MDAdvisor Spring 2023

Since the COVID-19 pandemic, many Americans have been, understandably, feeling isolated and concerned about their health, their families, their jobs and their future. During this stressful time, people have shown a strong tendency to share their views, news, fears and concerns with those around them. However, there is now a subset of people who are feeling more empowered to share something else: ideologies that include racism, sexism and xenophobia. This is happening in all environments, and certainly has been noticed within medical practices, emergency departments, hospitals and other healthcare facilities. As a result, there has been a documented uptick in violence against medical professionals.¹

One way to combat this trend is through education on the topics of diversity, equity and inclusion (DEI). These are not just buzzwords. Recent social justice movements such as Black Lives Matter, Stop AAPI Hate and #MeToo have highlighted the need for improvements within organizations’ cultures and hiring practices. While DEI initiatives in the workplace have existed since the 1960s, there has been a rapid expansion of organizations creating DEI offices, equity officers and other formal improvement programs since the pandemic. In fact, between May and September 2020, the number of DEI-related job openings increased by 123 percent.² In the healthcare industry, we are seeing a similar movement to address DEI. Academic medicine programs are creating equity and diversity commissions, and hospitals are assembling committees and focus groups. However, not every medical practice has the adequate resources and staffing to create a commission to examine the environment and identify strategies for improvement. This article focuses on a more individualized approach, asking: What can we do as individuals to address these concerns as we go forward?

Diversity

Diversity is a term we often hear, but what does it really mean? Certainly, diversity does not reflect only the color of one’s skin or one’s cultural background; it also encompasses many other types of differences that physicians need to think about. It is helpful to consciously take a step back and appreciate what types of diversity are most prevalent in your practice. Factors of diversity can include culture, gender, religious belief, sexual orientation, socioeconomic status and educational or intellectual differences.

Equity

The Robert Wood Johnson Foundation provides the following definition of equity: “Health equity means that everyone has a fair and just opportunity to be as healthy as possible. This requires removing obstacles to health such as poverty, discrimination, and their consequences, including powerlessness and lack of access to good jobs with fair pay, quality education and housing, safe environments, and health care.”³

During the COVID-19 pandemic, we saw the impact that disparate healthcare and socioeconomics can have on people. The COVID-19 epidemic affected everyone, but the disease was particularly harmful to people of color and other vulnerable populations, especially those living in dense urban areas who found it more difficult to practice isolation.⁴

Inclusion

The Centers for Medicaid & Medicare Services defines inclusion as “the actions taken to understand, embrace, and leverage the unique identities and perspectives of all individuals so that all feel welcomed, valued and supported.”⁵ This means giving staff members and patients from all backgrounds a voice in providing and receiving high-quality care. The move to become more inclusive has been around for many years in the United States, but now there appears to be a change in the way people perceive it. Some of this is generational and reflects how the world is changing in terms of access. While it is common to talk about racial inclusion because it has been at the forefront of American discourse since the civil rights movement, gender, sexual orientation and ability inclusion are equally important. 

Bias in the Medical Practice

Bias is a prejudice in favor of or against a person or group compared with another, usually in a way that is considered to be unfair. Bias in the workplace typically comes down to unfair exclusion. The most obvious biases are gender bias and racial bias. However, biases may exist toward any social group. One’s age, gender identity, physical abilities, religion, sexual orientation, weight and many other characteristics are also subject to bias. It’s important to take the time to ask ourselves, How might I be excluding someone because of their differences?

Unconscious bias (also known as implicit bias) involves associations outside conscious awareness that lead to a negative evaluation of a person on the basis of irrelevant characteristics such as race or gender.⁶ Everyone holds unconscious beliefs about various social and identity groups, and these biases stem from one’s tendency to organize social worlds by categories.

Think carefully about how you might unintentionally treat different people in different ways and have a plan in place to correct any signs of bias. For example, we are now seeing more nonbinary individuals who may use the gender-neutral pronouns they and them. Many of those individuals find it offensive if you refer to them as she or he. They have taken the position that they have a nonbinary gender and should not be confounded by gender-specific pronouns. This becomes particularly significant in medicine because there often are anatomical issues to consider. If your patient is someone whose assigned gender at birth was male, but that person now identifies as female or nonbinary, you may still have to talk to them about issues with their male anatomy.

Many of us think, I’m not racist, or I’m not sexist, or I’m not homophobic. But maybe if you stop to think about it, you may realize that you tend to favor people who are like you. Affinity bias is the tendency to favor people who share similar interests, backgrounds and experiences with us. We tend to feel more comfortable around people who are like us. Some examples of affinity bias in the workplace include actions such as the following:

• Hiring candidates who are not the most qualified for a given role
• Passing over deserving people for promotions
• Dismissing new or different ideas

It is natural to be drawn to people who are like you. Within every county, and even within states and local towns, similar populations tend to stick together. So it is important to consider how affinity bias may play a role in your everyday treatment of your staff, your patients and your hiring practices. If you are practicing in an area that has a particular patient population based on culture or religious affinity or affiliation, it serves you and your patient community to try to understand some of those cultural nuances. You might also think about the specific traits you look for when interviewing people and how affinity bias may play a role.

