Improving Equity of Care Through Understanding Bias

By Matt Phillion

A recent cultural sensitivity study has demonstrated a range of issues that patients with diverse backgrounds face when seeking out care. For example:

• Only 25% of Black, Indigenous, and people of color (BIPOC) respondents had seen a healthcare professional in the past year who shared their race or ethnicity, compared to 64% of White respondents
• Hispanic respondents were more likely to forgo treatment because of costs, with 33% saying they had avoided seeking care within the past two years due to cost concerns, compared to 20% of Black or White respondents

There are many reasons for this disparity in healthcare experiences, but it starts with social determinants of health, says Dr. Soo Rhee, vice president of medical board-certified solutions for Healthgrades and a board-certified physician in endocrinology, diabetes, and metabolism; internal medicine; and obesity medicine.

“Where a person lives, their occupation, their education, the available resources, all of this plays a large role in your healthcare,” says Rhee. This can impact the basics of living and lead to health challenges, she notes: Do patients have access to a grocery store? Do they have access to air conditioning in an area impacted by climate change?

“BIPOC, LGBTQIA+, other different groups can have disproportionate barriers to equity, whether it’s social, political, historical, or all of the above. It’s access to resources, living conditions, even language and cultural barriers,” says Rhee. “Much of healthcare and our wellness is who we are, where we live, how we communicate.”

There are also implicit biases, both conscious and unconscious, that can lead to disparities in treatment and patient experience, Rhee notes. “Representation is a huge factor and can be an underlying cause for different results. The lack of racial and ethnic diversity in the healthcare profession can play into these factors of cultural bias and even how we understand social determinants of health,” she says.

And on top of these social and cultural factors, we must also consider overall accessibility: the financial affordability of care, insurance coverage, and regional access to care providers.

The challenges of change

A Census Bureau survey just five years ago found that only 5.4% of physicians and 3.6% of full-time medical school students were Black, Rhee notes. Similarly, less than 10% of medical school enrollees were Hispanic.

“Considering the training cycle, those enrollees in 2018 may still be in training,” she says. And that survey just looked at physicians; the shortage of representation stretches across the entire industry.

“At the end of the day, it’s both access and the ability to support education initiatives,” says Rhee. “The type of financial, social, economic barriers that impact whether or not a person is even going to pursue a career in medicine. Will they have the opportunity to enter a career that requires so much support and investment of time, energy, and focus?”

The concept of modeling comes into play as well. If someone does not see a person like themselves in a career, they may not consider that career possible.

“It’s not just an identification issue, but also an inspiration issue. If you think there’s a problem that you can be the solution to, that’s a different path forward than a system where you feel overwhelmed and blocked by that system,” says Rhee.

If more representation is key, but the pipeline from school to working in the field requires many years of training, what can we do in the meantime to combat inequity in healthcare?

“Concordance—“I am X type of person and I have an X provider”—is one goal, but cultural competency can bridge that gap,” says Rhee. “Providing interpreter services, both in person and online, offering patient materials and community outreach; there are many ways to enter into and even address the issues that a lack of concordance shows.”

Even if we can’t solve the concordance gap, Rhee says, it is possible to meet people where they are and make meaningful connections that strengthen the patient-provider bond. “If I can be curious and open and educate myself as a provider, hopefully I can close that gap,” she says.

Closing that gap takes effort, though, Rhee says. A recent study found that providers learning about how to best serve the LGBTQIA+ community require only a couple hours of curriculum but at least 30 hours of field experience. The same can be said about serving communities of color.

Concordance also may not necessarily be the main issue at hand, Rhee explains. “The physician and patient may not share the same cultural background. They may have different upbringings. What’s important to you? What do you celebrate? These small details have a large impact on someone developing trust with their provider and their health system,” she says.

That cultural understanding, even in the absence of concordance, can help improve outcomes. “People having negative outcomes when they are from a more marginalized group—there’s a type of barrier there, feeling dismissed or not seen,” says Rhee.

Hurdles to better care

As with many challenges, the first hurdle to overcome is time.

“Ironically, this kind of improvement of care, looking at the whole person, seemed to get pushed to the side during the pandemic because there was a more immediate need. There was a never-happen event happening and we had a first-responder kind of focus to keep patients physically safe,” says Rhee. “There’s now more of an opportunity to look back and reflect.”

Currently, the healthcare system doesn’t always allow for adding the whole-person perspective. “There’s so much to consider: medications, side effects, how the patient is doing with their treatment, so many requirements and competition for time in such a short period,” Rhee says.

Beyond making the time for a whole-patient perspective, providers need to pause and self-reflect as well, to be self-aware of their biases or blind spots. Rhee mentions two additional studies in which 80% of the surveyed physicians felt they were competent in treating LGBTQIA+ patients, but the community scored their confidence in providers at 50%, showing a disconnect between physician confidence and community comfort.

Improving cultural competency comes from training, which also requires time. “There was a cultural competency survey of providers that found that most are interested in attending training, but most said they want to take it online so they can do it on their own time. These providers are at the mercy of their schedules,” Rhee says. “It can’t just be a provider solution. It almost has to be a requirement at the licensing level—that to remain certified, you need to take a certain amount of cultural competency courses.”

This kind of shift requires policy-level changes defining what a competent physician is. “It’s not just medical knowledge but also cultural competency as part of the definition for competent care,” says Rhee.

For that kind of change to occur, it also needs to be part of how healthcare is paid for. “Medicare is making social determinants of health a requirement for billing,” says Rhee. “If there’s a regulation, it becomes part of the requirement. If we want reform, it has to happen on the individual level, the network level, the regulatory level. At the end of the day, it’s a population health management concept that needs to happen long term.”

Many sources can lead the charge for this type of industry shift. It may start with government and policymakers as well as regulatory bodies who can address legislation and regulatory standards.

“They can say, ‘Yes, you’re assessing for preventable complications, but do you also have interpreter services, do you have community outreach, do you offer documents in different languages?’ ” says Rhee.

And the efforts shouldn’t only involve regulation. Healthcare organizations large and small need to implement training requirements, engage in community outreach, and promote diversity in leadership, Rhee says.

Medical schools have already started offering cultural competency training, but it is not yet ubiquitous across the board. “I myself had very clear cultural competency courses, and that was how I was raised as a physician,” she says. “It’s important to set the stage that competency is not just the medical science, but also [whether] I understand my patient as a person.”

Champions for change can come from every aspect of the continuum of care, however.

“It’s just so important for patients to know they have a voice, too; that they have options and can look for that care,” says Rhee. “One negative experience or a feeling of being dismissed can shape their relationship with healthcare. It’s important that we not let our past or even current obstacles deter us from advocating for ourselves, and the same goes for providers, who want to learn and care and grow. When people make it a goal for patients to be seen and heard, that will lead to meaningful change.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.