Continuing Education Activity

America is becoming increasingly diverse. Discrimination against minority groups persists and contributes to negative disparate outcomes for patients and healthcare professionals. Healthcare professionals have a responsibility to address inequity in the medical system. This activity defines the terms “diversity” and “discrimination” and highlights the interprofessional team's role in improving care for patients from diverse backgrounds.

Objectives:

• Define the terms “diversity” and “discrimination” and discuss their implications in healthcare.
• Explain the different levels on which bias and discrimination occur.
• Summarize relationships between bias and negative patient outcomes.
• Outline actions that healthcare systems can take to increase diversity and reduce disparities.

Introduction

Diversity is broadly defined as the inclusion of varied attributes or characteristics.  In the medical community, diversity often refers to the inclusion of healthcare professionals, trainees, educators, researchers, and patients of varied race, ethnicity, gender, disability, social class, socioeconomic status, sexual orientation, gender identity, primary spoken language, and geographic region.

Discrimination in the healthcare setting can be defined as negative actions or lack of consideration given to an individual or group that occurs because of a preconceived and unjustified opinion. It is worth noting that individuals do not need to be members of an unfairly treated group to experience discrimination against that group. Discrimination can occur based upon perceived membership.  Furthermore, harm does not need to occur for discrimination to exist. A group may be discriminated against if they receive something of less value than another group solely because of their race, ethnicity, gender, disability, social class, socioeconomic status, sexual orientation, gender identity, primary spoken language, or location of residence.

While people can be discriminated against for various reasons, this article focuses mainly on gender, ethnicity, and race-based discrimination in the healthcare setting, not because these are the most important, but because these areas are best represented in the literature. We hope that the next version of this article will include more information on discrimination involving other underrepresented and marginalized groups.[1]

Issues of Concern

The two main types of discriminatory acts or comments are macroaggressions and microaggressions. Macroaggressions are more overt and radical forms of racism rooted in a society or within a system. Examples of macroaggressions are the forced relocation of Japanese-Americans into internment camps during World War II, laws preventing equal suffrage rights for women, and the Tuskegee study in which Black men were intentionally misled and denied standard of care treatment for syphilis.

Laws such as Title VII of the Civil Rights Act and the Americans with Disabilities Act prohibiting unequal treatment based on race, sex, and disability have decreased overt racism in the healthcare setting. In areas where overt racism has declined, awareness of microaggressions has increased. Microaggression can be defined as short, everyday insults or snubs that can be barely perceptible or difficult to define but convey a negative message to a person because of their affiliation with a marginalized group.[2] Microaggressions can be unintentional and rooted in unconscious bias.[3][4] They can be difficult to identify, easily concealed, and delivered involuntarily through verbal or non-verbal communication.[4][5] Microaggressions are often delivered during one-on-one interactions, whereas macroaggressions are typically rooted in systems.[3] 

Despite the insidious nature of microaggressions, they have clearly perceptible negative impacts upon the oppressed's quality of life.[6] Increased exposure to microaggressions is associated with an increased likelihood that an individual will feel discriminated against. Microaggressions may damage the oppressed's mental health, causing lower self-esteem, poorer self-care, and increasing susceptibility to substance abuse, depression, suicidal ideation, and anxiety.[7][8][6][9][10] There is growing evidence that regular exposure to microaggressions is associated with a higher incidence of hypertension, increased frequency of hospital admission, and more severe diabetes-specific distress.[10][11]

The killing of George Floyd in conjunction with the disproportionate burden of COVID-19 in communities of color has elevated the national consciousness regarding diversity and discrimination. Americans are becoming more aware that structural racism is causing healthcare disparities.[12] Research is being produced that shows that discrimination and bias exacerbate current healthcare disparities and create new ones.[13] As a result, the national conversation surrounding racism has resulted in the recognition of racism as a public health crisis.[14] As the national discussion surrounding diversity, discrimination, and structural racism continues, a number of matters have been brought to the forefront. They include:

 An Increasingly Multicultural Society Requires a More Diverse Workforce

As our country's racial and ethnic diversity continues to increase, there is a greater need to diversify our healthcare workforce. Unfortunately, the physician workforce's diversification is occurring at a slower rate than that of the general population.[15] The Flexner report significantly slowed the inclusion of Black physicians in the American medical system.[16][17] In 1910, Abraham Flexner (at the Carnegie foundation's direction) undertook a review of the American medical education system. Flexner concluded that medical education within African American schools was deficient.[18] He prescribed a limited role for black physicians in the medical community and hinted that black physicians possessed less potential and ability than their white counterparts.[18] The result of this characterization was the closure of five of seven African American medical schools. The impact is still felt today.

