STAT News recently noted this year marks the 20th anniversary of “Unequal Treatment,” the first major U.S. report to conclude that health disparities stem, in part, from racial bias. Written by National Academies’ Institute of Medicine, “Unequal Treatment” explained that racial and ethnic minorities experience lower quality health services, and are less likely to receive routine medical procedures than white Americans.
The COVID-19 pandemic made it clear these disparities persist, but we now know more about root causes and solutions which may shift these paradigms for the better.
To increase perspectives, understanding and reduce bias, the health care community has changed medical school accreditation to encourage diversity. The number of women and people of color being accepted to and matriculating at medical schools has increased steadily even if people of color are still massively underrepresented on faculty. More medical schools have included diversity training in their curriculum. Representation is necessary and yet, the question remains, “are these conscious efforts, and initiatives actually helping patients?”
What we understand is that medical school metrics don’t always equate to inclusive behaviors which ensure that patients are heard. Numbers do not address the desire to be seen –as a patient and as a person– and fully understood. Think of the physician who has immigrated to the United States and must begin again. In a country where it is hard for clinicians to practice across state lines, some ask how might we benefit in news ways from the training, perspective and expertise these clinicians have? What might we be missing that enriches our healthcare journey?
Medical professionals and hospitals, along with the wider health care community, have the opportunity to improve their own practices and perceptions of patients who come from underserved communities. Bias can be harmful which makes this a necessary change. It is time to focus not just on counting people, but on making people count. Here’s how.
Every single person, from the emergency department physician to the private practice receptionist, has naturally explicit and implicit biases. These views develop over a lifetime of personal experiences. But they also can be transformed into inclusive behaviors that appreciate and value others.
The first step to addressing our biases — the first “E” — is education or putting ourselves in a learning posture. We can evaluate our openness to change by asking what rating we would give ourselves when it comes to diversity and equity. How would others assess you? Are you skeptical? Do you believe diversity is important for your business, but not relevant to your life? Or are you ready to be a champion?
One does not have to be a champion to head to the next three “Es,” but it helps.
The second “E” is assessing our environment and our willingness to challenge it. A mono-cultural environment values one group over others and will take significant action to change, and that effort may be uncomfortable. Rather, focus should be placed on designing a culture where it is safe to ask questions. An environment where challenge is accepted and removes the feelings of vulnerability. Safety to learn, question, contribute and challenge makes stronger and more effective organizations and patient care.
Lack of psychological safety harms an enterprise. A cognitive intelligence study done by MIT engineers and researchers observed that successful teams had four things in common:
That all comes from culture — from environment. We must be willing to do the hard work of ensuring safety, facilitating conversation, and creating a culture of belonging.
The third “E” is exposure. This step can include direct exposure to people with different experiences, or listening to and reading stories about the struggles faced by women, people of color, the LGBTQ+ community, families struggling with homelessness, etc.
Great Places to Work has suggested that mentorship programs offer excellent platforms for exposure. Giving established leaders the chance to see first-hand the struggles faced by women or people of color facilitates learning and can be transformative. “A robust mentorship program sets clear expectations for both mentor and mentee, crosses all levels of the business and encourages dynamic, two-way mentorship — enabling people to learn from each other rather than simply setting up a teacher-student arrangement,” the article concluded.
Employee Network Groups (sometimes called employee resource groups) are another option. In addition to providing an incredible venue for storytelling, these communities provide important places for allies to learn perspectives, to give voice to member journeys, experiences and problems and the co-develop solutions.
The fourth “E” is experience. A friend took a college class where he, a white male, was required to attend a service at a predominantly Black church. The pastor noted his presence and called attention to him. My friend felt the pressure of being different — and that experience helped him empathize with how those worshipers and others must feel in daily life.
Role-playing in a classroom setting generally is not a sufficient way to gain experience. Clinicians must put themselves in the shoes of patients. A 2009 paper in Medical Teacher recommended taking students outside the classroom and hospital to experience the authentic context people in underserved communities face. At the Northern Ontario School of Medicine in Canada, for example, 40 percent of learning occurs in community-based sites where students generally are not in the majority.
Once we have changed ourselves and our environment, we can better serve others. Still, there are important principles to keep in mind when treating patients from underserved communities. These are the five Cs: caring, curiosity, critical thinking, courage, and collaboration.
Take curiosity and caring in tandem, for example. Study after study, including a 2017 report in the Journal of Racial and Ethnic Health Disparities, has found Black patients consistently experience poorer communication quality, information-giving, patient participation, and participatory decision-making than White patients. When we are genuinely curious about a person — when we truly care, we raise our eyes to meet them. We listen, and then take notes.
Good leaders facilitate collaboration. The same is true for clinicians. Physicians can better serve patients by inviting the perspectives of colleagues, including nurses, who may have first-hand experience dealing with the challenges a patient is experiencing. A 1999 Journal of American Medicine study found that, in general, Black patients rated their visits with physicians as less participatory than Whites did. When patients saw physicians of their own race, however, they rated their physicians’ decision-making styles as more participatory.
Clinicians also will need the courage to challenge colleagues who are not modeling caring and curiosity. As STAT News has noted, “[D]octors and other health care workers are taught — and sometimes even required — to keep their beliefs to themselves.” In 2011, for example, Wisconsin’s state medical association sanctioned physicians for writing doctors’ notes to excuse political protestors from their jobs. In 2014, Brown University administrators threatened to discipline medical students for organizing a protest in response to the deaths of three young people of color. The culture of silence is changing, but the change must come faster.
We also must think critically, and not only about our own conscious and unconscious bias. The health care community needs to examine the diversity solutions that have been posited. Effective diversity, equity, and inclusion measurements ensure an organization is using factual evidence and not relying on bias to evaluate programs. The adage of “what gets measured, gets done” reinforces that DEI programs should be data-driven and strategic with clearly defined success metrics to achieve equity of experience and better outcomes for all.
I have worked with businesses and nonprofits all over the United States. I have closely watched how the media, celebrities, and local, state, and federal policymakers have approached questions of diversity and equity. I am continually struck by the number of people who eagerly embrace the idea of DEI but find it hard to empathize with the public plight of others suffering from health disparities. Moving from understanding inclusion to action is the work of inclusion.
While external events can be polarizing, we must remember that inclusivity is ultimately about hearing the voices of all people — even those with whom you don’t identify or disagree – and acting with intention and equity. We might have to work to empathize with a father struggling with opioid addiction, to understand a veteran facing homelessness, or to perceive the incredible pain felt by a Black mother with sickle cell, but that work begins by listening.
Reducing health care disparities is about more than numbers. It is about ensuring our natural biases do no harm and working with intention to create a culture of belonging where our ears and hearts are open, and our eyes are up and focused on the patient.