An internal dialogue on closing the gaps

Black people are dying at disproportionate rates from the pandemic.  For decades, racial disparities in health care have resulted in poor outcomes even before COVID-19.

Individual risk factors for poor health are more pronounced in Black people and racial minorities. However, these individual risk factors may not account for all outcomes. There are also additional factors at the community level. Health care outcomes in Black children may be limited by socioeconomic status to segregated housing and schools with economic disadvantages since childhood. The racial disparity is evident in the affordability of health care as well as differences in insurance coverage. Racial minorities receive an unequal quality of care even after insurance status, risk factors, and affordability are controlled. Stereotyping, biases, and uncertainty from health care professionals contribute to this unequal treatment – for example, Blacks are less likely to receive stroke prevention treatment, cardiac transplantation, and counseling for life-saving defibrillator therapy.

Narrowing these gaps will need the engagement of clinicians on an individual level and system as a whole. Health care professionals and support systems are as much a part of the solution as a part of the problem. On the one hand, we strive for exceptional quality of health care for all. On the other hand, there are many factors that undermine our efforts, from our own implicit biases at an individual level, to lack of targeted initiatives at a system level.

Undo implicit biases

The health care professional’s implicit biases add another layer to these underlying individual and community disparities. Implicit biases are pervasive amongst all, including physicians, administrators, allied professionals, and nurses. These biases could be due to perceived differences in a person’s outfit, language, dialect, body habitus, name, or skin color. These assumptions may be innate or learned. Health care professionals are humans, and as humans, we need to admit that we are prone to often-unrecognized biases that result in exhibiting stereotypical behaviors that may actually worsen the problem that we want to tackle.

Taking self-assessment tests and soliciting feedback are initial key steps toward change.

Research and dialogue from bedside to the boardroom is the key to pointing out this elephant into the room. Social determinants of diseases are a hot topic for discussion, both at the international level with WHO, to regional levels with governors and other leaders. However, change does not happen with publishing data and collecting statistics alone. Programs similar to the diversity and inclusion classrooms should be an integral part of the curriculum for medical and other health care students and during bedside training. A persistent, purposeful, and repetitive intervention to undo biases on individual and organizational levels might take us one step forward.

Dissect “non-compliance” more often

Sometimes we label patients who do not follow our advice as “non-compliant,” but maybe we need to pause more often to wonder why. Dissecting the root cause of non-compliance may be the key – it is often synonymous with the lack of a multitude of factors such as affordability of medications, smartphones for telehealth, transportation, healthy diet, and literacy gaps leading to poor insight into health issues. These patients may be living in safe houses or shelters. They may be poverty-stricken. Or they may just be uncomfortable letting others know their plight. Some of these might perceive language and cultural barriers when seeking medical care. As health care professionals, we can make an effort to help our patients overcome these obstacles. Asking questions with the intention of understanding their situation and clinical presentation might take us one step towards our goal of health care equity.

Organizational targeted initiatives

As health care professionals, we do not work in silos independent of our support systems. Our introspection and education alone will not suffice in bringing forth the necessary change. At an institutional level, we need to set aside funds for transportation, access to telemedicine, free medications, integrated clinics, and community-based care for patients who have socioeconomic restraints. Although some organizations are helping with these efforts, it needs to be universal.  We should focus on prevention of disease rather than treatment alone. These funds can provide free or affordable exercise programs, weight loss facilities, dieticians, and mental health resources. These will mitigate the barriers to the conscious efforts to undo implicit biases.

Physicians or other health care professionals may not have the energy or time to see themselves as the problem in racial disparities. If we are to make a difference, addressing this issue will need all hands-on deck – physicians, nurses, allied professionals, policymakers, organizations, and administrators. As clinicians, we can change the way we practice by ensuring that we treat patients without biases and advocating for our patients at the levels of our medical organizations, state, and national legislatures.

Kamala Tamirisa and Annabelle Santos Volgman are cardiologists.

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