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Health Care Has a Bias Problem: Here’s How to Fix It

Bias in Medicine

Bias in medicine — based on race and sex — is a well-documented problem. It’s a problem because the health care system has historically marginalized the medical concerns of people of color and women, which has led to worse health outcomes.

On this episode of The Dose, host Shanoor Seervai discusses ways to tackle bias in health care with Ann-Gel Palermo, who works on diversity and inclusion at New York’s Icahn School of Medicine at Mount Sinai, and Joia Crear-Perry, who founded the National Birth Equity Collaborative to address racial disparities in health care.

They explain that bias is not just a concern at the individual provider level; it’s actually baked into the system, starting in medical school. While fundamental change will be an uphill battle, they say, the fight is critical to ensuring that all patients are treated fairly when they seek care.

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Show Notes
Guest: Ann-Gel Palermo
Guest: Joia Crear-Perry
Read: Closing the Medical Research Gap

Transcript

SHANOOR SEERVAI: Hi everyone, welcome to The Dose. On this episode we’re talking about a well-documented problem, bias in medicine. So a lot of you know this, but discrimination usually based on race and sex has an impact on people’s health. And my guests today have been working on this issue for several years. I have with me Ann-Gel Palermo. Ann-Gel is the associate dean for diversity and inclusion at the Mt. Sinai Medical School. She is also the chief program officer for the office for for the office of diversity and inclusion of the Mt. Sinai Health System, which has a reputation as one of the best in the country. I also have with me Joia Crear-Perry. She is the founder and president of the National Birth Equity Collaborative, an organization working to address racial disparities in health care, particularly when it comes to black women and their children.

Ann-Gel, Joia, thanks for being here.

ANN-GEL PALERMO: Thank you for having us.

JOIA CREAR-PERRY: Thank you. Thank you for having us.

SHANOOR SEERVAI: My pleasure. So let’s start by spelling out in a little more detail what is the problem? Why is bias bad for people’s health?

JOIA CREAR-PERRY: You’re the expert.

ANN-GEL PALERMO: Ah! So I think that is a wicked question to ask, right? And I think the wicked questions are the most simplest, yet have a very complex answer. And I think it’s clearly been well documented that health disparities exist, and that people of color and patient populations of color receive fewer and less access to treatments and procedures and just health care in general that would actually prevent worse health, mitigate worse health, and avoid premature death and dying, right? And so we know that, and we’re very good at documenting but we’re also not good at sort of unpacking like why this is so. And I think that in more recent times, researchers have begun to really understand, well let’s look at the individuals who are in charge of delivering care, right?

Who are responsible, who are trained to deliver patient care, be in the patient care setting. So we’re talking about clinicians, health providers, anyone who is part of a patient care team. And thinking about, what is it about these individuals that might be — impact the way which care is delivered. And that’s where we started looking at bias, right? The community, the literature started looking at, let’s look at just bias in general as a human behavior and how that gets constructed and how that plays out in one’s professional role as a health care provider. And lo and behold, the methods are not necessarily super advanced and rigorous, but there is evolving body of methods to really understand, measure, and unpack bias. And we can talk about what we mean by bias as well —

SHANOOR SEERVAI: Yeah, let’s —

ANN-GEL PALERMO: So if we just — one of the simple ways I like to talk about it — and this is based on training that my team has taken on through Cook Ross — it is that really it’s just a tendency or an inclination to judge without question. And it’s really just a shortcut to interact with the world. I like to also use the metaphor that reading, viewing a short film on bias for the New York Times, they put these sort of short videos together and they use the metaphor peanut butter and jelly, right?

This association. I personally don’t ever question peanut butter and jelly, like they just go together. And so we have these sort of peanut butter and jelly associations, these snap associations that we make all the time every day all day, and when you’re trained in medicine, in health care, you’re socialized as a clinician to sort of really pay attention to things that are important, or what to expect. And so it’s really easy to create blind spots. And so when you factor in the training, the socialization of that training, on top of who we are as people and how we relate to people, things, circumstances in our life, and the images that we get, and that creates opinions and attitudes and mindset, there is no accident as to why bias is a really important thing to look at.

And you can’t necessarily separate your personal life from your professional life, you know? Your mind is your mind; it doesn’t split in two. And so recognizing bias as a source of disparities in health is a complicated — is complicated and critically important, because what it requires is a people-sided change, not necessarily the system — the system doesn’t change without the people in it changing. And so that’s what this is about.

SHANOOR SEERVAI: Well I was just going to ask, Ann-Gel, you mentioned blind spots, but could you give me an example of what a blind spot is? Because sort of the peanut butter jelly association, it could be a bad thing, like something that’s just — it could be a bad thing just in daily life. But I feel like it’s particularly bad if you are going in to see your doctor, you’re sick and you need something, and they have this association that they make about you, and then you don’t get the right diagnosis.

