How Much is too Much: Discrimination in Healthcare

While the American Nursing Association (ANA) and other healthcare organizations recognize movement towards anti-discriminatory behaviors in healthcare, only total elimination of discrimination is the acceptable resolution. Discrimination occurs when a patient is treated unfairly, unfavorably, or unjustly due to a particular characteristic like race, gender, age, or religious viewpoint. In addition, there are many other statuses that could create discrimination such as political views or weight. Most technology has been designed around the average white male. Consider the crash-test dummy designed for the average male, not female; or facial recognition software that does not work as quickly for people of color as it does for Caucasian men.

While privately held, subconscious personal discriminatory beliefs or so-called unconscious or implicit biases, may not be thought to impact professional behavior, however, discrimination does occur when these beliefs leak through and impact personal behavior. This may take the form of microaggressions, unintentional discriminatory behavior or purposeful misbehavior. Unfortunately, in these cases marginalized people become marginalized patients.

Perceived discrimination can strongly affect healthcare outcomes negatively as well as lead to a poorer physical and mental health experience for patients. Black women are 3 to 4 times more likely to die of pregnancy-related complications, more at risk of developing cardiac disease, and while less likely to develop breast cancer, they are 40% more likely to die from it. Couple that with the fact that all women are more likely than men to be dismissed when presenting with symptoms or receive delayed treatment and one can clearly see the health care disparity affecting Black women.

When healthcare providers hold negative attitudes and stereotypes, or even implicit biases, they can hinder appropriate diagnosis and care. A simple test whereby clinicians ask themselves if treatment would be different should a patient with the same symptoms presented in someone of a non-Caucasian race, different culture, or female gender would be treated versus a white male presenting the same way. This can often unveil hidden biases. Each healthcare provider must be held accountable to critically evaluate their own biases.

“Marginalized populations become marginalized patients through the expression of social factors and delivery system failures.“ - Shantanu Agrawal &  Adaeze Enekwechi

 Discrimination and perceived discrimination lead to delays in seeking healthcare for a wide array of treatable conditions, leading to poor outcomes. In addition, clinical algorithms have also made errant accommodations for race that have only delayed needed treatment and adversely affected quality of life. Many algorithms are now being reviewed and adjusted to improve clinical equity. 

Leadership Steps

The best way to decrease the occurrence of bias in healthcare is to enhance awareness. Training students and the next generation of workers to recognize implicit and explicit bias is the first step toward eliminating it. For leaders, this is only the beginning. Leaders must form a team that is intentionally diverse such that unintentional bias can be identified and eliminated from a company’s culture. While bias training for healthcare staff is recommended, other intentional steps should be taken.

Suggested steps include: 

• Creation of a Chief Equity Officer role, along with a staff and budget. Avoid creating this position as a simple figurehead

• Create real-time reporting opportunities to track and respond to events of inequitable or discriminatory behavior

• Create standardized measures of bias and outcomes, then tie both to social determinants and analyze

• Understand and analyze the current metrics and data that are generated

• Monitoring clinician fatigue that may exacerbate implicit bias behaviors

• Review and adjust algorithms which no longer monitor fair and equitable health

• Establish escalation policies for reporting incidents of bias

• Revise patient surveys to capture data on inequities

• Establish a multidisciplinary task force to create useful strategies and protocols and identify policies that may inadvertently protect identified bias or those who commit it

• Train team members to correctly identify microaggressions and address them appropriately, using them as a tool to learn

• Review relationships with minority-owned vendors

• Create equitable opportunities for advancement within the organization.

As you evaluate your practices, consider the following questions: 

• Does your leadership team reflect the diversities among your staff, patient base, and community? 

• Are your minority leaders and employees receiving the training they need to grow their talents at a rate equal to white team members? 

• Do minorities on your team feel they are able to contribute without fear of retribution? Have you created psychologically safe spaces?

• Are mistakes reprimanded more prominently than accomplishments applauded, whether minority or not? 

• Are all members of staff treated equally and fairly? 

The elimination of bias, at all levels of the organization, is necessary to result in equitable service and outcomes for all healthcare patients and providers. As leaders, we must encourage the creation of a discrimination-free culture.