19 minute read
The Importance of Diversity, Equity and Inclusion From the Clinician's Perspective
Pamela S. Arbuckle Alston, DDS, MPP; Jessica Baisley, DDS; Andrea Akabike, DDS; and Jack Luomanen, DMD
ABSTRACT
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Background: Clinical care contributes approximately 16% to health outcomes. Access to care and quality of care contribute to favorable health outcomes. Clinicians employing diversity, equity and inclusionary strategies in their patient encounters can improve access to care and quality care.
Methods: Vignettes are used to personify elements of diversity, equity and inclusion (DEI) during clinician encounters and how they impact their patient outcomes.
Results: Diversity in the oral health team composition is important to the clinician because it helps the clinician relate more effectively to a diverse patient population and offer more resources. Having difficult but necessary conversations can facilitate getting patients the resources they need to achieve their highest state of health. Inclusion is important to clinicians who leverage interprofessional collaborations for whole-person care and involve their team members to make their patients feel respected, understood and welcome. Embracing DEI helps the clinician to facilitate getting patients into treatment, promote continuity of care and adherence.
Conclusions: Providing oral care that is equitable and inclusive in a diverse environment helps safeguard patients from vulnerabilities that adversely affect health outcomes. Employing DEI in clinical encounters is important to clinicians because it helps them meet their obligation of service to patients.
Practical implications: Dental clinicians are in a position to play a key role in promoting health equity by embodying DEI principles. Working interprofessionally and creating a dental team with a diverse representation of social identities are some of the many ways clinicians can foster inclusion and equity within their practice.
Keywords: Health equity, diversity, inclusion, DEI, vignettes, empathy, whole-person care
AUTHORS
Pamela S. Arbuckle Alston, DDS, MPP, served as president for the National Dental Association in 2021. She is a lead oral health specialist for the U.S. Department of Labor Job Corps Program health support contractor. Her clinical career spanned 37 years finishing as dental director at Alameda Health System. Dr. Arbuckle is a fellow of the American College of Dentists. Conflict of Interest Disclosure: None reported.
Jessica Baisley, DDS, is a member of the National Dental Association. She graduated from the pediatric dental residency program at the Herman Ostrow School of Dentistry of USC. She practices at a federally qualified health center in Richmond, California. Conflict of Interest Disclosure: None reported.
Andrea Akabike, DDS, is a member of the National Dental Association. She is a general dentist practicing at a federally qualified health center in the San Francisco Bay Area. Dr. Akabike currently serves as an associate director on the California Dental Association Foundation Board of Directors. Conflict of Interest Disclosure: None reported.
Jack Luomanen, DMD, is a member of the National Dental Association, National Network for Oral Health Access and National Coalition of Dentists for Health Equity. His clinical career spanned 46 years. Dr. Luomanen is the principal of JCL Consulting and has served as an oral health consultant, clinical consultant and peer reviewer expert advisor for a number of governmental agencies as well as dental director in four FQHC clinics. Conflict of Interest Disclosure: None reported.
Race and economic status are linked. The appalling truth is that they are social predictors of health. For example, the ADA Health Policy Institute reported oral health disparities by income, race and insurance status for seniors. A disproportionate number of low-income and minority adults seek oral care only for emergency needs compared to higher income and nonminority adults. Despite improvements in oral health and in oral disease prevention, oral health disparities persist. The Centers for Disease Control and Prevention (CDC) defines health disparities as “preventable differences in the burden of disease, injury, violence or opportunities to achieve optimal health that are experienced by socially disadvantaged populations.”
Oral health disparities experienced by socially disadvantaged populations are unconscionable and unjust because they cause avoidable harm. Eliminating them is an ethical and moral imperative.
Oral health disparities are the result of inequities. Our nation depends upon public-private partnerships for structural change to overcome inequities and eliminate disparities in the living, working and economic conditions that influence health. There is also a pivotal role that clinicians are positioned to play. Clinicians have influence over a measure of access to care and quality of care, two components of clinical care that contribute to health outcomes. Clinicians have within their purview the ability to create spaces that are equitable and inclusive for patients during care. They have the opportunity to deliver productive patient encounters that contribute to favorable health outcomes and help to eliminate oral health disparities.
This commentary features vignettes with clinical scenarios that create “teaching points” to illustrate how clinicians use strategies that integrate approaches to diversity, equity and inclusion (DEI) in their clinical encounters.
Diversity is “involving the representation or composition of various social identity groups.” An oral health team composed of members with a diverse representation of social identities can relate to a diverse patient population. Equity is “providing resources according to the need to help diverse populations achieve their highest state of health and other functioning.” Inclusion is “an environment that offers affirmation, celebration and appreciation of different approaches, styles, perspectives and experiences. Inclusion allows all individuals to bring in their whole selves, i.e., all their social identities and to demonstrate their strengths and capacity.”
