DIVERSITY AND INCLUSION IN HEALTHCARE

AN ONGOING EFFORT

By Areeha Khalid Emory Kim

Imagine that you have been invited to a dinner party. You get all dressed up, you are super excited...and then when you arrive at the venue, you notice that all the seats are filled. You are standing there in an expensive suit after spending twenty minutes on your hair only to realize there is nowhere for you to sit.

Not pleasant, right?

Now, imagine this one more time. Except this time, you are a doctor, the dinner party is the hospital, and the featured dish is your patients. If there is no room for you at the table, will you ever get to the meal?

DIVErSITY AND INCLuSION IN HEALTHCArE

These days, the terms “diversity” and “inclusion” are often used interchangeably. However, they do not mean the same thing.

Diversity is the incorporation of all different types of people into a group. In the scenario above, this means inviting people to the dinner party. By issuing more invites to all kinds of guests, you increase the diversity of people present.

Inclusion means having equal opportunities and spaces to express your ideas within the larger group. If you are at the dinner party but there is no room for you to participate in the conversation or get to any of the dishes, then you are not “included” in the main space. This means that just because a space is diverse does not automatically mean it is also inclusive.

Oftentimes, we get caught up in making sure things are outwardly diverse, whether that be through “cancel culture” on social media or excessive political correctness. However, these reactions are not necessarily the best way to bring about lasting change.

When it comes to healthcare specifically, inclusivity needs to be a foundational part of the system. This means creating open environments in medical schools and research where diverse healthcare providers can learn to cater to diverse patient populations. From there, inclusivity will extend to hospitals through methods such as anti-racist practices, diverse hires, and culturally-sensitive training for current staff.

DIVErSE AND INCLuSIVE PATIENT POPuLATIONS DICTATE MEDICAL TrAINING AND rESEArCH

In debates about diversity and inclusion in healthcare, many argue that because doctors are trained to treat all humans, factors such as race, gender, or socioeconomic status should not affect their ability to provide necessary care. For example, a prevalent perspective in the U.S. right now is the idea of being “colorblind,” where one believes that since all humans are equal, disparities based on race should not be taken into account.

The colorblind perspective is problematic because it instills a false sense of diversity that sounds more helpful than it is. However, research consistently shows that by ignoring diversity in medical training, doctors are actually less able to effectively treat patients.

For example, many American dermatological textbooks are limited in the photos they contain of skin conditions on people with darker skin. Based on the colorblind perspective, this should not affect the quality of dermatological

care because all human skin “is the same.” However, it turns out this is not the case.

According to Dr. Lynn McKinley-Grant, a dermatology professor at Howard University, medical students are trained from their first day in “pattern recognition,” or to learn how to identify an illness consistently and treat it. But if a skin condition that looks red on white skin is purple on darker skin, doctors may struggle to identify that condition on a darker-skinned patient because they have been trained exclusively on light-skin pattern recognition. This results in misdiagnoses, or a failure to notice an illness altogether.

In addition to diagnoses, diversity and inclusion is equally as important when it comes to treatments for illnesses. Although many hospitals and labs already consider race in tests and medication dosages, we need to take a closer look at whether these existing practices are truly effective and accurate.

For instance, kidney filtration problems can be detected through blood tests that measure the amount of creatinine present in the body, where low levels of the protein indicate the patient may need further medical attention. Typically, a score of 30 or fewer would prompt a primary care doctor to refer a patient to a kidney specialist.

In these tests, race is seen as a proxy for genetic differences, and automatically factored into a patient’s final score. This can be dangerous, as exemplified by a 2019 study by Eneanya, Yang, and Reese, which found that while a white patient may score a 28, a Black patient with the same level of creatinine might score a 33 and not be referred to a specialist.

Further, this same race correction might mean that a Black patient will not be eligible for a necessary kidney transplant, as one needs a score of 20 or less to qualify.

These are just some examples that illustrate the harmful effects of overfocusing on race or overlooking it altogether when it comes to healthcare. We need diversity and inclusion in the types of people medical students study, as well as the way medical treatments are administered, in order to build safer hospital settings.

STErEOTYPES, IMPLICIT BIAS, AND THE NEED FOr BEING ANTIrACIST IN MEDICINE

Racism is a public health crisis in medicine. While individual doctors may not necessarily be racist, research shows that implicit stereotypes and biases affect how healthcare workers may respond to a patient, especially in crisis situations.

The Implicit Association Test (IAT) is the most commonly-used test for implicit biases among doctors, consisting of a computerized timed dual categorization task. This test is usually used to see how the test taker evaluates Black/White faces with “Good/ Bad” words to reveal the implicit assumptions they might make while under a time constraint.

In a study by Sabin and Greenwald (2012), researchers used the IAT to determine that doctors who claimed to have “warm feelings” towards both African and European Americans still could have implicit biases towards either group. These biases affected how they chose to treat patients, as doctors with more “pro-white” tendencies on the IAT were more likely to prescribe narcotic pain medication to a white patient after surgery, but not a Black patient.

This study demonstrates the need for doctors to not just condemn racism in medicine, but to be actively anti-racist. According to news reporter Eric Deggans, anti-racism means accepting racism as an undeniable part of American culture and history, working to educate oneself about it, and uplifting marginalized voices by supporting anti-racist organizations and outreach. In healthcare, anti-racism might mean that doctors need to make an active effort to become aware of their implicit biases because they can may unwittingly impact how doctors provide care.

