1 Question, 5 Answers is a column where we ask different types of healthcare pros to weigh in on the same issue.
Race shouldn’t have any bearing on whether someone gets sick, gets treatment or gets over a health scare. But in the U.S., it often does. Rates of chronic disease and early death, for example, are disproportionately high among people of color. Many factors contribute to these healthcare disparities, and research suggests that racial bias in the exam room is one of them.
While public health officials are working to address the problem, minority patients are still receiving lower-quality care. As a result, health systems, clinics and med schools are taking a variety of measures to root out racial bias. We asked five healthcare experts what they’re doing to equalize the patient experience. Here’s what they had to say.
Keisha Ray, PhD
Assistant professor and bioethicist with the Center for Humanities and Ethics at McGovern Medical School at UTHealth
At the University of Texas, we’re part of a general curriculum on ethics in humanities, but we also have our own humanities program our medical students are enrolled in. Since I research racial disparity in various areas of healthcare, one of the areas I focus on with our students is race and medicine. In my race and gender class, we talk about the narratives we assign to bodies, and how those narratives influence how we treat certain bodies. For example, we look at how society looks at black and women patients, and then we tease out our own biases. Where do our biases come from, how do they impact the care we will give and how can we check the narrative we associate with our patients before we even talk to them?
Luckily, our classes are chosen, so the students in my classes want to know more about these issues. Often they feel the information they have on race and healthcare is lacking, or they want to be in an environment where they can academically talk about topics they already know a little bit about. Sometimes students give me feedback that they hope to become more aware of their own biases and use their knowledge of racial injustice in healthcare in their own patient care. Since their patients too might be aware of this disparity in healthcare — which can keep them from trusting medical personnel or cause them to wait a long time to be seen — these students can reassure them that they’re in a safe place to receive care.
Dr. Leah Backhus, MD
Thoracic surgeon at Stanford Healthcare
Palo Alto, California
The first way to overcome bias is to acknowledge its existence — which you’d think would be a given in 2019, but this perspective is by no means pervasive. I think part of the issue we have is that those who go into healthcare perceive ourselves as [altruistic] people; we’re trying to heal people and minimize pain and suffering. To think or acknowledge that one does carry biases, whether conscious or unconscious, seems to fly in the face of that. There’s this cognitive dissonance there which can be a major barrier. But if we would acknowledge that we all carry and cultivate bias, it would lose its stigma and allow us to truly address it in a meaningful way.
More broadly, I have done a lot of work within the diversity and inclusion committees I sit on. We have really tried to take the bull by the horns in terms of describing the problem and its impact within our small world of cardiothoracic surgery, which has huge implications for the two biggest killers in the U.S.: cancer and cardiovascular health. Recently we’ve done a survey of our members to learn about the myths and barriers out there and to try to take that information to inform our strategies to move forward and overcome them. We’re also trying to figure out what we can do to diversify our workforce, which could have a big impact.
On a smaller scale, one of the things I’ve found helpful is participating in a patient communication class focused on how to communicate more effectively, how to be more attuned to subtle cues your patients exhibit and how to foster trust in patient interactions. All of these things are critical not just in terms of adjusting bias but for improving healthcare in general.
Paula L. Houston, EdD
Director of healthcare equity, Office of the Chief Medical Officer, University of Washington Medicine
Our work started about two years ago. A group of leaders got together and decided we wanted to address the needs of our patient populations who were seeing the greatest disparities. We came up with our healthcare equity blueprint, which has three objectives. The first is to create a more inclusive workforce where people understand the issues of institutional racism, the history of racialized medicine, implicit bias, intersectionality and microaggressions. We do a lot of training for our staff all over our 30,000-person system, and many of the clinics and hospitals have equity, diversity and inclusion committees.
The second piece is our community engagement. In a series of community conversations, we are asking people in the community how are they experiencing healthcare, what inequities they’ve experienced and how can we do a better job.
Our third objective involves clinical improvements — this is how we use the data we gather to actually decrease the disparities in our system. We have all of our data broken down on inequity dashboards, and we can see by clinic what’s going on in different populations with issues like diabetes, breast cancer screening, hypertension and depression. If we see a disparity, we can do an intervention in those areas.
For example, when we looked at the eye screening for retinopathy for people with diabetes and noticed there was no disparity between African Americans and whites, we realized the reason was that the clinic had a very low-barrier way of screening patients’ eyes. Instead of being sent to an opthamologist, which for many would mean taking time off work or getting childcare, patients can have their eyes checked right in their primary care clinics. In response, we ordered 24 more cameras, which are now being put in place in 24 of our other clinics.
Maria Alonso Luaces, PhD
Director of the Office of Diversity and Inclusion and assistant professor at the University of Kansas School of Medicine
Kansas City, Kansas
For more than 20 years, the University of Kansas School of Medicine has developed, implemented and sustained pipeline programs aimed at increasing the number of graduates from underserved communities who have the knowledge and skills needed to address health inequity.
From a curricular standpoint, our new class orientation activities physically immerse learners in nearby underserved neighborhoods, providing an opportunity to observe firsthand and critically reflect on the social, political and economic structures that influence health outcomes. Starting in “Introduction to Doctoring,” students participate in didactics, small group sessions and standardized patient encounters with a focus on the effect of social factors on patients’ health. Topics addressed include unconscious bias, racial and ethnic disparities, trust, immigrant health, language barriers, lesbian, gay, bisexual, and transgender health, homeless populations and healthcare access in rural America.
During the third and fourth years of medical school, the learning shifts to primarily clinical settings. The diversity of our teaching sites, including hospitals, clinics and community centers in both urban and rural locations, provides exposure to diverse patient populations and further exposes students to the detrimental effects of inequity on health. For instance, the family medicine clerkship introduces students to the Health Equity Action Transformation report, a study on the effects of redlining (historically racist housing policies) in Wyandotte County in order to frame clinical care beyond the confinements of a hospital.
Dr. Wudeneh Mulugeta, MD, MPH
Internal medicine physician with Cambridge Health Alliance and instructor at Harvard Medical School
I think one of the best ways to address racial bias in healthcare is with diverse providers. Many of our providers are multilingual, and they have experience and passion in working with diverse patient populations — not just racial minorities, but also people from various socioeconomic backgrounds and with different genders and sexual orientations. Patients see and appreciate that diversity and experience in not just the physicians, but also the supporting staff, nurses and medical assistants, and front desk employees.
That diversity can help a lot in making patients feel comfortable when they see us. I recently saw a patient who wanted a referral to a therapist, but she spoke another language and didn’t want to use an interpreter. I was able to refer her to a mental health practitioner who spoke her language. For patients who don’t have a provider who speaks their native language, we also have interpreters available. Our interpreters not only provide language interpretation, but also help us with cultural differences to give us a better sense of a patient’s cultural background.
Responses have been condensed and lightly edited.