[Yellow Cohort] Module 8 2018-2019 – Healthcare Equity

[Nabil Al-Kourainy]

Please enter your reflections here. Thank you.

[Nabil Al-Kourainy]

Week 8: Healthcare Equity

Healthcare inequality follows a growing trend of an increasing gap in economic inequality in the United States. As the middle class continues to shrink, an opposite effect is seen on health care outcomes. The Affordable Care Act (ACA), passed in 2010, sought to and has successfully improved access to healthcare for millions of Americans, including those in the state of Michigan, following Medicaid expansion. However, health care access represents only a piece of healthcare disparity. It is important to recognize that racism of minority populations as well as institutional policies that lead to the incarceration of a disproportionate number of minority populations, further worsens the health care inequality gap.
It is an established fact that racial bias in medicine leads to worse health outcomes. One need only look at the egregious disparity in maternal mortality in Detroit, three times the national average for an example of the deleterious effect that health care inequality and racial bias can have on a population. Social determinants such as lower socioeconomic status is often cited as rationale for higher rates of disease in African American and other ethnic minority populations. And, while social determinants certainly contribute to the healthcare inequities, leading to poorer health outcomes, this does not address the internal biases that exist within America’s healthcare system. For example, an African American or Latino who presents to the Emergency Department with a kidney stone, is less likely to receive analgesics at a palliative level than their Caucasian counterparts. This is an unfortunate trend that is homogeneous in the U.S.

Another factor to consider is the mental toll that being subjected to racial bias has on minority populations. This no doubt leads to mistrust of the medical system, which causes a downstream effect of minorities not seeking primary or preventive care, which correlates to increased presentations to the emergency department for these populations, or ignoring their symptoms all-together, until a catastrophic and often deadly complications arises. Why do we see these disparities in care, amongst individuals who often times entered a profession for the purpose of improving the quality of life for their patients?
In order to understand the basis of these disparities, it is important for healthcare organizations as well as individual providers to recognize that they may harbor unconscious biases towards minority populations that can potentially lead to disparate care decisions when treating minority patients compared to their Caucasian counterparts. In addition, even in the event that treatment decisions are unaffected by unconscious bias, studies have shown that physicians when treating a black patient may nonverbally communicate a lack of empathy or attempts to build rapport. Physicians have been observed to stand farther away from the patient’s bed, or spend less time physically examining the patient.

To address these non-verbal differences in care, it is important for physicians to make a conscious effort when examining a patient, to communicate empathy, make efforts to build rapport, breakdown complex pathophysiology to terms that are commensurate with their individual patient’s level of education and understanding, as well as spend an appropriate amount of time not just doing chart review, but physically placing his/her hands on the patient. These efforts can likely go a long way to build trust between patient and physician and will likely lead to better health outcomes.

Additional Sources:
– https://health.usnews.com/health-news/patient-advice/articles/2016-02-11/racial-bias-in-medicine-leads-to-worse-care-for-minorities
– https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30398-7/fulltext
– https://www.nytimes.com/2019/02/25/upshot/doctors-and-racial-bias-still-a-long-way-to-go.html

[Shivani Agrawal]

The article, Youtube video and interactive session had important teaching points about bias. On Monday, in clinic – a patient talked about bullying at her work place for being the “new” employee. This person is a hard work individual who recently got hired full time (was per diem before) and was trying to do a good job in the role.

I just finished reading the book called Becoming Nicole. This book is about a family who adopted twin boys. One of the boys, even early on identified with female traits and the other son was a “typical” boy. The bullying of the transgendered child lead to the family having to move, switch school and eventually pursue legal action. The family did win their legal case after a lot of heartache. The child eventually changed her name and had sex reassignment surgery. The book was very detailed about the family’s struggle and the science behind gender/identity. Reading this book helped me learn more about the LGBT community.

