By Robert L. Moore, MD, MPH, MBA, Chief Medical Officer
We at Partnership HealthPlan of California (PHC) are deeply saddened by the recent killings of George Floyd and many other Black Americans. Further, we recognize that systemic and historic racism remains the core cause of this violence.
As respected clinicians, we acknowledge that you are participating and advocating to address local policing practices. Additionally, we know you are involved in the broader community dialogue to address underlying causes of bias and discrimination, which disproportionately affect the Black members of our communities. Through your actions, you are also helping many other disenfranchised populations.
In the health care community, we are generally not part of a police force and think of our caring profession as one that serves everyone regardless of race, ethnicity, sexual orientation, gender identification, incarceration status, religion, disability, etc. However, there is a deep history of racial injustice in health care in our country ranging from early experiments in gynecological surgery done on American slave women, to the infamous Tuskegee study of the natural history of tertiary syphilis, which withheld curative penicillin from Black American men to document the progressive neurological symptoms of this curable disease.
Implicit and explicit bias is still present and impacts the health and well-being of all the patients we have taken an oath to serve as health care professionals. An example of the consequences of bias impacting Black Americans in healthcare today is the differential evaluation of pain symptoms of pregnant Black women in California, causing delay in diagnosis of serious complications and contributing to a maternal mortality rate in California that is three times the rate of all other ethnic groups.
These biases are more commonly manifested in less tragic ways and are found in the way non-white patients are treated by doctors, nurses and others within the healthcare delivery system. As an example, many years ago, a Latino nurse at a health center where I worked was injured when he worked on his car– the engine fell on his chest. He arrived to the ED in his grease-stained work clothes and pain in his chest. The ED nurses who cared for him did not know that he was nurse. While he was in their care, they were making comments, using body language and words that lacked compassion and respect, and withheld pain medication. The physician progress note referred to him as “greasy Mexican” in his chief complaint statement. He indeed had motor oil on his clothes and skin.
On a broader level, physical conditions are the manifestations of the environment/social conditions in which your patients live in and carry with them when they seek care. When a significant portion of the patient population feels dismissed, disenfranchised or discarded, doing no harm then has to stretch beyond the mere facts and symptoms you see and face in the few minutes you have with your patients. Instead, we must strive toward mindful and thoughtful consideration of a world in which our patients dwell.
We must take action to initiate changes within our health care delivery system to parallel to actions being carried out by our society to ameliorate the effects of bias and to decrease institutional racism that afflicts our patients and communities.
On an individual level, both in the health care arena and the broader societal arena, we need to have thoughtful and meaningful dialogue with:
- Our friends
The rationale and tactics are different for each of these levels of dialogue.
Ourselves. The first level, dialogue with ourselves, is another way of describing introspection, where we seek to understand our own implicit biases and address them. This can be done by reading one of many excellent books on this topic like Thinking Fast and Slow, How to be an Antiracist and White Fragility, by enrolling in a class or community discussion group on racism, and by writing and reflecting about how the ideas in these books and groups affect you. Changing the brain pathways that cause implicit bias takes time and effort; we need to make it a life-long personal self-educational priority.
Our Friends. As we are better able to understand our values and biases, we are in a position to use this insight to influence those we interact with every day: friends, family, and co-workers (including those with a different set of political beliefs). Being an activist against bullying behavior and violence is especially important for addressing abuses in use of force and underlying policies promoting or allowing such abuses. However, influencing other people’s thinking in order to foster their better understanding of their own biases requires different and individualized approaches. This might mean responding to a gratuitous racial generalization with disagreement and a reflection of how it makes us feel. More subtle cases may be better addressed in a dialogue to promote introspection: “What did you mean by that?” or “What makes you think that?” A more round-about way of changing beliefs is through skillful storytelling, tapping into the human brain’s built-in capacity to absorb new values. Collecting a repertoire of stories to use requires being alert to examples in our everyday lives, and recording and using stories we hear from other sources.
Strangers. As clinicians, we frequently meet with new patients with very different racial, ethnic, religious, nationality, etc. backgrounds. These interactions may go very wrong, with lack of trust in the clinician, incorrect diagnoses, poor adherence to clinician recommendation, and general dissatisfaction by the patient. Each day PHC receives member complaints of poor communication or possible discrimination. These are a reflection of sub-optimal interaction with patients.
While many clinicians are experts at developing trust with their patients, others struggle and would benefit from training and mentoring, something not widely available after residency. In the January 7 issue of JAMA, an expert panel identified 5 elements of high quality patient interaction:
- Prepare with intention
- Listen intently and completely
- Agree on what matters most
- Connect with the patient’s story
- Explore emotional cues
Recently, resident physicians from across Northern California recommended adding a new aspect to the Prepare with Intention element. Very simply, pause before entering the room, (or starting a video or telephone visit) to acknowledge your own explicit and implicit biases that may exist when providing care to this patient. Pause to consider ways to customize your interaction with this particular patient to build trust and show respect.
Conversely, when our patients make biased, discriminatory or racist remarks, as clinicians we must be prepared with a menu of responses that balances our responsibilities to our individual patients to consider the larger societal imperative in which each member of our community learns to be cognizant of their own biases.
On June 10, scientists around the world took a day off from their research to reflect on issues around racism and contemplate changes they could make in their lives to dismantle the inequities left by racism. To be most effective in our dialogues with ourselves, our friends and strangers, clinicians must also periodically carve out time to do this hard work. Read books. Collect stories. Develop a repertoire of responses to racist comments.
What actions can PHC take to support this work in the health care arena? We have an internal team focused on many aspects of health equity, including education of PHC staff about implicit bias and review of health disparities data of our members, and planning interventions. One of our core organizational values is valuing diversity as a company and as a leadership team.
We investigate patient complaints involving potential discriminatory behavior, but most do not represent overt discrimination (e.g. “I’m not giving you pain medication because you are Black.”), but rather those patterns of sub-optimal verbal and non-verbal communication driven by implicit bias not subject to civil rights action. Still, such biased communication can be addressed. PHC will look at potential options to do this better in the months ahead.
We welcome your thoughts and suggestions on additional actions we might consider. We are most effective when we work in partnership with you, your organizations and the communities we serve.