It is my job to spend a lot of time on the burn unit and in the ER consulting on burns, and plastic and reconstructive cases. I am exposed to healthcare delivery on the front lines of emergent care, and think a lot about healthcare equality in day-to-day practice.
Health equity refers to the study of differences in the quality of health and healthcare across different populations. Other terms include health disparities and inequalities.
Healthcare disparities can definitely affect the health of our patients, and can result in unnecessary morbidity and mortality.
Most physicians and physician assistants alike would reject the notion of implicit (unconscious) bias against patients and its effect on clinical decision-making. We all were taught and acculturated to the notion that our work is altruistic and evidence-based in every area.
However, because implicit racial, gender, sexual orientation, etc. bias is prevalent in the United States in general, it is not surprising that researchers find this same bias among physicians (and by extension all healthcare providers).
I can say from experience of interacting with my physician and PA colleagues that some of this bias actually surfaces (explicit) in ways that makes me uncomfortable. Implicit and explicit bias is an issue that is being continually discussed by researchers to better understand its effect on care delivery.
Green, et al studied implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients.1 Physicians were surveyed with an Internet-based tool comprising a clinical vignette of a patient presenting to the emergency department with an acute coronary syndrome, followed by a questionnaire and three Implicit Association Tests (IATs).
The researcher concluded physicians’ explicit (self-reported) attitudes toward patients or stereotypes about cooperativeness by race did not influence their decision to give thrombolysis for black versus white patients. Physicians’ implicit biases, however, showed strong associations with their decisions to give thrombolysis.
It is interesting to me that the unconscious bias is the one most associated with affecting treatment decisions. I believe that their conclusions can be applied to every clinical setting, and are exacerbated by other issues that create disparities, such as access to care. So what do we do with this knowledge?
The number one thing that a physician, PA, or other healthcare provider can do is to recognize bias for what it is. Self-awareness of bias helps to reduce its effect on the medical decisions we make every day.
There are a number of resources that can help us to deal with health equality in the community and within ourselves:
• AMA Ending Disparities E-Letter
• CDC Office of Minority Health and Health Disparities
• Disparities Solutions Center
• American Academy of Physician Assistants 2011 Position Paper on Health Disparities
• EquityPA Twitter Feed
• Healthy People 2020 Disparities Section
• Kaiser Monthly Health Disparities Update
• Kaiser Minority Health
• National Partnership for Action to End Health Disparities
• Robert Wood Johnson Foundation Quality/Equality News Digest
The goals that we set for ourselves in creating equitable delivery of healthcare need to be achievable, but we must also realize that true health equity can never be fully achieved. Physicians, PAs, and other healthcare providers — after increasing their own awareness of health equity issues and solutions — can take a leadership role on the healthcare team in training their colleagues and raising everyone’s awareness.
Please take the time to look at some of the resources in the list above and consider how you deliver care to the diverse populations you serve. The bottom line is that when you get physicians and PAs to just consider the data, it increases awareness of health equity and decreases likelihood the care will be delivered in an “unequal” manner. This is a good first goal.
1Green, Alexander R. et al. "Implicit Bias among Physicians and its Prediction of Thrombolysis Decisions for Black and White Patients." Journal of General Internal Medicine. 22-9 (2007): 1231-1238