Targeting Inequity Requires Behavior Change

Ruban Dhaliwal, MD, MPH

Even though bias has no place in science and medicine, it is pervasive, particularly in healthcare, making it a public health problem.

Patients may face bias or discrimination in their encounters with physicians, resulting in lower rates of screening or substandard care. However, the reverse is true as well — physicians may also experience race-based problems. Physicians of ethnic minority groups are frequently exposed to overt and covert discrimination during training and in the workplace. Research also shows that physicians who self-identify as visible minorities experience workforce attrition due to discrimination.

Lack of personal experiences or direct observations do not imply that bias in healthcare doesn't exist. Denying the existence of bias only exacerbates the problem.

So how do we avoid letting this bias enter into our interactions with our patients and coworkers? 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 evaluations of racial/ethnic minorities are realized by persistent avoidance of interaction with other racial and ethnic groups.

Understanding our own biases is challenging by itself but when combined with avoidance, those interactions have a negative effect.

Exploring Acquired Biases

"Know thyself," a phrase coined during Socrates's time and chiseled into the forecourt of the Temple of Apollo at Delphi, provides only a starting point for examining our instinctively rooted 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 originate in legacy rules and systems, some originate from a small group of individuals, whereas others may have structural origins or come from systematic practices.

Bias, no matter its roots, eventually becomes pervasive and entrenched. An example of this is the use of negative patient descriptors in physician notes, which are more prevalent in detailing encounters with patients of certain ethnicities and races. This implicit bias stems from the fact that health disparities are taught without context, and medical students learn to associate these descriptors, such as race, as independent risk factors for certain diseases.

Accepting race as a biological construct not only unfairly places the onus on genetics but shifts the focus away from 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 left unexamined and unaddressed, these practices will continue to affect health outcomes in marginalized and minority communities.

Changing Behavior, Minimizing Biases

Creating equity is an ambitious goal with significant challenges.

Racial inequities in healthcare are pivotal problems to solve. Understanding factors affecting racial health disparities is not sufficient; this knowledge needs to translate into "behavior change."

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

An integrated approach is needed to address and offset the implicit biases. Addressing systemic biases requires policy-level changes.

Recently, the Endocrine Society put out a call to action and proposed strategies to advance health equity. Outcomes improvement in healthcare requires a tenacious, multiyear, multipronged approach, and the Society is committed to achieving this vision.

The goal of the Society's policy is to bring awareness on the issue of racial disparities in healthcare, specifically in the care and research of endocrine disorders. Authors of the policy focused on validated reports and research data.

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

However, awareness of our own biases and institutional inequities as a root cause of health disparities improves structural competency in clinical practice and across all facets of healthcare.

Dismantling Racism in Healthcare

The healthcare community needs to move beyond practicing nonracism to anti-racism. The continued inertia of "colorblindness" or other ways of attempting to "be nonracist" are approaches that neglect to include awareness of discriminatory practices that made minorities more vulnerable.

Understanding race is essential for health disparities research. Many reports state that race-neutral algorithms lead to inaccurate risk stratification in identifying high-risk patients. When significant findings 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 Healthcare Research and Quality has recently taken positive steps in this direction, but more needs to be done from everyone involved regarding the importance of reducing health disparities. We should address this problem with the same fervor that "meaningful use" and "interoperability" were addressed with a few years back.

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

At present, there is heightened attention among policymakers, institutions, regulators, change-makers, healthcare professionals, and the general public. A policy that will translate into coordinated effort and action from all stakeholders will help commit resources to address upstream causes and downstream consequences of health disparities and make a transformative and impactful change.

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

There is much more work to be done in this area, but we must take responsibility and make concerted efforts to do our part. Diversity exists in many forms (including race, ethnicity, sex, gender identity, religion, age, sexual orientation, disability, life experiences, geographic backgrounds) and across multiple platforms. We need to leverage diversity to drive creativity, innovation, change, and excellence and create a healthcare system that ensures equitable care to all individuals.

Acknowledgement: The author thanks R. Sharma for assistance with manuscript preparation.

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