The Dose - Health Care has a Bias Problem: Here's How to Fix It

Episode Date: November 15, 2019

Bias in medicine –based on race and sex – is a well-documented problem. It’s a problem because the health care system has historically marginalized the medical concerns of people of color and women, which has led to worse health outcomes. On the latest episode of The Dose, host Shanoor Seervai discusses ways to tackle bias in health care with Ann-Gel Palermo, who works on diversity and inclusion at New York’s Icahn School of Medicine at Mount Sinai, and Joia Crear-Perry, who founded the National Birth Equity Birth Collaborative to address racial disparities in health care. They explain that bias is not just a concern at the individual provider level; it’s actually baked into the system, starting in medical school. While fundamental change will be an uphill battle, they say, the fight is critical to ensuring that all patients are treated fairly when they seek care.

The Dose is a production of the Commonwealth Fund, a foundation dedicated to affordable, high-quality health care for everyone. Hi everyone, welcome to The Dose. On this episode, we're talking about a well-documented problem, bias in medicine. So a lot of you know this, but discrimination, usually based on race and sex, has an impact on people's health. And my guests today have been working on this issue for several years. I have with me Angel Palermo. Angel is the Associate Dean for Diversity and Inclusion at the Mount Sinai Medical School. She's also the Chief Program Officer for the Office for Diversity and Inclusion

of the Mount Sinai Health System, which has a reputation as one of the best in the country. I also have with me Joya Crear-Perry. She's the founder and president of the National Birth Equity Collaborative, an organization working to address racial disparities in healthcare, particularly when it comes to Black women and their children. Angel, Joya, thanks for being here. Thank you. Thank you. Thanks for having us.

My pleasure. So let's start by spelling out in a little more detail, what is the problem? Why is bias bad for people's health? You're the expert. So I think that is a wicked question to ask, right? And I think the wicked questions are the most simplest yet have a very complex answer. And I think, you know, it's clearly been well documented that health disparities exist in that people of color and patient populations of color receive fewer and less access to treatments and procedures and just healthcare in general that would actually prevent worse health,

mitigate worse health, and avoid premature death and dying, right? And so we know that. And we're very good at documenting, but we're also not good at sort of unpacking like why this is so. And I think that in more recent times, researchers have begun to really understand, well, you know, let's look at the individuals who are in charge of delivering care, right? Who are responsible, who are trained to deliver patient care, be in the patient care setting. And so we're talking about clinicians, health providers, anyone who's part of a patient care team and thinking about what is it about these individuals that might be impacting the way which care is delivered. And that's where we started looking at bias, right? And the community, the literature started looking at, let's look at just bias in general

as a human behavior and how that gets constructed and how that plays out in one's professional role as a healthcare provider. And lo and behold, right, the methods are not necessarily super advanced and rigorous, but there is evolving body of methods to really understand, measure, and unpack bias. And we can talk about what we mean by bias as well. So if we just, you know, one of the simple ways I like to talk about it, and this is based on some training that my team has taken on through Cook-Ross, is that really it's just a tendency or an inclination to judge without question. And it's really just a shortcut to interact with the world. I like to also use the metaphor that I'm reading, viewing a short film on bias by the New York Times.

They put these sort of short videos together, and they use the metaphor peanut butter and jelly, right? This association. I personally don't ever question peanut butter and jelly. Like, they just go together. And so we have these sort of peanut butter and jelly associations, these snap associations that we make all the time, every day, all day. And, you know, when you're trained in medicine and healthcare,

you're socialized as a clinician to sort of really pay attention to things that are important or what to expect. And so it's really easy to create blind spots. And so when you factor in the training, the socialization of that training, on top of who we are as people and how we relate to people, things, circumstances in our life and the images that we get and that creates opinions and attitudes and mindset, there's no accident as to why bias is a really important thing to look at. And, you know, you can't necessarily separate your personal life from your professional life. You know, your mind is your mind. It doesn't split in two. And so, you know, recognizing bias as a source of disparities in

health is a complicated, is complicated and critically important because what it requires is a people side of change, not necessarily the system. The system doesn't change without the people in it changing. And so, uh, that's what, that's what this is about. Well, I was just going to ask, um, Angel, you mentioned blind spots, but could you give me an example of what a, what a blind spot is? Cause sort of the peanut butter jelly association, it could be a bad thing, like something that's just assumed it could be a bad thing just in daily life. But I feel like it's particularly bad if you're going in to see your doctor, you're sick and you need something. And they have this association that they make about you and then you don't get the right diagnosis. I mean, I think for me, going back to how we got to the biases are important, right? And so because the images that we were all taught about race and gender come from some

assumptions we have around black and brown people, around women. And so they are socialized not just in how we teach in medical school, but they're in the media, they're in our school books, they're in our history. So then that feeds into the bias. But I'll give you today a concrete example of how bias can work. So if you believe that preeclampsia or hypertension in pregnancy is something that only happens to black people, right? Because the shortcut, as she mentioned, we do a lot of shortcuts in medicine. We have acronyms and we believe it's easier for us to just say sickle cell black, right? So those

kind of very concrete shortcuts. There are white people who have sickle cell disease. And so you will then ignore the fact that they do. Or if you are a white person who has hypertension in pregnancy or high blood pressure in pregnancy because of our bias, we're not going to say, oh, you must just be in pain today. So it becomes really lethal when we assume groups of people have very concrete medical issues or medical symptoms based upon the amount of melanin they produce or based upon having a uterus or not. And as a person with power, as a provider, you're making decisions that could really harm the patient and the blind spots of missing all kinds of ignoring pain, not seeing high blood pressures because you've lumped people into certain categories that are not real categories. And so when we think about how bias has been failing large groups of people, what I'm hearing is that we have a problem that's the system. It's baked into a system that sort of measures broader societal problems that we have in the U.S.