The Progression from Individual Racism to Structural Racism

Racism is a social construct that emphasizes phenotype. According to the National Museum of African American History & Culture, there is individual racism, interpersonal racism, institutional racism, and structural racism. Individual racism is most directly related to the biases which we hold, and interpersonal racism is an expression of these biases between individuals. Institutional racism is reflected in the policies and procedures of an organization. Structural racism is the cumulative effect of these forces across systems and between institutions or organizations. The promotion of health equity and a decrease in health disparities requires addressing individual and interpersonal racism and dismantling institutional and structural racism.[19][20]

Bias, Stereotype Threat and Negative Outcomes

There is increasing awareness in the United States that implicit bias leads to poorer healthcare outcomes for patients of color.[21] It is also becoming clearer that racist behavior negatively impacts patient wellbeing. Stereotype threat is a psychological state in which a person has impaired performance because of their fear of fulfilling negative stereotypes. It is hypothesized that stereotype threat impairs minority performance in college, on the Medical College Admission Test, and on the United States Medical Licensing Examination.[22] Stereotype threat has also been found to cause psychological harm in students and trainees of color.[23]

Clinical Significance

Individual racism is a personal belief in the superiority of one’s race over another. It may result in discriminatory behavior, which is a reflection of both implicit and explicit bias. Historically, racist beliefs regarding biological differences between Blacks and Whites were used to justify slavery and medical experimentation on men and women of color. Unfortunately, the legacy of this false belief in fundamental and innate biological differences between Blacks and Whites is still present in medical practice, leading to health disparities such as the undertreatment of pain in Black patients. A research study published in the Proceedings of the National Academy of Sciences of the United States of America demonstrates the connection between false beliefs about biological differences between Blacks and Whites and racial bias in pain assessment and treatment recommendations.[21] In this two-part study, medical students and residents endorsed beliefs of biological differences between Blacks and Whites. These beliefs included that Blacks’ nerve endings are less sensitive than Whites’ and that Blacks’ skin is thicker than Whites’. Furthermore, medical students and residents who held these beliefs rated Blacks’ pain lower than Whites’ and therefore made less accurate treatment recommendations.[21]

Structural racism is rooted in societal, historical, and cultural norms that support racial group inequality.  As an institution, medicine has adopted and implemented practices and policies that promote structural racism. Race-adjusted algorithms are based on the historic racist belief that Blacks are physiologically different.  For instance, “race corrected” estimated glomerular filtration rate measurements are based on the unscientifically supported belief that Blacks are more muscular and have higher creatinine levels. Consequently, this may result in a higher reported estimated glomerular filtration rate, which is interpreted as the better renal function for anyone identified as Black.[24] This may lead to delays in diagnosing renal disease and reduce access to transplantation.[25]

At a systems level, the failure to identify the health implications of racism and access to care may result in developing a structurally racist system that promotes health disparities. For example, an algorithmic bias was identified in a medical artificial intelligence program that took into account past healthcare costs when predicting clinical risk.[24] Consequently, due to White patients having greater health care expenditures than Black patients, they were determined to have higher risk scores than Black patients. These scores may have led to more referrals for white patients to specialty services, perpetuating both spending discrepancies and race bias in health care.[24]

Other Issues

Diversity Education

This section is intended primarily for health professions educators.  However, all HCPs can use it for peer and self-education.

Diversity Education Preface

The Liaison Committee on Medical Education and the Commission on Osteopathic College Accreditation require medical schools to promote diversity and prohibit discrimination.

However, researchers have yet to confirm whether such actions affect health outcomes. A search in PubMed for studies of health professions diversity education did not yield studies large enough to have generalizable results about the effectiveness of one educational strategy over another on health outcomes.   An intermediate step before modifying healthcare outcomes is raising HCP’s awareness of bias to modify their perceptions and behaviors; research in this area is abundant and is described below.  