Conformity bias is a less-obvious type of unconscious bias that refers to our tendency to take cues for proper behavior from the actions of others rather than exercise our own independent judgment. Conformity bias may occur when we try to fit into particular professional or social environments. Conformity bias shows up in school-age children as peer pressure. As adults, it is less about someone guilting or pressuring us into doing something. Rather, it is more subtle. We become so accustomed to staying within our circles of comfort that often we do not seek out new experiences or people with different experiences.

The halo effect occurs when one trait is used to make an overall judgement of a person or thing. For example, some people will look at a person with an Ivy League education and automatically put them on a high pedestal. In contrast, the horns effect is a form of bias that causes one’s perception of another to be unduly influenced by a single negative trait. For example, people who are short in stature or overweight are often at a disadvantage when it comes to employment and hiring, even though their size may not have anything to do with their ability to perform the job—and may even be out of their control.

Addressing Explicit Discrimination and Inappropriate Behavior in Your Practice

Unfortunately, while Chinese people weren’t responsible for the coronavirus pandemic simply because cases were reported there first, derogatory references to the Asian population became frequent during the pandemic, particularly on the Internet. Some even went so far as to suggest that China should apologize for the coronavirus.⁷ While it might be tempting to shake off these statements as simply ignorant, racist and xenophobic, words have real-world, negative effects. Racist jokes can quickly become racist rants, and those rants can turn into violence. It is up to all of us in the medical community, and as human beings, to make it clear that we are not okay with any form of discriminatory language or behavior.  

In response to discriminatory statements or actions, remember the following four-step process of interrupting, questioning, educating and echoing.

Interrupting means taking a time out. It shows the person who is communicating with you that what they have said has impacted you and is important enough to pause your conversation to address it. You might say something like, Hang on. I want to go back to what you just said about the virus.

Questioning means following up with additional questions for your staff member or patient.  You might ask, Why did you call it the Chinese coronavirus?

Educating means continuing the conversation by keeping your colleague, employee or patient talking about the issue. The goal is not to just provide facts about a topic that they already have a specific opinion on, but rather to explain why what they have said needs rethinking. Physicians are very adept at opening a dialogue and educating their patients about why change is necessary. That is something physicians have in their skillset already. The person to whom you are speaking may have very different views than you. The trick is to not close the dialogue.

Echoing means repeating and supporting another person who speaks up against biased ideas and language. When someone else speaks up, you echo them. If someone says, “I don’t like to be called hon,” you might say, “You know what? I’m hearing you. I see how that may be uncomfortable. I won’t call you hon anymore.” You let them know you’re hearing them because this not only encourages more speaking up, it also indicates that no one thinks your silence in response to the biased ideas or language or lack of inclusion means you are okay with it. 

Addressing Your Own Workplace Environment and Culture

Healthcare leaders have a responsibility to improve diversity and inclusion for patients and staff members. In addition to internal training and discussions with staff members, medical practices should strive to hire and retain a workforce representing the patient populations they serve. Of course, the goal is not to hire based on diversity in and of itself, but to look at factors such as gender and race and think about why they may be underrepresented among your healthcare providers and employees.

There are also ways you can promote diversity or gain a better understanding of different populations that go beyond hiring. Mentoring someone who is outside your comfort circle is a good way to expand your workplace culture by creating opportunities for others who may not have the advantages that you do. Volunteering at different organizations to enrich your world view can also make you a better practitioner. Many patients feel an affinity or an appreciation toward physicians who understand the cultural implications of why they are seeking healthcare or why they are not seeking healthcare for a particular condition.

Employee compensation, too, often is entangled in issues of diversity and bias. The 9th Circuit has made changes (that were adopted in part by the Supreme Court) regarding what questions can be asked in an interview.⁸ You are not permitted to ask someone how much they made at their last job. This is because if a woman or a minority was paid less than other employees doing the same job at their last place of employment, they will likely continue to be paid less at every subsequent job if they are required to reveal their salary. A helpful exercise for employers is to review salaries and look for patterns as to why a particular group makes more money than others. As a business owner who is trying to maximize your profits, you may think, If someone doesn’t ask for more money, why would I give it to them? But this kind of thinking perpetuates this problem. Consider that if even if someone does not ask for the level of compensation they are entitled to, it is your obligation to inform them.

Additionally, think about the language you use at work. Be mindful of the types of words and phrases that you may think are funny or amusing but really can lead to a toxic work environment or a sexual harassment suit. The world has changed; gone are the days of people shrugging off insensitive, hurtful or biased comments. We need to realize that any terms that group people together or diminish their individuality are hurtful. Even comments intended to be compliments can be taken the wrong way (i.e. For your age, you are quite fit). And it’s important to keep in mind that it is very easy these days for people to take out their phones and record your words. Although sometimes it is difficult to put ourselves in the shoes of individuals who may be disadvantaged or who don’t have a seat at the table, it is vital that we try to understand where people come from and why their concerns and viewpoints may be different than ours.

When it comes to addressing bias in the medical practice, self-reflection is always an important first step. Your job as a healthcare leader is to look at how you can unite people rather than divide them. Be an advocate for change and let your leadership be accountable. If you plan to make changes to address the value of diversity, inclusion and equity, whether it be in yourself or at your institution, commit to making that change. The result will be an environment of trust amongst leadership, which will encourage others to come forward and do the same.