The teaching points of the following vignettes are used to illustrate how DEI strategies eliminate inequities and oral health disparities.
Vignette One: Whole-Person Care
Toward the end of the clinic session, a teenager and her father presented to the dental clinic without an appointment. The teen complained of a toothache for which she specifically requested an opioid prescription. The dental receptionist notified the dentist who welcomed the teenager and father into an exam room. The dentist asked the teenager why she was specifically requesting the opioid. The teenager said she experienced a toothache previously at another dental office and received a prescription for the opioid. With the father’s consent, an X-ray was taken and the patient was examined. The dentist explained that the tooth was restorable.
The teenager and father requested the prescription instead. However, they agreed to listen to the dentist explain the inevitable progression of decay without treatment. The dentist also spoke about opioids and their misuse. The father seemed disinterested until the dentist shared that people with opioid substance use disorders are successfully treated with buprenorphine medication-assisted treatment (MAT) as part of an opioid withdrawal and recovery program. The dentist praised the local hospital’s MAT program. At the end of the visit, the father reluctantly agreed to give his daughter ibuprofen instead for pain relief and to bring her back for treatment the following day. The patient returned the following day for a successful treatment.
Several months later, the dentist received a referral from the MAT program physician. The referral was for the father, now a patient in the MAT program. The patient was referred to the dentist for the buprenorphine side effects of dry mouth and dental decay. The patient agreed to the caries and xerostomia management plans. The dentist notified the physician of the clinical findings and treatment plan. The physician was relieved because the unmanaged side effects could have jeopardized the patient’s willing participation in the MAT program. The case manager, who was also part of the MAT team, reached out to the dentist to inform him that she was working with the father to keep his family sheltered because he was out of work.
Discussion of Vignette One
A dimension of diversity in the oral health team is the knowledge and skill set of the oral health team members. The clinician was familiar with treatment for opioid use disorders, knew how to treat the oral side effects of the treatment medication and had a referral relationship with the program clinicians. The clinician was skilled in treating extremely high-caries-risk patients according to the caries management by risk assessment (CAMBRA) approach, thus increasing the patient’s retention prospects in the MAT program. Moreover, the clinician had a skill set that allowed him to converse comfortably with the patient about opioid use disorder. Conversations about substance use are often difficult, but those conversations are necessary in order to gain acceptance by patients for appropriate treatment.
The initial information that the clinician provided with sensitivity and without judgment may have motivated the parent to obtain the help he needed to overcome his opioid use disorder. In providing oral care to the patient while he was in the MAT program, the clinician participated in a whole-person, interprofessional approach in collaboration with the physician, behavioral health specialist and case manager. The comprehensive case management that the father received was essential to his retention in treatment and the continuity of care across disciplines. He obtained linkages to needed housing to deter a downward spiral that could have led to relapse and missed oral health visits. 8 Individuals with opioid use disorder often experience unstable employment with risks of being unhoused. 9 The MAT while the patient was in opioid recovery, caries management and case management were health equity approaches available to the patient to achieve his highest state of health. The clinical environment was inclusive enough to be welcoming to this patient who had a history of opioid use disorder, was low-income and on the brink of homelessness without social support. The clinician did not stigmatize or marginalize the father for having an opioid use disorder. Ronni Brown, DDS, MPH, commented in her book “A State of Decay: Your Guide to Understanding and Treating ‘Meth Mouth:’” “How you understand addiction will determine whether your treatment of a patient who is addicted is appropriate or just plain silly.” Drug addiction is a chronic, relapsing brain disease. Just as the physician and behavioral health specialist partnered with the patient to overcome the opioid substance use disorder, the dentist partnered with the patient to manage his oral side effects. The wholeperson approach to the patient’s opioid addiction included the dentist as part of the treatment team. The whole-person approach promoted inclusion and enabled the patient to demonstrate his strength and capacity to overcome addiction.
Vignette Two: Empathy
A 67-year-old Black woman presented to a local private dental practice for an emergency visit the day after her discharge from the emergency department (ED) for a swollen jaw. When she met with the dentist, who was also a Black female, the patient complained that the ED physician had given her the same prescriptions for an antibiotic and an analgesic that she said neither relieved the swelling nor pain. She said she overheard the physician tell the nurse, “Those people just want medication, and they don’t follow through.” The patient said she was offended. She believed the physician was referring to Black people as “those people,” because he was white and the waiting room was full of Black people. The dentist reassured the woman that her appearance in the dental office was evidence that she did follow through. The patient apologized for missing previous dental appointments. She said the planned dental treatment was more than she could afford. She said that she was aware that neither her state Medicaid program nor her Medicare plan offered dental benefits. She said she could barely afford to pay for the office visit that day and certainly not for the treatment she needed.