JOIA CREAR-PERRY: I mean, I think for me going back to how we got to the biases are important, right? And so because the images that we were all taught about race and gender come from some assumptions we have around black and brown people, around women. And so they are socialized not just in how we teach in medical school, but they’re in the media, they’re in our schoolbooks, they’re in our history. So then that feeds into the bias. But I’ll give you today a concrete example of how bias can work. So if you believe that preeclampsia or hypertension in pregnancy is something that only happens to black people, right? Because the shortcut as she mentioned, we do a lot of shortcuts in medicine, we have acronyms and we believe it’s easier for us to just say, “Sickle cell, black,” right? So those kind of very concrete shortcuts. There are white people who have sickle cell disease. And so you will then ignore the fact that they do. Or if you are a white person who has hypertension in pregnancy or high blood pressure in pregnancy, because of our bias we’re not going to — we’re going to say, “Oh you must just be in pain today.”

So it becomes really lethal when we assume groups of people have very concrete medical issues or medical symptoms based upon the amount of melanin they produce. Or based upon having a uterus or not. And as a person with power, as a provider, you’re making decisions that could really harm the patient. And the blind spots of missing all kinds of — ignoring pain, not seeing high blood pressure — it’s because you’ve lumped people into certain categories that are not real categories.

SHANOOR SEERVAI: And so when we think about how bias has been failing large groups of people, it’s — what I’m hearing is that we have a problem, that’s the system, it’s baked into a system that sort of measures broader societal problems that we have in the U.S. People of color and women have been treated differently their whole lives. And then we have what plays out on an individual basis. How your specific doctor or your nurse responds to you. And what are the outcomes for these large groups of people our system ignores and treats differently?

JOIA CREAR-PERRY: Yeah, I mean I think for us — that’s why this work around maternal mortality is so important. Because it really shows you, despite income, despite education, despite weight, that black women still have worse outcomes and we’re more likely to die in childbirth. So it challenges your shortcut, right? So if the shortcut — we knew when the data came out that showed that black women were dying in childbirth in New York City at twelve times the rate of their white counterparts, that immediately the narrative would be, of course they are. They don’t go to the doctor, they’re too fat, they don’t listen, they’re noncompliant. As if, a, all white patients are compliant and skinny, let’s just start with that. But, b, despite doing all of those things, we are still more likely to die. And so that makes you then have to take a step back and say, how are we failing with our biases large groups of people?

So that — that belief that if only we would just get skinnier, if only we would just listen, and if only — all of those “if only’s” don’t play out in the data, and that’s our biases around how we believe black women show up, right? So I mean that’s just one example. Rural communities have the same issue, right? This idea that if you don’t have as much education if you’re in rural America, the idea that if you are Native American you’re going to have — all of these narratives play out when people — you show up, the doctor then practices, or provider based upon those narratives and then therefore you lose. The patients are the ones who ultimately lose.

And I fear that if we don’t get to talk about where the biases come from — so I just thought it was really important to bring that into the room, into the conversation — and how especially when you’re working to improve health care outcomes, we have to talk about structural racism, we have to talk about gender oppression. Like, where do these biases originate? Because we have to retrain systems. Individuals and systems to act differently.

SHANOOR SEERVAI: And while you can’t make it go away, there are things that both of you are doing to try and change the way these systems work. So, talk to us more about that. How are you working to change a curriculum that has perpetuated our system of racism?

ANN-GEL PALERMO: In Diversity Affairs, we have no position of power in a medical education system. We’re not in charge of curriculum, admissions, student affairs, student research. We just exist in these spaces. And if you have a really effective Diversity Affairs unit, you can be effective in influencing those other functional areas to think about students who don’t know how to swim well, right? And are sinking.

And it was just a total mind shift. And when we realized that the fix-it approaches were not going to work, like, “Let’s just get rid of this person and change the name of that.” And it was like, “No. We need actually transformative change. We have to actually reveal the system onto itself,” as my colleague Leona Hess says. And then think about, what are the levers for change inside of that?

So that’s when we decided to establish and create what’s called The Racism and Bias Initiative. And it’s really a strategy to really transform a medical education learning environment, using a change management approach. Because we believe that the way the system is gonna change, is if the people in the system, you work on people side of change. Right?

SHANOOR SEERVAI: Right. Yeah.

ANN-GEL PALERMO: And most importantly, the people who have positional power in that system. And to work on shifting mindsets and mental models.

And so that curriculum specifically has been a longitudinal dialogue on addressing racism and bias inside of their training. It starts in orientation with a conversation from the dean, David Muller, to a series of interactive activities that’s about building community, identity formation. Exploring that, unpacking that. To their two-year doctoring chorus, where we thread through all the concepts and topics discussed. And what — we teach them how to literally interview a patient, is recognizing their biases at play.