[Marvin Kajy]

Racism still exists in 21st American society. This fact may be an inconvenient truth for some, but for millions of Americans it is ever-present. It is an inescapable aspect of their every day life. It well known that inequality may be present at work, school or social affairs. What is less known is that inequality is also present in the health care system. Medicine has historically been a field where a provider, like a physician or nurse, has a significant amount of power as compared with the recipient of the service, the patient. Doctors and nurses take an oath to treat all patients equally. However, not all patients are treated equally well. There is a deluge of news articles detailing how minorities are undertreated for pain, have higher readmission rates or have poor follow up. However, most physicians and nurses are not explicitly racist and are committed to treating all patients effectively and equally to the best of their abilities. One may argue that health care work in an inherently racist system. In addition, our own subconscious prejudices, also called implicit bias, influence how we treat our patients. Racism and discrimination are deeply ingrained in the social, political, and economic structures of our society. American history is marked by inequality and violence between people of different racial and ethnic groups. To fight racism, we need to understand these differences, just like previous generations did. To fight racism and discrimination, we all need to recognize, name, and understand these attitudes and actions. We need to be open to identifying and controlling our own implicit biases. During our clinic week we performed an activity called cross the line. During the activity we realized about the past events that we were a part off or some things that we have done that perpetuated negativity toward an individual or a group. At the end of the activity, there were several things that ran through my mind. I felt feelings of shame and embarrassment because of the things that I have done when I was younger. Admittedly, I’ve said some bad things about people or I would turn away when I see someone bullying others. I also felt a sense of growth because I can never imagine myself doing those things. As residents, we are often taught from our parents and attendings that we should lead by example because people do look up to us inside and outside of the hospital. With the help of the internet, our modern society is filled with places where one can project their opinion. Literally at the click of a button, someone’s life can be flipped upside down because of differences of opinion. We need to be able to manage differences of opinion safely, learn from it, and educate others. These ideas need to be a component of medical education, as well as health care policy. We need to practice and model tolerance, respect, open-mindedness, and peace for each other.

[Lea Monday]

This week we discussed a video and an article. the gardening article hit me really hard. It did a good job of making a simple analogy to describe a very complex issue. The part about the pink flowers wishing they were red or feeling like red was more beautiful broke my heart. America is such a messed up country. It required the genocide of one group and then the enslavement and persecution of another to make this country. and now it is a big mess. I have very little hope for the future in general, but perhaps the saving grace will be younger generations being raised more socially aware, having diverse friends and experiences, being educating on privilege, and trying to be better to other humans and to the earth. II want to thank Dr. Nnodium and my colleagues for being so generous with their sharing and emotions during our exercise this week.

[Aliza Rizwan]

Healthcare equality has been a growing issue for everyday Americans, as the economic model in America has changed. Traditional racism (i.e. race, gender and sexuality) has evolved into economic racism and institutionalize by political pressure. The insurance industry represent a large part of the economy and to challenge it would not only risk the anger of the insurance industry, but to deal with the economic challenges that arises when a large industry undergoes drastic change. Economic racism arises where certain offerings are only offered to folks who show the economic ability to pay for the service. We may have had that awkward conversation when we visit a provider’s ER where they ask you about your insurance info and see the reaction of the staff at the provider. As healthcare costs continue to escalate, the patterns of segregation that we’ve seen in urban environments will replicate in the healthcare environment, unless we as a society make concrete effort to develop natural pricing pressures downward by providing pricing transparency and competition.

[Deya Obaidat]

It is of nature that human-beings tend to notice something different about others, whether it is where they are coming from, their accent,their religion, their body shape, their gender or their race as well as mostly everything I can think of, even it can go as silly as their favorite movie, however most of these differences influence our lives in a positive way, as with diversity comes different perspectives and different perspectives make life worth living as there is something new everyday that you look forward to discover everyday, whether it is a culture, a religion or even as simple as new food from a different place. Diversity is a blessing that we under-appreciate in our communities.

