Editor’s Note: Throughout 2015, an AAMCNews series explored how medical schools and teaching hospitals are addressing social determinants of health in their communities through research, clinical care, and education.
Thirty years ago, the U.S. Department of Health and Human Services released a landmark report documenting racial and ethnic health disparities in the United States. The 1985 report, commonly known as the Heckler Report, found that despite an “unprecedented explosion” in scientific knowledge and the “phenomenal capacity” of medicine, not all communities were benefiting equitably.
Decades later, while researchers continue to document racial disparities in health and disease burden, others are digging even deeper to better understand how race—and by extension, racism and bias—manifests as a social determinant of health in clinical settings. For example, a study published in 2013 in Maternal and Child Health Journal found that among low-income black women in Milwaukee, where black infants die at higher rates than white infants, perceptions of discriminatory provider interactions may adversely impact patients’ attempts to access prenatal care. Another study, published in 2008 in JAMA Surgery, found that race was a factor in trauma-related mortality risk regardless of insurance status. In other words, even with insurance, black and Hispanic patients faced greater mortality rates than their white counterparts.
“We need to take the shame and stigma out of recognizing unconscious bias so we can help each other provide excellent care to all patients.”
Cristina M. Gonzalez, MD, MEd
Albert Einstein College of Medicine
For Adil Haider, MD, MPH, coauthor of the JAMA Surgery study and director of the Brigham and Women’s Hospital’s Center for Surgery and Public Health, such outcomes led him to explore how race and perception combine to affect care delivery.
“I truly believe that equality is the cornerstone of medicine,” Haider said. “I don’t think most people go to medical school to treat people differently …but just like the general population, we all have unconscious biases.”
During his time at Johns Hopkins University School of Medicine, Haider led a study among 202 first-year medical students using clinical scenarios and the Implicit Association Test, a validated tool to detect unconscious bias. He found that a majority had an unconscious bias toward whites, but it did not appear to affect how they treated patients during the clinical vignettes. Haider noted conflicting science on exactly how unconscious bias affects minority patients, especially since few related studies have been conducted in real-life settings. Still, he said such studies are critical to understanding race as a social determinant of health.
“If we have the courage to talk about [bias], we can make progress,” said Haider, who is leading efforts at Brigham and Women’s Hospital to develop a provider-focused intervention aimed at closing surgical disparity gaps.
Around the country, medical schools are integrating discussions about race, bias, and disparities into curricula, though the journey can be a bumpy one. At the University of New Mexico School of Medicine, Felisha Rohan-Minjares, MD, an associate professor and codirector of the school’s cultural competency curriculum, has codirected the Diversity of Human Experience course for first-, second-, and third-year medical students since 2008. The experience, Rohan-Minjares said, has taught her a lot about how to talk about racial bias in a way that opens students’ minds to an often uncomfortable topic. Originally, she talked explicitly about race, historical trauma, and white privilege, “but it created such resistance that it distracted from learning.”
Now, the curriculum has been reframed in a way that invites more openness to the topic. First, Rohan-Minjares said, the conversation became more “asset based.” For example, instead of focusing on historical trauma, the conversation now zeroes in on how to build genuine trust between patient and provider. In addition, the majority of the course’s teachings are done in small-group settings, where the same students and facilitators stick together over three years with a goal of developing comfortable, nonjudgmental settings.
“Many of the students come with a good understanding of health disparities and are eager to help fix the problem,” Rohan-Minjares said.
At Albert Einstein College of Medicine in the Bronx, Cristina M. Gonzalez, MD, MEd, an associate professor of clinical medicine and attending physician at Montefiore Health System, developed the elective Health Disparities: Awareness to Action with a purposeful focus on racial and ethnic disparities. Offered since 2009, a portion of the course explores race as a social determinant of health and its connection to unconscious bias. At first, students took the Implicit Association Test before receiving much contextual background in physician bias. Similar to the New Mexico experience, the test certainly triggered a discussion, but many students were too uncomfortable to participate. In turn, Gonzalez and her colleagues introduced implicit bias earlier in the course to help destigmatize and normalize the topic.
“We need to take the shame and stigma out of recognizing unconscious bias so we can help each other provide excellent care to all patients,” Gonzalez said.
Elevating discussions around race are becoming a priority for many medical students as well. Ashley White-Stern, MA, a second-year medical student at Columbia University College of Physicians and Surgeons and president of the college’s Black and Latino Student Organization, said acknowledging bias in both patient care and medical education is “foundational” to eliminating disparities. On her campus, White-Stern, also a member of the WhiteCoats4BlackLives National Working Group, is collaborating with the school administration to develop faculty trainings on microaggressions and how racism can percolate in subtle ways.
“Physician attitudes go so much further than the experience in the exam room,” she said. “Attitudes can play a role much more broadly, like in advocating for Medicaid expansion or better housing conditions.… Working on personal bias will invariably affect health care outcomes.”
While bias education is certainly warranted, “a concentrated effort can’t divorce the overall climate from the curricula—equity and inclusion permeates every aspect of an organization,” said Michelle van Ryn, PhD, professor of health services research at Mayo Clinic College of Medicine and director of the institution’s Research Program on Equity and Inclusion in Healthcare. Van Ryn’s own research has found that when medical students are exposed to negative comments from attending physicians, their own negative implicit attitudes can worsen. In fact, as part of her work at Mayo, van Ryn is the scientific lead on an institution-wide effort to survey Mayo’s entire workforce on unconscious attitudes and inclusive work environments. Eventually, the data will be used to develop equity-focused training programs.
“We already focus a lot on curricula,” she said. “But we really need to focus more on faculty and especially on clinical faculty in clinical training sites if we really want to make a difference.”
This article originally appeared in print in the December 2015 issue of the AAMC Reporter.