The face of America, and the people who seek health care every day at clinics, hospitals, urgent care centers and emergency rooms, is becoming ever more diverse. But you’d never know it by looking at the average U.S. medical school, where the faculty remains resolutely white and male.
The Association of American Medical Colleges recently examined this implicit bias in an article that takes a look at the situation and what medical schools are doing to cultivate a leadership that is more diverse.
It matters because when medical school leaders and faculty come from varied backgrounds, they bring a more inclusive approach to how medical students – the physician workforce of the future – are trained, Dr. Hannah Valantine, senior associate dean of faculty affairs at the Stanford University Medical School Office of Diversity and Leadership, told the AAMC Reporter recently.
“We are facing complex problems that will require diverse perspectives to solve,” she said. “The extent to which we can retain diverse faculty will drive our excellence in education, research and patient care.”
Disparities in health and in health care unfortunately are pervasive. They’re manifested in many ways: how people live, whether their environment is safe, whether they have access to health insurance and affordable care. At least some of the disparities, however, seem to be rooted in a health care system that doesn’t always recognize or appreciate the differences, both clinical and cultural, that make human beings so diverse.
Take, for example, a cardiovascular health initiative that was one of the topics of discussion last month at the 10th annual national summit on health disparities. The initiative, now in its second phase, is aimed at giving doctors more knowledge about treating minority patients and improving their cardiovascular outcomes.
Speakers at the event said physicians often are unaware of the nuances in treating patients of diverse ethnic and racial backgrounds, hence may fail to recognize heightened risk or important early signs of chronic disease. One of them is the so-called triglyceride paradox, or the fact that blacks can have high levels of high-density lipoproteins (“good” cholesterol) and low triglycerides yet still be at high risk of cardiovascular disease.
To what extent does the failure to see these nuances reflect assumptions that “every patient is like me,” i.e. white? Some studies have noted that black patients are referred for cardiac catheterization or bypass surgery less often than white patients, even when their symptoms are the same, which suggests at least some level of inequality.
“Clearly there is some subconscious bias that is going on,” Dr. Conrad Smith of the University of Pittsburgh Medical Center told MedPage Today last week.
Physicians need to be aware of the differences in how they approach patients of varying backgrounds and the impact this has on outcomes, Dr. Smith said. “The education of physicians is going to be paramount if we want to close that gap.”
This isn’t to say prejudice and discrimination are rampant among health care professionals. The vast majority are skilled and well-intentioned. Yet their training and background may not necessarily have equipped them to recognize their own assumptions.
Consider, for example, the implications this may have for conducting end-of-life discussions. Americans strongly favor telling the truth to patients when further medical care is futile; other cultures view this as harmful and believe the patient should not be told.
U.S. clinicians might become deeply frustrated, perhaps even angry, with immigrant or refugee patients who refuse testing and treatment for tuberculosis. What they may not understand is the stigma associated with TB in these cultures and differing practices in when and how medication is prescribed.
It’s not hard to see how misunderstandings can arise. Sometimes these spill over into the clinician-patient relationship, not only in how people communicate with each other (Do they feel their perspective is heard? Do they feel their values are respected?) but in the quality of care the patient receives.
Some studies have found that doctors relate better to patients when they share common ground, such as socioeconomic background – in other words, patients who aren’t perceived as “other.” These same studies also have found that when doctor and patient come from similar backgrounds, the doctor is more likely to take the patient’s symptoms seriously and more likely to trust that the patient will follow medical advice.
It argues that unconscious bias in favor of one’s own tribe is very real. It also argues for a better doctor-patient relationship and greater comfort level when an increasingly diverse patient population can receive care from someone with whom they identify.
That the health professions are having robust discussion about instilling diversity and cultural competency within their ranks is an indication of how much progress has been made in the past couple of decades. There in fact have been calls to broaden the definition of what constitutes diversity to include religion, gender identity and sexual orientation. In a newly published study, students in the medicine, physician assistant and physical therapy programs at the University of Colorado supported the value of an inclusive, respectful campus environment – but they also reported that disparaging remarks and offensive behavior toward minorities of all kinds continue to persist.
“According to these students, the institution must embrace a broader definition of diversity, such that all minority groups are valued, including individuals with conservative viewpoints or strong religious beliefs, the poor and uninsured, GLBT individuals, women and non-English speakers,” the researchers concluded.
Few people are without bias in some form and this goes for every walk of life, not just health care. The challenge lies in recognizing it and overcoming it so all patients get the care they need, even if the clinician doesn’t look like them.