The dentist explained that the tooth was a partially impacted third molar, and due to the complexity of removing it, the tooth would need to be extracted by a specialist. She referred the patient to the local federally qualified health center (FQHC) for follow-up treatment by the oral and maxillofacial surgeon on staff. The FQHC had a sliding scale payment system based on the individual’s income. The dentist also shared that she worked at the FQHC part time, which enabled her to continue to treat her patients of record who aged out of Medicaid dental benefits. She divulged that she had been a dental patient at that particular FQHC before attending dental school and did not have to pay for her oral care due to her low-income level. The dentist introduced the patient to the dental care coordinator who helped the patient schedule an appointment. The dentist also took time to explain the course of untreated oral infections and the importance of taking antibiotics as prescribed. The patient told the dentist she would fill the prescriptions and take them as prescribed. She also agreed to return to the dental office if the symptoms worsened and to keep her appointment at the FQHC. She thanked the dentist and said, “I trust you.”
Discussion of Vignette Two
The dimensions of diversity include race and other social identities. The clinician and patient were the same race, and on that basis, the clinician related to the patient with empathy and understanding to build trust. Health outcomes are improved when there is racial concordance, that is, when the race is the same. The clinician easily established rapport with the patient when she divulged that she came from a low-income background. Her disclosure was an inclusionary strategy to make the patient feel welcome and comfortable sharing that her low-income status was a barrier to care. Even without racial concordance, genuine expressions of empathy, respectfulness and understanding by the clinician help to overcome patients’ feelings of marginalization and promote adherence to recommendations.
The patient indicated that she had financial barriers to treatment. Research shows that lack of income can cause health disparities. 12 She resided in a state that did not offer adult dental benefits in its Medicaid program. The FQHC to which the patient was referred provided care to patients regardless of ability to pay. The sliding fee schedule that the FQHC offered is an equity measure. Assistance by the dental care coordinator to make the appointment was another equity measure. These factors help patients follow through with treatment to reach their highest state of oral health.
The ED physician’s remarks to a co-worker about the patient were racially biased. Cultural racism, which is negative racial and ethnic stereotypes, can affect health in various ways. Cultural stereotypes can lead to biases in health care delivery that perpetuate health inequities. Health care provider bias has been associated with lower levels of patient adherence to treatment plans and lower trust in health care providers.
Vignette Three: Cultural Competency and Humility
A 4-year-old Latino boy, accompanied by his mother, presented for an initial oral examination with the pediatric dentist. The dental assistant informed the dentist that the family was Spanish monolingual and that the patient would neither sit in the chair nor cooperate for radiographs. No medical or behavioral conditions were listed on the medical history. However, the mother reported that the patient was overdue for his annual visit with the pediatrician. When the dentist entered the exam room, she noticed the child was extremely anxious. Instead of sitting in the chair, he was huddled in the corner near his mother. The mother reported that her son was complaining of pain and having trouble eating on the right side.
The dental assistant interpreted for the dentist who was not fluent in Spanish. The dentist greeted the boy. The child acknowledged her, but he made no eye contact. The dentist asked if he would like to sit in the chair so she could count his teeth, and he began to cry, scream and cover his mouth with his hands. He did not move from the corner, but after much coaxing, the dentist got a quick look inside his mouth where she discovered multiple decayed teeth. The mother reported that the previous dentist was unable to perform an exam due to the patient’s behavior. She also reported that she could only manage to brush his teeth twice a week and without toothpaste due to his oral aversion. The dentist informed her that the patient had multiple large cavities. She discussed the clinic’s treatment modalities including nitrous oxide sedation, oral conscious sedation and general anesthesia.
Due to the amount of restorative treatment the patient needed and the patient’s age and severe dental anxiety, the dentist recommended treatment under general anesthesia. The mother breathed a sigh of relief that there was an option for her son to finally be treated. The dentist then inquired about the patient’s behavior with the opening question, “What is it like to be his mama?” The mother shared the details of his behavior at home and during previous dental visits. As the dentist listened intently, the mother opened up to share her own concerns candidly about her son’s behavior. The dentist asked if she could share those concerns with the pediatrician and make a request for a behavioral and developmental evaluation when she requested an anesthesia clearance. The mother consented.
The dentist smiled at her reassuringly and gave the assistant instructions to help the mother schedule the appointment with the pediatrician. This patient interaction inspired the dentist to schedule a meeting with the clinic’s pediatricians to discuss correlations between behavioral disorders and dental fears in pediatric patients. The pediatric dentist and pediatricians collaborated to introduce a program to the clinic in which child-life specialists accompanied highly anxious children during dental visits.