But as all things are, there is no good without evil, as most of us thinks about some of these differences as something of inferiority as we do view some people as lesser than us due to certain differences, which we are all guilty of at some point of our lives, as we were young and thinking that the way we are raised is the best way and the only way of doing things, we didn’t have much acceptance to who is “different”, because we grew up in a community where we are right and everyone who thinks otherwise or different is wrong. At this week session we had to play a game called “cross the line”, where he we had to stand behind the line and couple of questions were asked about some acts in the past that you if you have treated people in a different way just because they were different you had to cross the line, and I kept seeing myself crossing the line in every single question that was asked, I was guilty of it as much as I was a victim, and I didn’t like this at all, looking at my past and what I have done at some point of my life (despite me not noticing that at that time) made me feel regret to my actions and my thoughts in the past. Years have come after those acts, and I feel myself now a different person, someone who is more accepting to others who are different, not even that but I also embrace diversity today, something that I’m proud of today.

In this weeks topic we had to read an article and watch a video. I really appreciated the article when it came to the levels or racism and the way that they classified racism depending on who is guilty of it, in the first type they talked about Institutionalized racism, where the system is based to prefer some people over others, personally mediated where most of us think of when we hear about the word racism, and the last type was Internalized Racism where they defined it as the acceptance of negative stigma just because you belong to a certain race which is something I’ve never thought about when I thought about the concept of racism, however I felt that this type is extremely relevant in our society.

It is sad to think that in the 21st century and in a country that was built on diversity and welcoming others, we are still seeing some form of racism in our daily lives, what makes it even more sad that we are all guilty of it. It is really hard to change what is a human nature, specially if you try to change everyone at once, I don’t think that there is going to be a solution in the near future that will eliminate racism from America, and with that it seems that the only level of racism that we can control as human beings is the Internalized Racism, where it is time to believe that society doesn’t set who you are and what you should do, on the contrary, you should be proud of how different you are and try to show the community of what are you capable of doing.

[Salina Faidhalla]

this week we had a different SDH activity, was more eye opening and beneficial than the routine discussion that we usually had.
we did do an exercise that made us all second think our own past actions and reflect them on our daily practice, racism and inequality are global issues that now a days are still very much present just like they were decades ago maybe just disguised.
as physicians we should always remember the nature of our job and that regardless of the patient race, color, religion, sexual orientation or belief we are there to offer the best health care and support for them.
I hope one day this world can see beyond the outside.

[Leslie Kao]

Healthcare inequality in the US is as rampant as ever. The US one of the highest maternal mortality rates of first world nations. However, even within the US it is stratified with states like California with generous pre-natal care and interventions ranking alongside Scandinavia in maternal mortality rates and places like Texas with no expansion of Medicaide with maternal mortality rates that rank alongside third world countries. What strikes me in this difference is the pure heartlessness of the policies in places like Texas or other similar states that did not expand Medicaide when offered the opportunity by the ACA. These policies are systemically keeping a portion of our population suppressed by poor health and poor opportunities. As individual healthcare providers we can try to do our best to row against the tide and provide the best care that we can. If any of us find ourselves practicing in severely underserved areas like the poor South, I hope that we fight against the inmorality of these states’ policies.

[brandon twardy]

The video reveals the affect that prejudice has on health care directly and indirectly. Discrimination it self plays a toll on each individual creating adverse outcomes such as premature births as exemplified by the video. As physicians it is important that we treat all patients similarly, regardless of their differences, to prevent these adverse outcomes. At the same time we should also be advocating against prejudice with in our community to promote policy changes and increase access to health care where needed.

[Dana Kabbani]

I had a black patient tell me this week in clinic to please treat him like I would treat my husband, brother, or father, because of the negative experiences he has had with white physicians in the past. I explained to my patient that this exact topic of conversation was one that occurs daily in my household because my husband is black, and while I can never relate to what he directly goes through on a daily basis, I promised him that I would treat him better than that. This subsequently helped my patient feel more at ease, and I was able to obtain a thorough history and began to build a patient-doctor relationship. It is our duty to be patient advocates and to give every patient that we treat not only our best treatment, but equal treatment, and rid ourselves of social biases that do impact patient care. Premium health care is a basic human right that every person is entitled to. Examples of this are the Texan federal judge who struck down Obamacare; this will now go to the Supreme Court for further decision. This was a particularly upsetting decision that if proceeds, will impact so many patients, including the ones we care for on a daily basis.

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