Addressing health disparities can seem overwhelming, especially at a time when health professionals are already under immense demands–and pressures to be almost superhuman. Yet often, the providers I talk to espouse values of equity and justice.
National Minority Health Month draws attention to how Americans have experienced variable access to care based on race, ethnicity, socioeconomic status, age, sex, disability status, sexual orientation, gender identity, and residential location (AHRQ 2016 National Healthcare Quality and Disparities Report).
Health disparities are due to many factors that are man-made. Even when population demographics–such as socio-economic risk factors and behavioral factors–are accounted for, disparities continue.
Partly in response to this, elements of health systems, organizations or services (what some researchers call supply-side dimensions of access) have been studied in order to help address disparities.
Some of this research has focused on bias–some at the organizational level, and some at the level of individual providers. Here, I will focus on the second group: some of what research has found, and importantly, what an be done, at the individual level.
But as usual, I’ll keep an eye on the bigger picture, too.
Bias in a helping profession?
There are documented links between health care professionals’ implicit bias, and disparities in people’s receipt of health care (and in multiple clinical outcomes). This is distressing, and almost unbelievable, considering that most health professionals genuinely seek to help all patients and clients.
A 2011 JAMA editorial opens with a similar sentiment: “The evidence that physician behavior and decision making may contribute to racial inequalities in health care is difficult to reconcile with the fact that most physicians are genuinely motivated to provide good care to all their patients.”
As an educator, I see parallels between these findings and similar findings in the education sector. There are decades of research showing that teachers can unintentionally treat students differently based on race, class, gender, sexual orientation, language background, and more.
Again, this can be difficult for teachers–and the public–to hear, given that most individuals who choose a career in education do so in order to help young people. Some of this research, and my 20+ years of experience with students and faculty, informs what I’ll share here.
Conversations about implicit bias can put us in a defensive position. As thoughtful, well-educated people who take our professional commitments seriously, we likely have good reasons for thinking we’ve already done our best to understand the communities we work with, and how we work with them. It can be threatening to acknowledge that we live and participate in networks and systems geared to work better for some than for others; and that we have a place in maintaining these.
Yet some educators, providers, practitioners and organizations have been addressing racism and discrimination on individual and systemic levels for many years. This work, in turn, is built on years of sustained efforts of marginalized people from different race and class groups, who have focused national and international attention on issues of discrimination for multiple decades.
Bias as “human nature”
Bias is something everyone has. An author from the Royal College of Surgeons described in BMJ that implicit bias involves placing people in a ‘category’ when we first meet them. It is something we do “by mistake, without thinking, unconsciously—and that’s fine, that’s human nature. But the question is what we do with that.”
Similarly, an editorial in the Journal of Gerontological Nursing indicates that “even educated individuals with the best intentions can display” it. But biases also “can reflect a negative perspective that reveals one’s knowledge, beliefs and expectations about a particular group, such as older adults.”
For instance, this recent tweet and blog post from Children’s Hospital of Philadelphia addresses the dangers of holding stereotypes about adolescents with eating disorders:
An individual’s race, body weight and sex do not dictate whether or not they have an eating disorder. Blog post on why we need to look beyond these factors to help kids with these conditions: https://t.co/Pt0UutTEU1 #MinorityHealthMonth
— PolicyLabCHOP (@PolicyLabCHOP) April 23, 2019
As much as bias may be “human nature” or “a universal trait,” it is an obstacle, a blind spot –with some serious consequences.
Implicit bias on the part of health care providers has been linked to errors in clinical decision making, as described in this recent BMJ paper. Disparities in care along racial and/or ethnic lines have been documented–even when the patient is a newborn, as described in this paper.
How actions and inactions can contribute to inequity
This 2015 AJPH study summarizes subtle ways unconscious actions and attitudes can emerge in the care setting:
- “approaching patients with a dominant and condescending tone that decreases the likelihood that patients will feel heard and valued by their providers
- failing to provide interpreters when needed
- doing more or less thorough diagnostic work
- recommending different treatment options for patients based on assumptions about their treatment adherence capabilities
- granting special privileges, such as allowing some families to visit patients after hours while limiting visitation for other families.”
For example, consider the above example of people with eating disorders. Based on an individual’s race, body weight, or sex, a provider may unconsciously offer services different to what they would offer an individual who they felt conformed more to their imagined norm of a person with an eating disorder.
How words and silences can undermine equity
As you may know, I’m particularly interested in what language, literacy, and power have to do with each other in (and beyond) the health sector.
I’ve written before about microaggressions. Sue et al (2007) defined microaggressions as “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative slights and insults” to members of marginalized groups. They are communicated through words and actions.
Here’s one example from Sue et al: “A client of color expresses concern in discussing racial issues with her therapist. Her therapist replies with, ‘When I see you, I don’t see color.'” The ‘hidden message’ is “Your racial experiences are not valid.”
Another example: I overheard a nurse asking the White mother of multi-racial children if her children all had the same father. There are several not-so-hidden messages there, including “You are sexually promiscuous” and “Traditional family structures are not important to you.”
Yet you don’t have to have a negative attitude toward someone to be engaging in microaggressions. Some of the data in microaggressions research is collected from interactions between family members, friends, and intimate partners.
This draws attention to the fact that we tend to speak from the cultural norms we hold, many of which are unconscious. For example, it’s likely you have at some point unintentionally offended someone you care about. You may have assumed things that were untrue about this person, or about a social group they belonged to. Once you knew better, you did better.
Three things you can do
I promised that I would suggest what you as an individual provider can do to help address health disparities in your day-to-day practice. Here are three.
I’ll start with two sets of questions you can ask yourself to start thinking about your own words and actions–with all patients. (If you like these, I have more here and here.)
- Which patients do you find it easiest to get along with, or relate to, or reach? What is it about them that makes these interactions easy for you? What might this tell you about yourself? What might this tell you about how you interact with patients who don’t fit this description?
- What do you tend to assume ‘normal’ people do in terms of keeping healthy? What you would consider ‘normal’ displays of intelligence, concern, curiosity, commitment, and so on? Make explicit to yourself how you define ‘normal.’ Really tease these meanings out. Have standards, but be ready to look closely at what yours are, and at what it means to hold those standards rather than others.
And for #3…don’t do this alone.
This work merits support. When you’re ready, reach out to like-minded professionals. Maybe a colleague? Maybe a stranger on the internet? For the latter, I’ll suggest visiting #minorityhealthmonth because of the amazing individuals, groups, and organizations posting about their work. Like the Black Mamas Matter Alliance!
THANK YOU ALL for being part of our 2nd Annual #BlackMaternalHealthWeek! It's up to each of us to keep the momentum going far beyond this point. Sign up for our listserv for news, updates + event announcements by and for Black Mamas! https://t.co/2hHNBa2MJO #BMHW19
— Black Mamas Matter Alliance (@BlkMamasMatter) April 17, 2019