People of color and women have been treated differently their whole lives. And then we have in the US. People of color and women have been treated differently their whole lives. And then we have what plays out on an individual basis, how your specific doctor or your nurse responds to you. And what are the outcomes for these large groups of people

our system ignores and treats differently? Yeah. I mean, I think for us, that's why this work around maternal mortality is so important, because it really shows you, despite income, despite education, despite weight, that black women still have worse outcomes and we're more likely to die in childbirth. So it challenges your shortcut, right? So if the shortcut, we knew when the data came out that showed that black women were dying in childbirth in New York City at 12 times the rate of their white counterparts, that immediately the narrative would be, of course they are. They don't go to the doctor. They're too fat. They don't listen. They're non-compliant. As if, A, all white patients are compliant and skinny. Let's just start with that. But B,

despite doing all those things, we still are more likely to die. And so that makes you then have to take a step back and say, how are we failing with our biases, large groups of people? So that belief that if only we would just get skinnier, if only we would just listen, like all of those if onlys don't play out in the data. And that's our biases around how we believe black women show up, Right. And so I think that's just one example. Rural communities have the same issue. Right. This idea that if you don't have as much education, if you lose. The patients are the ones who ultimately lose. And I fear that if we don't get to talk about where the biases come from. And so I just thought it was really important to bring that into the room, into the conversation, and how, especially when you're working to improve healthcare outcomes, we have to talk about structural racism, we have to talk about gender oppression, like where do these biases

originate? Because we have to retrain systems, individuals and systems to act differently. And while you can't make it go away, there are things that both of you are doing to try and change the way these systems work. So talk to us more about that. How are you working to change a curriculum that has perpetuated our system of racism? Yeah. So in diversity affairs, we have no positional power in a medical education system. We're not in charge of curriculum, admissions, student affairs, student research.

We just exist in these spaces. And if you have a really effective diversity affairs unit, you can be effective in influencing those other functional areas to think about students who don't know how to swim well and are sinking. And it was just a total mind shift. And when we realized that the fix-it approaches were not going to work, like, let's just get rid of this person and change the name of that. And it was like, no, we need actually transformative change. We have to actually reveal the system onto itself, as my colleague, Leonona Hess says, and then think about what are the levers for change inside of that. So that's when we decided to establish and create what's called the Racism and Bias Initiative. And it's really a strategy to really transform our medical education and learning environment using a change

management approach, because we believe that the way the system is going to change is if the people in the system, you work on people's side of change, right? And most importantly, the people who have positional power in that system and to work on shifting mindsets and mental models. And so that curriculum specifically has been a longitudinal dialogue on addressing racism and bias inside of their training. It starts in orientation with a conversation from the dean, David Muller, to a series of interactive activities that's about building community, identity formation, exploring that, unpacking that, to their two-year doctoring course where we thread through all the concepts and topics discussed and what we teach them how to literally interview a patient is recognizing their biases at play.

So give me an example of that. What are some of the biases that come out when a doctor is interviewing their patient and how is your work around the doctoring courses changing that? So we teach our students to ask their patients, how would they like to be addressed? Instead of assuming we ask, we teach them, we teach them what are their preferred gender pronouns and how to do that in plain language instead of assuming. We teach them how to ask about their racial, ethnic identity, their spiritual faith background, their gender, sexual orientation. My favorite part is teaching them sexual history taking skills. And so we teach them to not assume the genders of their patients,

sexual partners. So we'll say, we'll teach them like, well, what are the genders of the people that you have sexual relations with? Like, right. Tell me who the genders are, you know? And so, so those are the ways in which we actually train them to, you know, because they want to know, what do I need to know? Right. What's the checklist of questions. So then let's take ownership of the checklist of questions and redesign the questions that gets at unpacking the bias and comes from a place of inquiry and letting the patient share versus coming in with a set of assumptions that, you know, and also we've, you know, one of the things we've noticed over time is that our students weren't asking the cisgendered gay identified man about family planning, right? And like asking about, are you interested in having children?

And what does that look like for you? Right. And so they were just like not doing it. And we recognize there's a bias at play. It's like this automatic peanut butter and jelly. Gay man, no kids. Right. Like, so, so those are the ways in which we try to unpack that.