Valuing cultures other than one’s own involves a willingness to learn and self-reflect in an ongoing manner.  For this reason, when discussing the ability of diversity education to change persons’ perceptions and behaviors, the terms “cultural humility,” “cultural awareness,” and “cultural sensitivity” are more appropriate than “cultural competency,” as “competency” implies having attained a finite body of knowledge.[26]

Diversity Education Technique

Culturally sensitive diversity education emphasizes that HCPs should consider patients in their unique individual contexts and remember that a situation may be experienced differently by different patients.  “It is (an individual’s) health views, needs, and experiences that matter when making an informed decision, not a patient's ethnicity, race, or social status.”[27] A critical skill for all HCPs is to understand patients not by employing any particular label but instead by employing an attitude of curiosity about how each patient’s experiences and context will shape their views and behaviors.  Developing an HCP’s critical consciousness, defined as a reflective “awareness of the self, others, and the world and a commitment to addressing issues of societal relevance in health care,” is believed to be a more effective approach to diversity education than teaching facts or even emphasizing the use of an individualized approach to patient care.[28] HCPs should also undergo training in recognizing their own implicit biases and biases of the institutions and systems in which they work.[29]

Recent review articles contain general guidance and practical examples for educators:

• In 2007, Smith et al. developed recommendations for curricula on health disparities and suggested that the broad goal of such curricula should be to eliminate health disparities.[30]
• In 2016, Dogra et al. published a curriculum guide and reviewed examples of diversity education. They recommended integrating diversity education throughout the curriculum and highlighted the importance of self-reflection in learning and teaching diversity-related concepts.[29]
• In 2020, Brottman et al. reviewed models of diversity education for trainees and/or practitioners in medicine, nursing, pharmacy, dentistry, physical and occupational therapy, public health, audiology, and social work. The interventions studied ranged from 20 minutes to hundreds of hours and included immersion experiences, simulation, discussion, lecture, reflection, educational technology, case-based learning, essays, presentations, readings, and videos.  This extensive review determined insufficient evidence to recommend any particular format as a best practice for diversity education.[31]

Despite the lack of large-scale evidence for best practices, many smaller studies focused on particular target populations or particular interventions.  There is some evidence for gains in learners’ knowledge, skills, and attitudes with multimodal, active learning formats, for example, a combination of faculty role modeling, interprofessional rounds, and Objective Structured Clinical Examinations.[32] Lectures can be useful but have potential pitfalls and “should be followed by hands-on practice with feedback and formative evaluation."[30] The discussion format is likely more effective than lectures alone to help learners explore and develop their attitudes on cultural issues.[30]

When diversity education is integrated longitudinally throughout a curriculum, appointing someone to oversee all curricular modules can maximize cohesion and minimize redundancy.[29] Smith et al. proposed that a curriculum committee not assign all teaching roles to minority faculty persons because that arrangement can imply that issues related to discrimination are only a problem for minorities to handle rather than the responsibility of all HCPs.[30]

Diversity education is a unique curricular topic. All healthcare team members (e.g., nurse, physician, pharmacist, social worker) at all expertise levels (from trainee to experienced practitioner) require the same skill set.  This may lend itself well to its use in interprofessional settings in which learners of different disciplines learn with and/or from each other.

Diversity Education Pitfalls

HCPs have made many false assumptions about the relationship between cultural variables and medical outcomes, unnecessarily reinforcing negative stereotypes.  Teaching “typical” characteristics of minority groups frequently promote stigmatization without promoting healthcare outcome improvements.  This approach makes culture a “proxy” that prevents HCPs “from noting the person behind the patient.”[27] Categorizing patients according to cultural characteristics assumes that culture and how culture impacts persons’ responses are fixed.  HCPs should instead realize that patients have dynamic views that vary according to their immediate contexts and recognize that cultures (e.g., gender, age, class, disability, sexuality, race, ethnicity) are multifaceted.[29]

Faculty preparation is essential for diversity education; well-intentioned but unprepared educators can inadvertently promote students' and patients' stereotyping.[33] Microaggressions embedded in curricular content create an “unsafe climate for cultural minority students.”[34] Emphasizing minority patient characteristics as inconsistent with the privileged majority’s norm marginalizes minority patients and paints them as a "problematic other."[35][27]

Finally, educators should realize that they are continually teaching a curriculum, either implicitly or explicitly.   Whereas the “planned curriculum” describes what educators perceive, the “experienced curriculum” describes what students perceive.[29] What educators teach students unintentionally is the “hidden curriculum,” which is also described as “a set of influences that function at the level of organizational structure and culture.”[36] The hidden curriculum can have positive effects, such as when an educator role models cultural humility.[34] The hidden curriculum can also have negative effects, such as using clinical vignettes that promote stereotypes, undermining cultural sensitivity training in other parts of the curriculum.[33] Also, a lack of diversity among faculty or institutional leaders can teach through the hidden curriculum that minorities do not have a role in those career positions.[29]