SHANOOR SEERVAI: So give me an example of that.

ANN-GEL PALERMO: Yeah.

SHANOOR SEERVAI: What are some of the biases that come out when a doctor is interviewing their patient, and how is your work around the doctoring courses changing that?

ANN-GEL PALERMO: So, we teach our students to ask their patients, “How would they like to be addressed?” Instead of assuming.

SHANOOR SEERVAI: Okay.

ANN-GEL PALERMO: We ask — we teach them, you know, what are their preferred gender pronouns? And how to do that in plain language, instead of assuming. We teach them how to ask about the racial, ethnic identity, their spiritual faith background. Their gender, sexual orientation. We — and my favorite part is teaching them sexual history-taking skills. And so we teach them to not assume the genders of their patients’ sexual partners. So we’ll say — we’ll teach them, like, “Well, what are the genders of the people that you have sexual relations with?”

SHANOOR SEERVAI: Right.

ANN-GEL PALERMO: Like, “Tell me who the genders are.” And so those are the ways in which we actually train them to — you know. Because they want to know, “What do I need to know?” Right? “What’s the checklist of questions.”

JOIA CREAR-PERRY: Right. Right. Right.

ANN-GEL PALERMO: So then, let’s take ownership of the checklist of questions, and redesign the questions that gets at unpacking the bias and comes from a place of inquiry, and letting the patient share. Versus coming in with a set of assumptions that — you know.

And — and also, we’ve — you know, one of the things we’ve noticed over time is that our students weren’t asking the cisgendered gay-identified man about family planning. Right?

JOIA CREAR-PERRY: Right. Right, right.

ANN-GEL PALERMO: And like, asking about —

JOIA CREAR-PERRY: That’s a big one.

ANN-GEL PALERMO: Are you interested in having children? And what does that look like for you? Right? And so, they were just like, not doing it. And it — we recognized, “Mmmm, there’s a bias at play.” It’s like, this automa— “Peanut butter and jelly. Gay man, no kids.” Right? So — so those are the ways in which we try to unpack that.

JOIA CREAR-PERRY: So our organization does similar work, but not necessarily with medical students. So, it’s hard to do it. We usually get called in when people are in trouble, right? So if the media says, “You’re treating your patients poorly. They want somebody to help them with their equity.” Or — or — or sometimes there’s just really good, nice people who are really — look at their own data internally and say, “Hey, we want to do better.”

SHANOOR SEERVAI: So, these people you’re talking about — a health system. A hospital, a clinic. Okay.

JOIA CREAR-PERRY: Yes. A clinic, yeah. So it could be a FQHC system. They could be a large health care system. We’ve been brought in by cities, right? So if a small city or a city of New York, right? To say, “Okay. We’re gonna look at our health systems, and look at where — the places where black and brown people are doing poorly, and work through how we can improve that.” And so some of that is one-on-one training. Some of that is role-playing. ‘Cause we don’t learn how to interview people in medical school.

So then, it’s put me on a journey of figuring out, what does quality mean in health care? And where is equity in quality? And how do we train for quality that actually meets with the patients’ need? And so that means undoing biases. That means actually listening to patients. So patients are on a very different QI measure then — they actually do want me to listen to the nurse, right? So, how do we change how we even identify quality? We work a lot around changing QI, changing and understanding around QI.

SHANOOR SEERVAI: Can you talk, Joia, maybe about a clinic or a health system that you’ve worked with that you feel like really needed you, but was resistant to change?

JOIA CREAR-PERRY: Ooooh.

SHANOOR SEERVAI: Or was really struggling with these issues?

JOIA CREAR-PERRY: Yep. Yep, yep. You know, I mean, what comes to mind right now is home. So, I’m from New Orleans. And I — I trained there. Charity Hospital, historically, up until the mid-’90s, is where a lot of people had their babies. And you would have your baby in a room with about 20 other people. There were wards, even in the 1990s, with — with — with just curtains in between. So although we got rid of those wards, the mentality that that’s what people deserve, still exists in our city, right?

And so about six months or so ago, a reporter reached out to me that they had data around my city, and how poorly the women were doing. And they were gonna release an article about it, in a large international paper. And the response from my hospitals, from my peers, was still to blame the patients and to blame the women, like they have always done. So we’ve done now town halls. We now recently went back and — I am opt— I’m hopeful, because there are some champions. Diversity Inclusion is a huge champion at the systems. But as you mentioned, the power really lies at the deans’ level. The power really lies at the CEO’s level.

And so, how do we then — the resistance to change that’s always existed is still kind of there. And the hope and the goal is to figure out a pathway so that we can get buy-in from the actual — because they need the same transformation that you are doing at Mount Sinai.