So our organization does similar work, but not necessarily with medical students. So it's hard to do it. We usually get called in when people are in trouble, right? So if the media says you're treating your patients poorly, they want somebody to help them with their equity. Or sometimes they're just really good, nice people who will really look at their own data internally and say, hey, we want to do better. So these people you're talking about, a health system, a hospital, a clinic. Clinic a clinic. So it could be an FQHC system. They could be a large

healthcare system. We've been brought in by cities. So a small city or a city of New York to say, okay, we're going to look at our health systems and look at where the places where black and brown people are doing poorly and work through how we can improve that. And so some of that is one-on-one training. Some of that is role-playing because we don't learn how to interview people in medical school. So then it spent me on a journey of figuring out what does quality mean in healthcare and where is equity in quality? And how do we train for quality that actually meets what the patients need? And so that means undoing biases. That means actually listening to patients. So with patients who want a very different QI measure than they don't.

They actually do want me to listen to the nurse, right? Right. So how do we change how we even identify quality? And so we work a lot around changing QI, changing the understandings around QI. Can you talk, Joya, maybe about a clinic or health system that you've worked with that you feel like really needed you but was resistant to change or was really struggling with these issues? You know, I mean, what comes to mind right now is home. So I'm from New Orleans, and I trained there.

Charity Hospital, historically, up until the mid-'90s, is where a lot of people had their babies. And you would have your baby in a room with about 20 other people. There were wards, even in the 1990s, with just curtains in between. So although we got rid of those wards, the mentality that that's what people deserve still exists in our city, right? And so about six months ago or so, a reporter reached out to me that they had data around my city and how poorly the women were doing and they were going to release an article about it um in a large international paper and um the response from my hospitals from my peers was still to blame the patients and to

blame the women like they have always done so we've done now town halls. We now recently went back and I am hopeful because there are some champions. Diversity and inclusion is a huge champion at the systems. But as you mentioned, the power really lies at the dean's level. The power really lies at the CEO's level. And so how do we then, the resistance to change that's always existed is still kind of there. And the hope and the goal is to figure out a pathway so that we can get buy-in from the actual, because they need the same transformation that you are doing at Mount Sinai. So I am still optimistic they will get there, but they need deep change. Half of the city doesn't have access to a hospital. The systems

have chosen not to reopen those hospitals since Hurricane Katrina. And so those are systems choices. And yet we still blame the patients for the poor outcomes. Let's talk about this blaming the patient, because I think that, you know, one of the reasons people are resistant to change is because you say, well, we've always done it this way. It's always been like this. Why should we do it differently? And what has always been done is that the patient has been blamed. Can you talk about the resistance you've experienced and how you're trying to overcome that? I think, yes. So the resistance is real. I think it shows up from my experience in this space, really in this space deeply in the last five I do so that I can stay nimble and ready. You know, like this work has been, if I let it, could really burn me out quick. And, you know, I'm doing this work 100% of the time,

largely because I'm situated in diversity affairs. And we're not interested in like doing the usual basic diversity affairs where cultural competency, et cetera, et cetera. We're going deep, right? We're going to take on racism and bias. And so that takes a certain something. And so that also means being able to understand and see resistance from colleagues. So I expect resistance all the time. I think what there is to do is to develop a set of skills,

both communication, set of skills, both communication, behavioral thinking skills, that you can sort of detect what the resistance is, right? How do we transform resistance? Some people need data. Some people just need a moment, like something to resonate with. Some people just need an incentive and a reward, right? Some people need a major event to happen before they choose to let go their resistance. So the thing is, is that you have to learn resistance training, basically. And that's a body of work. Well, as we're wrapping up, I wanted to ask both of you.

And obviously, again, change is hard. It takes a long time. But if there was one single thing you could do to make the delivery of healthcare in the United States less biased, what would it be? I know you asked that question when you put that in the emails, like shit. Oh man. So we only get one. So if I were to get one, the one that's probably the most targeted and effective is what she's doing right because i do think medical education is hard to fix like i work with people who are in practice and that's a lot harder um hall i do think medical students are still at the space where you could train them very differently and they could have

a very so you could change curriculum you could even change how you decide who gets into medical school right like we have no empathy score for medicine we have an MCAT score right but like I want I when I look for doctors for me and for my family I want to know that you actually care like for real you know and so that is a very concrete there are ways to measure that there's ways to find that out about people and so I would change how we who we accept and then how we teach them. So that over time, the workforce would look very different. Right. Yeah, I agree. I think if we can, not only in medicine, but in nursing and all the health professions, if we can really transform what we teach, how we teach and when we teach it, because those are the individuals that are part of the

patient care team, then I think that that is an opportunity for a real transformative shift in healthcare. All right. Well, let's hope for a transformative shift. Thank you both so much for joining me. Thank you for the conversation. This has been awesome. Yeah, it's wonderful. Thank you for being here.

The Dose is hosted by me, Shanwar Sirvai. Our sound engineer is Joshua Tallman. We produced this show for the Commonwealth Fund with editorial support from Barry Scholl and design support from Jen Wilson. Special thanks to our team at the Commonwealth Fund. Our theme music is Arizona Moon by Blue Dot Sessions. Additional music by Pottington Bear.

Our website is thedose.show. There you'll find show notes and other resources. That's it for The Dose. Thanks for listening.