According to recent statistical data in the U.S., a range of health disparities in life expectancy and cardiovascular and cancer outcomes exist. In the recent Pri-Med East Conference, 2022, held in Boston. Gregory L. Hall, MD, Associate Professor, Integrative Medical Sciences and Internal Medicine, Northeast Ohio Medical University College of Medicine, addressed how primary care providers (PCPs) can strive for health equity and reduce implicit bias in primary care.
The objectives of the session were: to review the range of health disparities in life expectancy and cardiovascular and cancer outcomes; summarize the latest data on patient bias, trust, and perceptions; and discuss why “treating all of my patients the same” is a poor approach to improving health outcomes.
Minority patients show the worst clinical care outcomes
According to the National Vital Statistics Report 2022, the life expectancy at birth in the U.S. in 2019 is lower in non-Hispanic Black (74.8 yrs) compared to Asians (85.6 yrs), Hispanics (81.9 yrs) and NH White (78.8yrs). African Americans also had the worst mortality rate from chronic diseases, including diabetes, cardiovascular diseases, and cancer.
For example, the course of prostate cancer is different in African American men compared to other ethnicities. Prostate cancer volume is higher in African American men, and advanced metastatic prostate cancer occurs at a 4:1 ratio (compared to white men). The death risk from prostate cancer in African Americans was consistently higher than in Whites in all socioeconomic status levels. Among patients with the same socioeconomic status, cancer screening with a PSA was still more common in Whites than in African Americans, and cancer detection was earlier in Whites.
Equality vs. Equity
Promoting equality or “Treating all of my patients the same” is a poor approach to improving health outcomes. Equity, on the contrary, is based on the principle that some patients may need additional resources/guidance to reach an equal outcome. According to the Centers for Disease Control and Prevention, “Health equity is the state in which everyone has a fair and just opportunity to attain their highest level of health.”
To improve health equity, PCPs should understand the patient’s “living landscape,” whether a particular patient is at an increased or decreased risk because of their other social determinants of health issues, including race/ethnicity, neighborhoods where they live, educational attainment, insurance, job status, access to nutritious food, housing issues, among others. PCPs must spend more time educating their patients who need the knowledge, ensure more screening in those who need more screening, apply research-confirmed interventions and be nimble in their approach to communication.
Biases
Bias and discrimination in healthcare, both at the interpersonal and institutional level, are well documented in the U.S. and globally. Biases can be either explicit or implicit. Explicit bias is the traditional conceptualization of bias where individuals are aware of their prejudices and attitudes toward certain groups. Positive or negative preferences for a particular group are conscious. Overt racism and racist comments are examples of explicit biases.
A growing body of research suggests that similar to the general US population, most healthcare professionals across multiple levels of training and disciplines have implicit biases against Black, Hispanic, American Indian, and dark-skinned individuals. However, there is limited research examining the impact of implicit bias on patient care and outcomes.
Most studies have been vignette-based and reveal mixed results, with four demonstrating a relationship between implicit bias and patient care/outcomes and eight findings with no association. Research on social dominance orientation provides strong evidence that racial bias is closely related to a sense of social dominance over people who are the target of this bias. Health disparities literature has shown that non-Black physicians’ implicit bias is associated with faster speech and longer talk time.
How to reduce implicit bias in primary care?
To reduce implicit bias, PCPs must advance using an approach where they can acknowledge the bias, compensate for them, and deliberately establish trust with their patients. Clinicians should listen wholly and intently to their patients without interruptions during their visits. The PCPs should agree to determine what their patient cares about and needs and incorporate these priorities into the visit agenda. Clinicians must try to explore their patients’ verbal and nonverbal emotional cues. Finally, the clinicians should connect with the patient’s story, focusing on the positives while acknowledging a patient’s efforts and celebrating successes.