Diversity Education Summary

Diversity education is not a time-bound goal; it is an ongoing journey. It should provide learners with “the opportunity to become actively engaged in fostering a level of critical awareness of the health care provider's position of power and privilege in society.”[35] Inclusiveness in a curriculum does not involve adding a few learning activities to the existing curriculum: it involves a culture shift.[34]

Enhancing Healthcare Team Outcomes

The fact that this article's title is Diversity and Discrimination suggests there is a link between these two.  It is hypothesized that an inverse relationship exists between discrimination and diversity.  It has been a prevailing thought within the medical community that discrimination would decrease and equity would increase if the percentage of underrepresented minorities reached a critical mass. Evidence suggests that although diversity is a goal unto itself, diversity alone does not create equity.  More than half the pediatricians and gynecologists in the United States are now female, yet department leaders remain predominantly male.[37][3] Men are more likely to be selected for editorial board membership and achieve status as an associate or full professor, department chair, or medical school dean.[38][37] Men also earn more at each academic rank.[37] 

These results are similarly found in the nursing profession. The male advantage in nursing has been described as a “glass escalator,” in which men are put on a fast track and almost pushed to achieve positions that include greater responsibility, higher salary, and more organizational benefits.[39] Thus, while diversity is necessary and important, it is equity that is needed to decrease disparities and mitigate the impact of discrimination. 

While an increase in diversity may not eliminate all problems related to healthcare disparities and discrimination, we strongly encourage healthcare systems to take steps to promote diversity amongst providers.  A larger talent pool that includes providers with heterogeneous customs, experiences, and problem-solving tactics, can create more innovative approaches to systems-based problems.[38] Individuals within a group may best solve healthcare issues that are more prevalent within that group. Diverse viewpoints enhance patient care and clinical research design by better incorporating individual patient perspectives, which may lead to the development of improved inclusiveness strategies.  In particular, research into healthcare disparities is likely to benefit from increased diversity amongst researcher staff.

Numerous studies have shown that increased provider diversity is associated with improved healthcare quality. Concordant care, defined as a patient and provider sharing a common attribute such as race, ethnicity, or gender, has been associated with improved quality of care.[38] Race-concordant patient-physician relationships are associated with improved communication, longer patient visits, greater medication adherence, and higher patient satisfaction scores.[40][38][41] Language and gender concordant patient-physician relationships have similarly been associated with improved home medication compliance and outcomes.[40][42] Such results suggest that patient-physician concordance may facilitate communication and trust.

Poor access to quality care continues to impact minority and low-income individuals in the United States disproportionately.  Recruitment and retention of providers who are underrepresented in medicine is one potential solution.  Underrepresented minority physicians are more likely to serve in areas with a physician-shortage and serve underserved groups, including minorities, low-income individuals, and the uninsured.[43][44][45]

We urge healthcare groups and systems to consider the following actions to improve the recruitment and retention of employees from underrepresented groups:

1. Eliminate financial barriers to higher education for socioeconomically disadvantaged groups via the development of scholarships, grants, and tuition assistance.
2. Create mentorship and pipeline programs to increase the number of underrepresented minorities in healthcare careers. When possible, these mentorship pairings should be race and gender concordant.
3. Offer opportunities for coaching and leadership training for HCPs from underrepresented groups.
4. Use transparent processes to select committee members and leaders with diverse backgrounds and viewpoints.
5. Provide pay transparency and freely accessible objective steps for promotion and salary increase.

We urge healthcare groups and systems to consider the following actions to quell discrimination and accelerate the remedy of healthcare disparities:

1. Acknowledge that past discrimination and current implicit biases lead to inequities related to race, gender, ethnicity, sexual orientation, and disability that still exist in the healthcare setting. Denying that discrimination and bias exist limits progress.
2. Educate HCPs on the impact of health disparities and structural racism on patient outcomes. Equip healthcare trainees and practitioners with tools and resources to confront macroaggressions and microaggressions.
3. Create a zero-tolerance policy for harassment and discrimination that includes a safe reporting mechanism for both the victim and the reporter.
4. Increase support for healthcare disparities research.

Review Questions

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• Comment on this article.

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Disclosure: Brandon Togioka declares no relevant financial relationships with ineligible companies.

Disclosure: Derick Duvivier declares no relevant financial relationships with ineligible companies.

Disclosure: Emily Young declares no relevant financial relationships with ineligible companies.