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#BlackLivesMatter Meets #AllLivesMatter: Equity That Elevates Everyone’s Medical Care

By News Creatives Authors , in Leadership , at August 29, 2021

If you combined #BlackLivesMatter and a good-faith version of #AllLivesMatter, what you might get is the work being done in medicine by Cardinale Smith and Charlene Hope.

Smith in New York and Hope in Chicago are pioneering equity innovations intended to eradicate the inferior care too often experienced by minorities even when providers’ intentions are good; i.e., the result of “unconscious bias.” Their efforts, however, could significantly improve care for everyone.

Unconscious or “implicit” bias refers to the instinctive stereotyping all of us are prone to practice. Not surprisingly, “health care professionals exhibit the same levels of this bias as the wider population,” a systematic review found. That, in turn, can “influence diagnosis and treatment decisions and levels of care,” even when providers are consciously committed to impartiality.

But unconscious bias isn’t only about race. Ethnicity, gender, socioeconomic status, age, weight and a host of other factors can singly or in combination influence our judgment – which isn’t to say that racial discrimination doesn’t stand out. As an editorial in a recent special issue of JAMA declared, “Racial and ethnic inequities in the U.S. health care system have been unremitting since the beginning of the country.” 

Insidious Inequities

Those inequities can be insidious. “We have witnessed black children not being treated as children at all, or not being given the same compassion or level of care – even the use of topical anesthetics – provided for white children,” wrote Drs. Shantanu Nundy and Adaeze Enekwechi in a 2020 Health Affairs Blog. “[But] medicine and health care act as if we have no role in producing or promulgating health disparities, but instead are simply responding to them.”

That’s where Smith and Hope come in. Smith, a medical oncologist and palliative care physician, is is chief quality officer for cancer services at the Mount Sinai Health System in New York City, while Hope is a pharmacist who’s the chief pharmacy quality and medication safety officer at University of Chicago Medicine. Both are also Black female clinicians deeply involved in efforts to improve equity.

I first spoke to Smith in late 2019. As I wrote in Medium, she had arranged oncologist visits for people with advanced breast, prostate and other solid-tumor cancers as part of her research on the doctor-patient interaction. The visit’s intended purpose was to discuss the patient’s latest scan results, and the visits were recorded.

Smith didn’t start out searching for equity imbalances, but the data delivered its own verdict. Despite the oncologists in the study practicing in a diverse group of urban and rural medical facilities in New York and Connecticut, Black and Hispanic patients received significantly less time with their oncologists than whites. It seemed, she said, a clear illustration of unconscious bias.

I asked Smith recently the reaction of the doctors whose behavior she had examined. There was, she acknowledged, “a lot of defensiveness. No one considers themselves a racist.” Instead, the doctors pointed the finger at the Black and Hispanic patients, saying they “didn’t talk as much.”

But the core problem is more fundamental. “You can’t say I’m going to suddenly empower this person who’s been structurally marginalized all of their lives,” says Smith. “How do you recognize this patient might be different than some of your other patients?”

Understanding the necessity of using varied communication methods that account for the ways in which patients differ, Smith adds, “is the thing that needs to get hard-wired.” That, of course, is important advice that applies to all patients, not just Black and Hispanic ones, and to all types of unconscious bias.

Hope, who works as a patient safety professional with patients with chronic conditions, advocates fighting unconscious bias by getting to know every patient “outside of their disease state.”

She adds, “It is in these interactions that we honor a patient’s basic dignity, understanding that everyone wants to exercise their autonomy as a human being. “

Equity That Elevates Everyone’s Care

Put simply, this is equity that elevates care for everyone.

Hope notes that minority patients who get upset or display frustration are quickly labeled as being difficult rather than clinicians taking the time to try to get to the heart of the problem causing the frustration. This kind of failure to communicate can raise the risk of poorer patient outcomes. A 2015 National Academy of Medicine report, Improving Diagnosis in Health Care, noted that “cultural and language barriers can be significant challenges that prevent patients from fully engaging in the diagnostic process.” Other research warns of a potential greater risk of adverse events for Black adults compared to whites even at the same hospitals.

Of course, having more clinicians of color and greater diversity in the executive suite would go a long ways towards enhancing efforts to systematically recognize unconscious bias in health care and mitigate it. Minority patients endure painful day-to-day interactions with the health care system to which even well-meaning white clinicians are oblivious.

Hope remembers talking to a young Hispanic patient who was uncomfortable asking a white doctor about the use of marijuana to control pain but said to Hope, “I guess I can mention this to you.”

Smith and Hope are well-versed in the six dimensions of quality described by the Institute of Medicine (now the National Academy of Medicine) in its 2001 report, Crossing the Quality Chasm. These include safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. Both women are applying to equity the same kind systemic improvement methodology that characterizes other care quality domains.  This type of approach includes care based on continuous healing relationships; customization based on patient needs and values; and shared knowledge and the free flow of information. 

One example of a customization idea: Given data showing that doctors prescribe more pain medication to white patients than Black ones, says Hope, why not incorporate that information into an alert on the electronic medical record? 

Both women are clear-eyed about the challenge of changing culture. Hope, for instance, talks about building relationships with new employees “to see what they’re bringing to the role” and then using those relationships to support a culture of inclusion. “People know in their mind the right thing to do, but that doesn’t mean it always happens, just like with patient safety,” she says. 

Smith and her colleagues, meanwhile, have combined an existing patient and family advisory council, a community advisory board and a cancer care “accelerator” group into a Cancer Equity Accelerator, charged with improving the quality of care and decreasing disparities throughout Mount Sinai’s catchment area.

“You have to have people open to recognizing there’s opportunity for improvement and then think how you engage,” says Smith. “Patients are stakeholders. That’s who we’re doing this for.”


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