On Christmas Day, an article was published in JAMA that confirmed what many of us had suspected for a long time. When hospitals are penalized for high 30-day readmission rates,...
We are the stewards of our nation’s journey toward equality. The journey was charted in the Constitution by our country’s founding fathers. The journey has been continued by each generation of Americans. It has been steered by the Supreme Court’s interpretation of the constitution and by legislation enacted by Congress. We are closer to achieving equality now than we were in 1950, in an era of segregation. In 1950, we were closer than we were in 1900, in an era when women could not vote. In 1900, we were closer than we were in 1850, in an era of slavery. And I have no doubt that in 2050, we will be closer to equality than we are today.
But this journey is one that requires every American to be an active participant – achieving equality is not a spectator event. Our nation’s hospitals play an integral role in the journey toward equality. Although we are not there yet, we have come a long way in a short time. In 1959, Dr. Paul Cornely did a survey of segregation in our nation’s health system. In the North, 17% of hospitals were segregated. In the South, 94% were segregated – in 33%, African Americans were not admitted at all; in 50%, patients were racially segregated in different wards; and in the rest, there were other degrees of segregation. Nationwide, less than 10% of hospitals accepted African American interns or residents and 58% of medical schools did not admit African American students.
Two key laws virtually eliminated hospital desegregation almost overnight: the Civil Rights Act of 1964 and the Medicare Act of 1965. In less than 4 months, one thousand U.S. hospitals became desegregated. If hospitals did not comply, they were not eligible to receive Federal funds. These two pieces of legislation directly addressed explicit bias in medicine. But today, we more commonly face implicit bias, when we are not even aware of it. Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner. It was partially out of concern about implicit bias that led us to give our three daughters relatively androgynous first names, so that they would be less likely to be discriminated on with job applications. Some of the common areas of implicit bias include:
- Socio-economic status
- Mental illness
- Brain-injured patients
- Intravenous drug users
In our hospitals, the next step in our journey toward equality is to address this implicit bias. In many ways, this is a lot harder than addressing explicit bias. Most people have some degree of implicit bias and do not even realize it. However, there are a number of things that we can do:
- Increase awareness of implicit bias. The reality is that everyone has some implicit biases, it is the way that the human brain is wired. It is incumbent on us to recognize our own implicit biases so that we can improve our self-awareness of how this may inadvertently affect our decision making.
- Maintain a robust human resources department. You have to be able to investigate report of subtle or overt discrimination in order to prevent explicit bias from poisoning the workplace. This is harder to do with implicit bias but a good human resources office can help you considerably.
- Critically examine who gets promoted in the hospital. In the United States, we have approximately 3.9 million nurses. Of those, 90% are women and 10% are men. However, women make up 73% of healthcare managers and men make up 27%. So, does that mean that we are promoting too many male nurses into management positions or does it mean that too few men are going into nursing? In other words, should the percentage of managers mirror the demographics of the employees that they manage or should it mirror the demographics of the population in general? If opportunities are equal, then managers should be reflective of the employees that they manage.
- Avoid cognitive overload in the hospital. When our brains are overtaxed, we tend to revert to framing information in stereotypes. Cognitive overload can be created by inadequate staffing, productivity pressures, inadequate training, information overload, inadequate sleep, overcrowding, and high noise levels.
- Promote understanding of of the cultures of your patient populations. Much of implicit bias arises from the stereotypes created by an absence of knowledge about or understanding of those cultural difference between ourselves and others.
- Continuously reinforce staff education about implicit bias. Case studies and videos are a great way of reminding staff of the common situations that implicit bias occurs. For example, two 25-year old men are brought into the emergency department stuporous and hypoventilating. One is African American and one is Caucasian. You have 1 dose of Narcan in your emergency department – which one do you give it to? If your first thought is to give it to the African American man, then you could have implicit bias about race and use of IV street drugs. In reality, in Ohio, 89% of people who die of opioid overdose are white.
- Establish outcome monitoring. In your hospital, does patient gender affect the decision of whether or not a patient gets a joint replacement? Does patient race affect how frequently screening colonoscopy is recommended? Does the insurance payor (Medicaid versus commercial) affect who gets flu shots? An effective electronic medical record can make monitoring patient populations for patterns of implicit bias much easier.
- Institute “Implicit Bias Rounds” in resident and medical student education. Morbidity and Mortality Conference has been a mainstay in doing a post-mortum examination of the factors that led to a patient’s death. Perhaps every residency program should have a regular “Morbidity and Implicit Bias Conference” as part of morning report 2 or 3 times a year to examine for any given patient what elements of implicit bias led to the patient’s illness or injury.
- Ensure that diversity in search committees for leadership positions. Part of implicit bias is the subconscious tendency to gravitate to those who we perceive as being similar to ourselves. If you are putting together a search committee for a department chairman and it is composed of a bunch of other chairmen who are all white men, then you are setting yourself up for group implicit bias.
Explicit bias and implicit bias are both bias. Explicit bias is usually easier to identify and easier to eliminate via rules and laws. Implicit bias is a lot more subtle and can’t be eliminated overnight as was done the the Civil Rights Act and the Medicare Act. Instead, elimination of implicit bias requires education and a change in healthcare culture. But as with all things, culture trumps policy and that change in culture will be what gets us farther along in our journey toward equality.
August 21, 2017