I know I was not alone at feeling shock and grief upon reading the JAMA tweet that “no physician is racist.” Beyond the 8,000+ and climbing signatories to the Change.org petition asking for a change to JAMA leadership, the data on microaggressions and their contributions to physician burnout published in a recent study in JAMA Surgery presents clear evidence to the contrary, as does a study in Family Medicine which finds that “physicians of color are likely to experience significant racism while providing health care in their workplace settings, and they are likely to feel unsupported by their institutions when these experiences occur” (2020). Dr. Amy Beck and medical student Michaela Stevenson’s experiences shared with KevinMD provide a moving window into the strain presented by these challenges.
These everyday slights place an extraordinary burden on underrepresented communities and physicians of color, who are already struggling with the industry-wide problem of physician burnout. A 2018 Merritt Hawkins survey found a staggering 78% of doctors suffered symptoms of burnout, and a 2017 paper in Mayo Clinic Proceedings showed that burnout was driving 1 in 50 physicians to plan an exit from medicine altogether. In January 2019, the Harvard School of Public Health and other institutions deemed physician burnout a “public health crisis.” And this was all before the pandemic.
It’s a structural problem. It extends down to the cost of the products doctors use to alleviate their workload. When my co-founders and I started DeepScribe, we interviewed hundreds of physicians for customer discovery. Through this experience, we discovered a sharp divide between doctors who could afford tools for clinical documentation, and those who could not. Doctors blessed to work at well-resourced, high-profile health systems had access to medical scribes — both human and technological — who took notes, summarized appointments, and filled out the paperwork that eats up so much time that could otherwise go to family and patient care.
But even physicians with access to documentation tools had to contend with embedded bias. The state-of-the-art dictation and transcription tools are trained using voices that feature General American English, or Standard American English, as some scholars prefer. As a result, they do a poor job recognizing the voices of physicians who may have immigrated from other parts of the world that speak in a manner accented beyond what the software may recognize as General American English.
My co-founders and I heard from a substantial number of the 200+ doctors we interviewed that dictation tools that couldn’t recognize their voice commands were worse than unusable. Doctors with accented English found that they had to rewrite the notes. The headaches created by these error-prone tools made these tools ineffective and unusable.
Bias doesn’t just affect the physician, but patient care as well. As Dr. David Williams of the Harvard T.H. Chan School of Public Health showed in his 2019 paper, “provider implicit bias was associated with poorer quality of patient provider communication and lower patient evaluation of the quality of the medical encounter.” Dr. Kester Nedd and the Colorado Coalition for the Medically Underserved are just two contributors whose work underscores the importance of provider implicit bias on health care outcomes.
One core adage of my team’s mission is “the care that is perceived is the care that is received.” Every good doctor knows that trust and confidence from the patient has a substantial impact on the patient’s long-term health. Dr. Williams and his fellow authors went on to find that “more implicit bias was associated with less patient-centered dialogue, lower patient positive affect, lower perception of respect from the clinician, less patient liking of the clinician and lower trust and confidence in [the] clinician.”
Williams and his fellow authors point to “structural competence [which] refers to increasing awareness among providers of how racism is embedded in our culture and institutions” in their discussion. Health tech vendors have an important choice to make: to examine whether their product competencies bolster or erode the work on structural competence within the health care organizations they partner with.
For our part, we focus on ensuring our solution works equally well for English speakers with any accent. We regularly hear from doctors how much of a difference this makes in their ability to deliver high-quality patient care. It’s our hope that more health tech vendors will take a good look at what they’ve chosen to prioritize and how that may contribute to inequities within the system. The factors which inspired the American Medical Association to recognize racism as a public health threat demand that we all play our role in the multi-faceted structures that contribute to delivering equitable health care to all Americans.
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