In a recent installment of From the Frontlines, a nationwide gathering of clinicians to discuss topics at the forefront of medicine, we discussed racial disparities in healthcare, unconscious bias, and what we can do to better serve the diverse communities that rely on us. Read more about the conversation with Jenice Forde-Baker, MD, FACEP, Director of Emergency Medicine in Camden, New Jersey, and Adam Brown, MD, MBA, FACEP, President of Emergency Medicine.
MD, MBA, FACEP
Let’s start with education. What resources are available for those who want to learn more about racial disparities in healthcare?
Dr. Baker: For my research, I began at PubMed searching for racial disparities and racism in medicine.
Once there, you'll start uncovering research that you can follow. Personal stories from colleagues and community members also contribute to our understanding and can teach us valuable lessons. I also draw from my experience as a Black woman.
There is plenty of data out there as well. The data shows racial bias influences the decisions we make. It also shows that medical students believe Black skin is thicker and that Black people are not prescribed the same degree of pain medication, because we are perceived to be “tougher” in some perverse sense. I like to use a scientific model and data to discuss racial disparities, which can then be supported with history and individual experience.
It’s great to start with education and understanding the problem. What actions are we taking as a national medical group?
Dr. Brown: When we started talking about what we could do as a medical group, I wanted to be clear that this wasn’t the time just to create a committee. We’ve all seen that happen in the past at different organizations — they create committees, but there are no real teeth or follow-through with specific actions.
As many of you may have heard, our CEO Jim Rechtin signed a CEO action pledge that includes a 60-day timeline for initiatives to begin. In addition, Kris Sanders, FACHE, Vice President of Operations, and I are developing the infrastructure to address diversity and inclusion throughout the organization.
Some of the things we’ll address are healthcare disparities and clinical education. We already have several great resources that enable us to deliver clinical education and best practices, but we need to make sure that a part of that education and curriculum is centered on health disparities and inclusion.
A second area of focus is human resources practices. First, we need the data to know how we can make Envision a more equitable employer. We want to create a place where people can grow and embrace their authentic selves.
A third aspect is centered on awareness and the different holidays and events that we can elevate, acknowledge and celebrate.
Dr. Baker: I agree that it needs to be operationalized and not just a committee. We can’t just talk about it now and then forget about it. We need markers and continuous process improvement.
We can also work on the clinical level with directors and colleagues in our practice to look at data and the populations we serve. We can assess our patient satisfaction scores and stratify demographically. In doing that, we may realize there is an issue in our communication and understanding.
I think this is where it is a process – yes, you can take the implicit bias test that Harvard has online and find that you have a bias, but that alone will not create change. We must implement a system and a process by which we can have an impact.
Can you address the misconception among providers that Black people have a higher threshold for pain?
Dr. Brown: There was a study at Princeton University that asked medical students about a few myths regarding the blood coagulation and skin thickness of Black people. These are not things we are taught in any physiology or anatomy classes, but they found it is a belief students have absorbed from somewhere over time.
This gets to the core of implicit bias. As students are going through their medical education, they are watching their professors and their attendings work and might see that they provide pain medication differently. Although it may not be written anywhere explicitly, they absorb what the culture is and how care is provided.
Another example of bias is when you think a Black patient might be seeking drugs, and a white patient may not be. Data shows that there is no disparity in how addiction affects people. Across the board, human beings experience addiction the same. Another situation would be a sickle cell patient that arrives in awful pain. This is a pain that patients have endured their whole lives, so the markers we use to identify pain may not be what they present with. You might then create a bias in how you treat the pain.
A solution could be to use evidenced-based models and create a standard in how we prescribe medicine. I read a paper recently where they were able to eliminate racial disparities in surgical patient care when they used an evidence-based model and an order set to dictate what would be needed for pre-op and post-op. It proves that we can provide equitable care; we just have to be conscious of the process we're using to do so.
Dr. Baker presented a session on psychological safety with a colleague last year. What role does psychological safety play in racism in healthcare?
Dr. Baker: It plays a huge role. When I think about everything going on at the national level, from COVID-19 to Black Lives Matter, it’s clear that we need psychological safety in the workplace to be successful.
I am an emergency physician working in Camden. When COVID-19 first arrived, everyone was making decisions in real-time: Do we have enough PPE? Do we have enough capacity? Do I come home to my family, or do I stay in a hotel for three months? Everyone was making these really tough decisions.
Then, the Black Lives Matter protests started and the questions that come with it: Am I looked upon differently by my patients? Am I held to a different standard? Do I have an additional burden to educate people around me? All of these extra stressors presented themselves as a Black woman in medicine.
Psychological safety allows someone to be their true authentic self in a setting no matter what's going on. Yes, I am both a physician and a Black woman. However, I feel comfortable and safe within my workspace to have those conversations and offload some of the stress and decision making.
Psychological safety doesn't happen by accident – it is an active process in creating groups, projects and processes. It's making sure that the person that is most comfortable speaking is not the only person speaking. It's being comfortable with accepting and providing pushback, acknowledging possible negatives and unpopular opinions and knowing there won't be retaliation for your voice.
When we talk about racism in healthcare, we are often talking about implicit or unconscious bias that people are not aware of. Psychological safety gives us a framework to discuss those topics so that people don’t feel personally attacked. It's important to know that I'm not trying to undermine any clinician's skills or their ethics – but we have to realize that implicit bias is structural and requires structural changes.
How can we start the conversation of ally-ship?
Dr. Baker: The ally question ties in again with the idea of psychological safety. How comfortable do we all feel with saying "I didn't know" and being vulnerable? Being providers, doctors, nurse practitioners etc., we are the ones that are supposed to know everything. People come to us to make decisions and move forward.
It's important to make spaces with people that feel comfortable discussing these topics. For anyone here at Envision, I am comfortable with it, and you can reach out to me any time to talk. But, I would challenge you to find someone within your group or division with whom you feel comfortable. Begin by acknowledging that there are things you might not know and you don’t want that knowledge gap to be a limiting factor. I think just being honest in that is significant.
You also have to go ahead and do the research yourself. We have access to so much information right now. You also have to be open and honest with yourself. Often, you hear, "I'm not doing this personally, and you're calling me a racist." But that's not where we want this conversation to go. It's not about personal attacks. We can look at the healthcare disparities and data and know they exist. We are here to take care of our patients, so what can we all learn to provide the best care possible.
Hosted by Adam Brown, MD, MBA, FACEP, President, Emergency Medicine, Co-Chair, National COVID-19 Task Force, From the Frontlines is a bi-weekly teleconference panel of multispecialty clinicians nationwide who speak from the frontlines and discuss the evolving best practices as they address the COVID-19 pandemic. Visit www.evhc.net/coronavirus to watch past webinars and learn more about our work on the frontlines of the COVID-19 pandemic.
As a leading national medical group, Envision brings clinicians together to offer transformative patient care and hospital practices. Our strength is in the shared expertise of thousands of clinicians across the country, each with a unique story and thoughtful understanding of medical practices.