Discussion of Vignette Three
An oral health team composed of members with a diverse representation of social identities can relate better to a diverse patient population. The clinician and patient neither shared the same ethnicity/race nor the same socioeconomic background, but the dentist was still able to build trust and a therapeutic alliance — a collaboration and mutual agreement on treatment goals and tasks. The dentist utilized her Spanish-English bilingual dental assistant to interpret for her and communicated with cultural sensitivity, empathy and caring. The dental assistant conveyed those qualities to the patient and parent as she interpreted the dentist’s statements. It has been shown that when patients perceive similarities with physicians in terms of personal beliefs, values and communication, the patientclinician relationship is strengthened. Effective communication is important. Research has shown that effective messaging along with strategies to improve patients’ ability to understand elementary health information enables them to navigate the health system more easily and adhere to regimens more readily. It is acknowledged that empathy in physician encounters has a positive impact on health outcomes 18 and empathy contributes to the quality of the oral health encounter.
The bilingual dental assistant on staff added to the diversity of the dentist’s oral health team. The bilingual assistant gave the clinician a better understanding of the patient’s and mother’s needs. The dentist was resourceful in working interprofessionally to obtain the necessary help for the patient. Patients with chronic diseases, oral health conditions and behavioral health conditions are better managed when medical, behavioral health and oral health clinicians work together. The pediatric dentist suspected that her patient may have a behavioral developmental disorder, so she referred the patient to his pediatrician for an evaluation. Interprofessional practice promotes health equity by encouraging providers across multiple disciplines (e.g., medical, dental, behavioral health, etc.) to collaborate to help patients achieve their best level of wellness. 19 Significant racial inequities exist in the diagnosis and treatment of Latino children with developmental disorders such as autism when compared to their white counterparts. The delay in diagnosing these patients prevents them from taking advantage of early interventions during a crucial time during their development. Identifying a possible developmental disorder allowed the dentist to arrange for a referral to the pediatrician, thus improving the patient’s prognosis.
The pediatric dentist and the bilingual dental assistant’s interaction with the patient’s mother displayed the importance of inclusion within the dental team. Because the clinician did not speak Spanish fluently, she managed to have a meaningful interaction with the mother by utilizing her assistant to interpret her concerns to the patient’s mother. Caregivers of Latino children have reported that clinician dismissal of health concerns and limited English proficiency are some of the reasons caregivers normalize their child’s behavior and lose trust in the health system. 21 Including bilingual and bicultural staff is a strategy clinicians can utilize to help develop trust with their patients. 21 Together with the clinician’s own cultural awareness, cultural competence and cultural humility utilized appropriately, a diverse oral health team enriches clinical encounters and creates an inclusive environment.
Cultural awareness is defined as the process of “developing knowledge about different cultures, including their beliefs, values, customs and language.” Cultural competence is defined as “the ability to work respectfully with people from diverse cultures, while recognizing one’s own cultural biases.” Cultural humility is defined as “the act of acknowledging one’s own biases and limitations in order to more deeply understand another culture.” All three are critical to maintaining a culture of respectful communication in the dental setting.
Summary
Empathy accompanied by a selfless concern for the well-being of others characterizes dentists. The dentists in the vignettes showed compassion and an empathetic understanding of their patients’ and patient families’ feelings.
Empathy and altruism are the motivation for clinicians to provide oral care that is equitable and inclusive in a diverse environment of care. The “American College of Dentists Ethics Handbook for Dentists” instructs, “The dentist’s primary obligation is service to the patient. Dentists have an obligation to use their knowledge, skills and experiences to improve the oral health of the public.” Dentists provide a valuable service to their patients when they find ways to incorporate diversity, equity and inclusionary values into their clinical encounters. Equity is important to clinicians who employ strategies in their clinician role to help patients overcome barriers to achieving their highest state of health. As the demographics change in the U.S., clinicians will continue to see an increasingly diverse patient population. A diverse oral health team equipped to address the needs of a diverse patient population along with other strategies can decrease health disparities. The interprofessional partnerships illustrated in the vignettes are also key to improving health access, quality and outcomes.
The minimum ethical duty of the professional relationship into which the clinician enters with a patient is a therapeutic alliance in order to maintain or improve the patient’s health. 25 Patients with diverse social identities who are welcomed into an inclusive clinical environment where they are heard and feel respected will be receptive to a therapeutic alliance with their clinicians. Employing diversity, equity and inclusion principles to the extent possible is an important aspect of providing the best service clinicians can to patients and achieving a beneficial therapeutic alliance. n