Furthermore, stereotypes, biases, and racism affect not only the kind of care a patient is receiving, but also a patient’s attitude toward hospitals and medicine in general. Put simply, when a patient no longer perceives the hospital environment as being inclusive, they may be disinclined toward seeking help. This contributes to the wide healthcare disparities in the U.S. for certain groups—such as women, POC, immigrants, and LGBTQ+ individuals, especially those that are transgender, who may feel discriminated against or that their “concerns are not being heard” by their healthcare providers.

As shown in the Sabin and Greenwald (2012) study, pain medication is particularly an area of medicine that is plagued by implicit bias and racism. For example, research shows that Black and Hispanic patients are less likely to receive prescription pain medications for the same conditions than white patients are.

Pain stereotypes extend to gender as well. Female patients with chronic pain consistently report feeling “mistrusted” and “not taken seriously” by doctors, perhaps due to stereotypes of women being “hysterical” and exaggerating their emotions. Women also report their appearance being brought up frequently as a reason they do not receive adequate care, such as by providers saying, “You don’t look ill.” or “You’re too young [to have chronic pain]!”

It is worth noting that on the flip side, men are stereotyped as “brave” and “masculine”, meaning that male patients are less likely to reach out to doctors for help

managing their chronic pain or to follow their doctor’s treatment advice due to the fear of being seen as feminine or weak.

Thus, the promotion of inclusive (anti-racist and anti-stereotyping) practices by doctors serves to increase both the quality of a patient’s care and the patient’s positive attitudes towards their provider and treatment.

A SEAT AT THE TABLE FOr EVErYONE

When reading about the studies and examples above, many people’s initial instinct is to ask, “So what? How can we solve this dilemma?” And inevitably, the solution proposed is to hire more diverse doctors from different backgrounds.

Improving diversity in the hospital and the clinic is indisputably the best first step. After all, diversity is the first step toward inclusivity. However, hiring more diverse doctors will not fully neutralize systemic problems that have been present for decades. Nor is it fair to put the burden of “fixing the system” on doctors from minority or underrepresented backgrounds in medicine.

Think back to the dinner party example. Inviting more guests to the table might increase inclusivity, but what about the guests who have already been sitting down?

All healthcare workers must make the effort to be more inclusive together, whether through training existing doctors to be more culturally sensitive, utilizing strategies that help doctors acknowledge and become aware of their implicit biases, or promoting bias-reduction at the institutional level.

These are not problems that can be fixed overnight, but larger systemic issues that will require a careful overhaul of research, policies, ideas, and training. By promoting self-reflection and active efforts against stereotypes and biases, we stand to create a more diverse hospital setting where everyone has a seat at the table, doctors and patients alike.

Chapman, Elizabeth N., Anna Kaatz, and Molly

Carnes. “Physicians and Implicit Bias: How

Doctors May Unwittingly Perpetuate Health

Care Disparities.” Journal of General Internal

Medicine 28, no. 11 (2013): 1504–10. https:// doi.org/10.1007/s11606-013-2441-1. Deggans, Eric. “'Not Racist' Is Not Enough:

Putting In The Work To Be Anti-Racist.”

NPR. NPR, August 25, 2020. https://www.npr. org/2020/08/24/905515398/not-racist-is-notenough-putting-in-the-work-to-be-anti-racist. Ebede, Tobechi, and Art Papier. “Disparities in

Dermatology Educational Resources.” Journal of the American Academy of Dermatology 55, no. 4 (2006): 687–90. https://doi.org/10.1016/j. jaad.2005.10.068. Eneanya, Nwamaka Denise, Wei Yang, and Peter

Philip Reese. “Reconsidering the Consequences of Using Race to Estimate Kidney Function.”

Jama 322, no. 2 (2019): 113. https://doi. org/10.1001/jama.2019.5774. Kolata, Gina. “Many Medical Decision Tools

Disadvantage Black Patients.” The New York

Times. The New York Times, June 17, 2020. https://www.nytimes.com/2020/06/17/health/ many-medical-decision-tools-disadvantageblack-patients.html. Macapagal, Kathryn, Ramona Bhatia, and George J.

Greene. “Differences in Healthcare Access, Use, and Experiences Within a Community Sample of Racially Diverse Lesbian, Gay, Bisexual,

Transgender, and Questioning Emerging

Adults.” LGBT Health 3, no. 6 (2016): 434–42. https://doi.org/10.1089/lgbt.2015.0124. Prichep, Deena. “Diagnostic Gaps: Skin Comes

In Many Shades And So Do Rashes.” NPR.

NPR, November 4, 2019. https://www.npr.org/ sections/health-shots/2019/11/04/774910915/ diagnostic-gaps-skin-comes-in-many-shadesand-so-do-rashes. Sabin, Janice A., and Anthony G. Greenwald.

“The Influence of Implicit Bias on Treatment

Recommendations for 4 Common Pediatric

Conditions: Pain, Urinary Tract Infection,

Attention Deficit Hyperactivity Disorder, and Asthma.” American Journal of Public

Health 102, no. 5 (2012): 988–95. https://doi. org/10.2105/ajph.2011.300621. Samulowitz, Anke, Ida Gremyr, Erik Eriksson, and

Gunnel Hensing. “‘Brave Men’ and ‘Emotional

Women’: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered

Norms towards Patients with Chronic Pain.”

Pain Research and Management 2018 (2018): 1–14. https://doi.org/10.1155/2018/6358624. Zestcott, Colin A., Irene V. Blair, and Jeff Stone.

“Examining the Presence, Consequences, and Reduction of Implicit Bias in Health

Care: A Narrative Review.” Group Processes &

Intergroup Relations 19, no. 4 (2016): 528–42. https://doi.org/10.1177/1368430216642029.