heart failure, presenting physicians with patients who differed only by race in otherwise identical scenarios. The patients were potentially eligible for advanced therapies such as a transplant or heart pump, and race influenced how physicians evaluated the cases.
When researchers asked physicians to explain their decisions, Dr. Hicks says, they uncovered perceptions that went beyond the patients’ medical information.
Black patients were perceived as “less trustworthy,” he explained, and more likely not to follow instructions. Those perceptions can influence decisions made by physicians and transplant committees evaluating candidates for advanced therapies.
When assumptions about trustworthiness or adherence become attached to race, Dr. Hicks argues, an ostensibly objective medical decision can become subjective.
“A lot of what we do in medicine is subjective and not objective,” he said.
The consequences of those judgments can be substantial. Heart failure is a progressive condition, and patients with advanced disease may eventually need mechanical circulatory support or transplantation. Delays in referral can mean fewer options by the time a patient reaches an advanced heart-failure center.
One finding makes disparities in access particularly troubling: In the REVIVAL study, Black patients were significantly less likely to receive an LVAD or transplant, but researchers did not find a significant racial difference in mortality among patients receiving care at advanced heart-failure centers.
That doesn’t prove that eliminating disparities in access would eliminate racial differences in mortality. Still, it does raise an important question: How much of the disparity in outcomes is shaped by differences in access to specialized care?
For Dr. Hicks, answering that question means examining decisions within the healthcare system: Who is getting referred? Who is getting access to specialists? Who is being evaluated for advanced therapies? And do those patterns differ by race?
Those questions won’t solve social determinants of health, but they can expose disparities occurring within the healthcare system itself. Unlike many structural forces that influence health, those decisions are potentially measurable and changeable.
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