So, I am still optimistic that we’ll get there. But they need deep change. Half of the city doesn’t have access to a hospital. The systems have chosen not to reopen those hospitals since Hurricane Katrina. And so those are systems choices. And yet, we still blame the patients for the poor outcomes, right?

SHANOOR SEERVAI: Let’s talk about this blaming the patient.

JOIA CREAR-PERRY: Yeah.

SHANOOR SEERVAI: Because I think that — you know, one of the reasons people are resistant to change is because you say, “Well, we’ve always done it this way. It’s always been like this. Why should we do it differently?” And what has always been done is that the patient has been blamed. Can you talk about the resistance you’ve experienced, and how you’re trying to overcome that?

ANN-GEL PALERMO: I think res— yes. So, the resistance is real. It’s — it — I think it shows up, from my experience in the space the last — really in the space deeply in the last five years — is that it shows up with a big R and a little R. It’s visible and hidden. And I will say personally, I’ve had to reconfigure my heart, mind, and soul, to do the work that I do, so that I can stay nimble and ready. You know, like, this work has been — if I let it, could really burn me out quick.

JOIA CREAR-PERRY: Yes. Yes.

ANN-GEL PALERMO: You know, I’m — I’m doing this work 100 percent of the time. Largely because I’m situated in Diversity Affairs. And we’re not interested in, like, doing the usual basic Diversity Affairs work. Cultural competency, et cetera, et cetera. We — we’re going deep. Right? We’re gonna take on racism and bias.

JOIA CREAR-PERRY: Right.

ANN-GEL PALERMO: And so that takes a certain something. And so that also means being able to understand and see resistance from colleagues.

JOIA CREAR-PERRY: Uh-huh.

ANN-GEL PALERMO: Right? How do we transform resistance? Some people need data. Some people just need a moment, like something to resonate with. Some people just need an incentive and a reward.

JOIA CREAR-PERRY: Right. Exactly.

ANN-GEL PALERMO: Right? Some people need a major event to happen before they choose to let go of their resistance. So the thing is, is that you  have to learn resistance training, basically.

JOIA CREAR-PERRY: Yeah. Right, right, right. Yeah.

ANN-GEL PALERMO: And that’s a body of work.

SHANOOR SEERVAI: Well, as we’re wrapping up, I wanted to ask both of you — and obviously again, change is hard. It takes a long time. But if there was one single thing you could do to make the delivery of health care in the United States less biased, what would it be?

ANN-GEL PALERMO: I know, you asked that question. When you put that in the e-mail, I was like, “Shit. Oh, man.” [LAUGHTER]

JOIA CREAR-PERRY: So, we only get one. So if I were to get one, the one that’s probably the most targeted and effective is what she’s doing, right? Because I do think medical education — it’s hard to fix — like, I work with people who are in practice. And that’s a lot harder haul.

SHANOOR SEERVAI: Yeah.

JOIA CREAR-PERRY: I do think medical students are still at the space where you could train them very differently, and they could have a very dif— so you could change curriculum. You could even change how you decide who gets into medical school.

ANN-GEL PALERMO: Absolutely.

JOIA CREAR-PERRY: Like, we have no empathy score for medicine. We have an MCAT score, right? But like, I want — when I look for doctors for me and for my family, I want to know that you actually care. Like, for real. You know? And so that is a very concrete — there are ways to measure that. There are ways to find that out about people. And so I would change how we — who we accept, and how we teach them, so that over time the workforce would look very different.

SHANOOR SEERVAI: Right.

ANN-GEL PALERMO: Yeah, I agree. I think if we can — not only in medicine, but in nursing and all the health professions.

JOIA CREAR-PERRY: Yep.

ANN-GEL PALERMO: If we can really transform what we teach, how we teach, and when we teach it. Because those are the individuals that are part of the patient care team. Then I think that that is an opportunity for a real transformative shift in health care.

JOIA CREAR-PERRY: Yes. Yes.

SHANOOR SEERVAI: All right. Well, let’s hope for a transformative shift! [LAUGHTER] Thank you both so much for joining me.

ANN-GEL PALERMO: Thank you for the conversation.

JOIA CREAR-PERRY: This has been awesome.

Illustration by Rose Wong

Publication Details

Publication Date: November 16, 2019
Contact: Shanoor Seervai, Senior Research Associate (President’s Office) and Communications Associate, The Commonwealth Fund
Citation:

Shanoor Seervai, “Health Care Has a Bias Problem: Here’s How to Fix It,” Nov. 15, 2019, in The Dose, produced by Joshua Tallman and Shanoor Seervai, podcast, MP3 audio, 20:22. https://doi.org/10.26099/mz0g-e671

Experts

Shanoor Seervai
Senior Research Associate (President’s Office) and Communications Associate, The Commonwealth Fund