Discrimination and the Role of the Clinician

Recognizing and confronting discrimination  is essential to eliminating health disparities. Healthy People 2030 highlights discrimination when addressing social determinants of health.¹  In this issue of Pediatrics, Lei et al²  contribute to the growing literature that discrimination adversely impacts mental health in young adults. The authors investigated the effect of discrimination (racism, sexism, ageism, physical appearance, other) over time on mental health, substance use, and well-being. Data analysis using the Transition to Adulthood Supplement of the Panel Study of Income Dynamics revealed that increased discrimination frequency was associated with higher levels of mental illness diagnosis, psychological distress, substance use, and languishing for up to 6 years after initial exposure.²  Clinicians should know 3 aspects vital to combating discrimination in health care: the impact of interpersonal discrimination, the role of implicit bias in perpetuating disparities, and decolonizing medical education and training.

First, interpersonal discrimination (sometimes called individual discrimination) refers to conscious or unconscious acts of prejudice committed by a member of a dominant or privileged group toward a member(s) of a marginalized group. Acts of interpersonal discrimination (ie, microaggressions) can manifest as lack of respect toward a person as well as marginalizing, undervaluing, and scapegoating a person. Experiences with acts of interpersonal discrimination have been found to contribute to poor mental health and physical health outcomes in children, adolescents, young adults, and adults. Within the health care setting, this can include making disparaging comments to a patient or colleague about their weight, accented speech, name, or religious affiliation.^3–6  Acts of interpersonal discrimination in health care also include failing to provide translation services for patients who are fluent in languages other than spoken English; making assumptions about a patient’s intelligence on the basis of their economic status, educational level, or geographic origin; or refusing to see patients who are members of sexual or gender minority groups.^7–9 

Secondly, acknowledging, mitigating, and eliminating the impact of implicit biases within the health care system is critical. Evidence suggests that clinicians endorse negative implicit biases toward race, sex, weight, age, and mental illness that are similar to those in the general population.¹⁰  Studies have found that clinicians’ negative implicit biases influence how they communicate with their patients, influence the treatments they recommend, and influence patient satisfaction ratings.¹¹  The Joint Commission report on implicit bias in health care suggested useful strategies for addressing implicit bias, including perspective-taking (the cognitive aspect of compassion that can reduce bias and deter unconscious stereotypes and prejudices), emotional self-regulation (experiencing positive emotions during patient encounters to build rapport, trust, and connection), and partnership building (working collaboratively with patients toward a common goal).¹² 

Lastly, we must address bias and discrimination in trainee curricula and continuing medical education. The Accreditation Council for Graduate Medical Education (ACGME) included in the Common Program Requirements that a trainee must demonstrate competence in “respect and responsiveness to diverse patient populations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation.”¹³  ACGME has 6 core educational competencies, but none specifically address bias, discrimination, and inequity. To fill this training gap, a new ACGME competency has been proposed: Structural Competency, Health Equity, and Social Responsibility.¹⁴  This includes 3 subthemes that address knowledge, skills, and attitudes: structural competency (eg, understand implicit and/or explicit race and/or gender bias and its effects on health outcomes, health inequities, and patient care), structural action (eg, incorporate direct interventions on patients’ social and structural determinants of health into all physician functions), and structural responsibility (eg, examine the ethics of patient care decisions, with a focus on structural vulnerability and reducing the inequities faced by historically marginalized and oppressed populations).¹⁴  The American Board of Pediatrics has an updated entrustable professional activity for general pediatrics, number 14, entitled “Use Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations” to address racism, other social determinants of health, clinician bias, and health inequities.¹⁵  This entrustable professional activity is focused on the following: clinician personal responsibility to their community and society, identifying populations at risk for poor health outcomes, cooperating with diverse stakeholders on creating and implementing initiatives to improve health outcomes, analyzing data from various resources for quality improvement and/or population health initiatives, and undoing the systems and processes that are rooted in discrimination that have led to health care inequities.¹⁵  To mitigate the influence of implicit biases on clinical decision-making, researchers from the Royal College of Physicians have suggested a checklist for determining if clinicians’ biases influence clinical decision-making.¹⁶  This checklist includes items that analyze how one reached a diagnosis and whether stereotypes were used.¹⁶ 

Interpersonal discrimination contributes to poor physical and mental health outcomes for children, adolescents, and adults. Clinician biases and discriminatory actions in practice and/or in training against patients based on their demographic characteristics can lead to serious health consequences. Clinicians play a central role in recognizing and addressing interpersonal discrimination in health care settings and during patient encounters. Institutions have a responsibility of addressing interpersonal discrimination within the work environment and with patient care activities. Committing to reducing and eliminating interpersonal discrimination in health care will promote a healthier society.

ACGME

Accreditation Council for Graduate Medical Education