Targeting inequalities requires behavior change

Ribbon Dhaliwal, MD, MPH

Even though bias has no place in science and medicine, it is pervasive, especially in health care, making it a public health issue.

Patients may face bias or discrimination when encountering doctors, resulting in lower screening rates or substandard care. However, the reverse is also true – doctors can also encounter race-related issues. Physicians from ethnic minority groups are frequently exposed to overt and covert discrimination during training and in the workplace. Research also shows that physicians who identify as visible minorities experience workforce attrition due to discrimination.

The lack of personal experiences or direct observations does not imply that biases in health care do not exist. Denying the existence of bias only exacerbates the problem.

So how do we avoid letting this bias enter our interactions with our patients and colleagues? How do we focus on providing equitable care?

In 1986, Samuel L. Gaertner and John F. Dovidio proposed a theory of “aversive racism“in which negative assessments of racial/ethnic minorities are realized through the persistent avoidance of interaction with other racial and ethnic groups.

Understanding our own biases is a challenge in itself, but when combined with avoidance, these interactions have a negative effect.

Exploring learned biases

“Know thyself”, a phrase coined in the time of Socrates and carved into the forecourt of the Temple of Apollo at Delphi, provides only a starting point for examining our instinctively ingrained and intuitively acquired biases.

We all have implicit or explicit biases; the point is how to learn from our biases and change our moral compass.

Some of these biases have their origin in rules and systems inherited from the past, some come from a small group of individuals, while others may have structural origins or come from systematic practices.

Prejudices, whatever their roots, eventually become pervasive and entrenched. An example of this is the use of negative patient descriptors in physician notes, which are more prevalent in detailed encounters with patients of certain ethnicities and races. This implicit bias arises because health disparities are taught without context and medical students are taught to associate these descriptors, such as race, with independent risk factors for certain diseases.

Accepting race as a biological construct not only unfairly places the onus on genetics, but deflects attention from the structural barriers and social determinants of health that overlap with race (such as socioeconomic status, access to healthcare environmental exposures), thereby perpetuating health disparities. If not addressed and ignored, these practices will continue to affect health outcomes in marginalized and minority communities.

Changing behavior, minimizing bias

Creating equity is an ambitious goal with significant challenges.

Racial inequalities in health care are critical issues to address. Understanding the factors affecting racial health disparities is not enough; this knowledge must translate into a “change in behavior”.

For example, the social determinants of health have been well known for over two decades. Despite this knowledge, much of current medical education does not include information about social inequalities as key factors influencing poor health outcomes.

An integrated approach is needed to address and compensate for implicit biases. Addressing systemic biases requires policy changes.

Recently, the Endocrine Society issued a call to action and proposed strategies to advance health equity. Improving health care outcomes requires a tenacious, multi-year, multi-pronged approach, and the Society is committed to realizing this vision.

The goal of the Society’s policy is to raise awareness of the issue of racial disparities in health care, particularly in the care and research of endocrine disorders. The authors of the policy focused on validated reports and research data.

The researchers separated personal experiences from their research to bring objectivity to the discovery and intervention and to avoid confirmation bias.

However, awareness of our own institutional biases and inequities as the root cause of health disparities improves structural competence in clinical practice and in all facets of health care.

Dismantling Racism in Health Care

The healthcare community must move beyond practicing non-racism to anti-racism. The continued inertia of “colorblindness” or other ways of trying to “be non-racist” are approaches that neglect to include awareness of discriminatory practices that have made minorities more vulnerable.

Understanding race is essential for research on health disparities. Many reports indicate that race-neutral algorithms lead to inaccurate risk stratification in identifying high-risk patients. When significant results support the use of race as a variable in clinical algorithms, these tools should be rigorously reviewed and analyzed with mediating variables (structural factors), reassessed and updated periodically.

The Agency for Research and Quality in Health has recently taken some positive steps in this direction, but there is still a lot to be done by all concerned regarding the importance of reducing health disparities. We should approach this problem with the same fervor with which “meaningful use” and “interoperability” were approached a few years ago.

Policies provide a blueprint for individuals, organizations, communities, and systems to implement specific practices and services. Policies need to be rewritten to help eliminate disparities in preventive screenings, standardized care, workforce, education, and research to achieve positive health outcomes in diverse populations.

Currently, policy makers, institutions, regulators, change makers, health professionals and the general public are receiving increased attention. A policy that results in coordinated efforts and actions by all stakeholders will help commit resources to address the upstream causes and downstream consequences of health disparities and bring about transformative and impactful change.

The Centers for Medicare & Medicaid Services has recently made progress in this regard. The Global and Professional Direct Contract (GPDC) model has been redesigned to advance health equity in underserved communities. Under the new model (called Accountable Care Organization Realizing Equity, Access, and Community Health [ACO REACH]) Entities must develop a health equity plan and report the results to the CMS. Entities must capture and report beneficiary-reported demographics, including race, ethnicity, gender identity, and sexual orientation. CMS also strongly encourages entities to collect data on social determinants of health.

Much remains to be done in this area, but we must assume our responsibilities and make concerted efforts to do our part. Diversity exists in many forms (including race, ethnicity, gender, gender identity, religion, age, sexual orientation, disability, life experiences, geographic origins ) and across multiple platforms. We must leverage diversity to drive creativity, innovation, change and excellence and create a health system that provides equitable care for all.

Acknowledgement: The author thanks R. Sharma for his help in preparing the manuscript.

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