Addressing inequity

Taking steps to confront the imbalance in healthcare

By Megan Headley

Data from the COVID-19 pandemic has overwhelmingly highlighted the longstanding inequity in healthcare. A May 2020 study from Sutter Health researchers that analyzed 1,052 confirmed cases of COVID-19 from January 1 through April 8, 2020, determined that African American patients had 2.7 times the odds of hospitalization, after adjustment for age, sex, comorbidities, and income, than non-Hispanic white patients. The APM Research Lab reported in March that Pacific Islander, Latino, Indigenous, and African Americans have died from COVID-19 at least twice as often as white and Asian Americans. And this is just the tip of the research mounting on this disparity.

The question now is what health systems are going to do about it.

For Maria Hernandez, president and CEO of Impact4Health, an organization that provides training and support for health systems around health equity, physicians may face a unique challenge in addressing the biases that can lead to this uneven treatment.

“In healthcare, the assumption is always that ‘we’re providing the best care possible,’ and that means treating everybody the same,” Hernandez says. That might just be the problem. Treating everyone the same too often ignores the fact that many communities are struggling with vast differences regarding treatment and preventive care accessibility, among other factors.

“If you’re poor, if you live in a food desert, etc., all of those factors make a difference in what you as a patient may need,” Hernandez says. “I think we are becoming more sensitive to that, but it’s a lot of work.”

Examine the data

Data will be a key part of the solution to this challenge. A January executive order on addressing the inequity in the healthcare response to the COVID-19 pandemic stated, “The lack of complete data, disaggregated by race and ethnicity, on COVID-19 infection, hospitalization, and mortality rates, as well as underlying health and social vulnerabilities, has … hampered efforts to ensure an equitable pandemic response. Other communities, often obscured in the data, are also disproportionately affected by COVID-19, including sexual and gender minority groups, those living with disabilities, and those living at the margins of our economy.”

“It really does start with data,” Hernandez adds. More specifically, it starts with a willingness to examine the data in search of problems. “You need to be willing to look at your health outcomes by demographic groups,” Hernandez says. That could include rehospitalization rates and HCAHPS patient satisfaction scores, she suggests.

As another example, Hernandez points to research from Sutter Health on racial and ethnic disparities in pain medication prescriptions. The researchers examined electronic health records for adults with bone fractures across more than 20 emergency departments. The study concluded that patients were prescribed opioids at similar rates, but Hispanic, Black, and Asian Americans received fewer milligrams of morphine than non-Hispanic whites. Identifying this trend became the first step to having a conversation about the unconscious bias, and the assumptions based on dialogues about patient pain, that might be driving these decisions.

“Once these findings were elevated to the organization, there’s been real effort to take responsibility and try to educate people how to avoid that,” Hernandez says. Impact4Health has supported health systems with unconscious bias training to raise awareness of this finding and help organizations understand how to respond to it.

Adopt a new mindset

No matter how critical it is to make a change, physicians may be reluctant to address their unconscious bias by adding one more thing to their already-overloaded plates. “Most physicians on the front line are seeing patients in 15-minute increments. When you add this additional level of detail that needs to be thought of, it really creates some enormous stress and strain on physicians who are trying to do the right thing,” Hernandez says.

Doing the right thing and opening the door to better care, however, can take only a few additional steps. The first, Hernandez suggests, is simply accepting that some form of bias is at play in every patient interaction. “Every single person on the planet has unconscious bias. It’s the way your brain works. We all take these mental shortcuts,” she says. Accepting this, rather than arguing against it, paves the way for solutions.

Next, Hernandez advises slowing down interactions to consider the big picture. Impact4Health frames this as the “ACE” mindset; ACE stands for Attention, Connection, and Empathy. In action, ACE looks like this:

• Pay attention to the individual and the context of what’s going on. Hernandez encourages physicians to slow down and think about their own bias as part of this context. Research indicates that people make roughly 11 decisions about the people they’re interacting with within the first seven seconds of that interaction. This includes rapid assumptions about likability, trustworthiness, competence, and aggressiveness. Paying attention to the judgments being made is a critical first step in moving past them.
• Make an authentic connection with the patient by leaning in and listening into what they’re saying. Listening may seem obvious—but the data indicates otherwise. A 2018 study in the Journal of General Internal Medicine revealed that patients get about 11 seconds to talk before they’re interrupted by their physician. Slowing down, listening for context, and digging deeper with questions about what spurred the patient’s visit can help physicians get a more complete picture of the problem without letting their bias drive decision-making.
• Demonstrate Hernandez encourages physicians to make their assessments “knowing that there’s so much happening in Black and Brown lives today, and really trying to have empathy for that population in a way that is more attentive to the fear, the anxiety, and the trepidation that some people feel just even going into the doctor’s office.” She calls empathy “the superpower of this era” because it can help people move past their differences.

On an organizational level, Impact4Health has developed a set of best practices to help health systems create an inclusive culture for patients, staff, and visitors. Its Inclusion Scorecard for Population Health is an online dashboard that identifies more than 70 best practices organized around the kinds of metrics hospitals need to collect to be more inclusive. However, setting out policies is just the first step. Organizations must also hold themselves accountable to link quality of care with health equity and make this care available to their communities through inclusive outreach and programming.

Connect with patients

Prioritizing health equity is a key strategy for providing better-quality care. It opens the door to stronger connections with patients: connections that can provide insight into the person’s condition, environments, and other factors.

Hernandez has experienced such insights firsthand. “When my dad had his first battle with cancer, and was being wheeled into the surgery room to have part of his lung removed, he was talking to me and my mom and my brothers in Spanish,” she shares. “And he says, ‘Stop speaking Spanish. They’re going to think I’m stupid and they’re not going to help me.’ ” For Hernandez, that became a moment of clarity in recognizing not just the presence of bias, but also the fear it could create among patients.

“Imagine that kind of fear among your patients, and imagine what that means in your engagement with that patient,” Hernandez advises physicians.

Clinicians who demonstrate a willingness to address their unconscious biases can garner patient trust. “You’re going to make them feel more assured that you’re there for them and that you’re going to do everything possible to have the best outcome. That’s culturally competent or culturally effective care,” Hernandez says.

Megan Headley is a freelance writer and owner of ClearStory Publications. She can be reached at megan@clearstorypublications.com