Overcoming Bias 101: Teaching Away Disparities in COVID-19
By Rachel Atkinson, MD and Doug Smink, MD, MPH with policy contributions by Esther Moberg, MPH and Amanda Reich, PhD, MPH
Part of the CSPH Series “What Comes Next: the Impact of COVID-19 on Surgery”
If the well-established data on higher morbidity and mortality rates for patients of racial, ethnic, socioeconomic, sexual orientation, and other minority groups wasn’t enough to spark interest in cultural dexterity… what possibly could?
Because of COVID-19 and broader conversations around racial inequity, the Provider Awareness and Cultural dexterity Toolkit for Surgeons (PACTS) is receiving new attention from clinical providers who are finding themselves reassigned out of their clinical comfort zones and caring for a more diverse patient population. PACTS, a novel surgical education curriculum designed to improve provider communication with culturally diverse patients, is particularly timely in our current medical and social environment.
Although cultural competency curricula are not new in medicine, PACTS is unique in this realm, as it focuses on improving providers’ situational awareness and adaptability in patient encounters rather than teaching “tips” for specific patient demographic groups based on stereotypes. For example, patients may feel stigmatized by providers’ personal protective equipment (PPE), leading to a sense of mistrust that must be identified and mitigated by the provider in order to optimize communication. In its current 8-site trial, PACTS is being deployed in surgical residency training programs across the U.S. to study whether it changes residents’ attitudes, their interaction with patients, and ultimately results in better clinical outcomes.
The realities of surgical residency, however, cannot be overlooked when hoping to implement any new skill set; residents are tired, hungry, and have a laser-focus on improving their clinical knowledge and technical skills. Most things beyond that are readily procrastinated or ignored completely. Although our research team has been able to garner interest and participation around PACTS from the residents, the lack of innate enthusiasm among residents in the trial felt like a personal failure for us as a resident and program director. If the well-established data on higher morbidity and mortality rates for patients of racial, ethnic, socioeconomic, sexual orientation, and other minority groups wasn’t enough to spark interest in cultural dexterity… what possibly could?
Unfortunately, it took a pandemic to generate greater awareness around these issues. In March 2020, COVID-19 began to rapidly spread across the United States (US), forcing residents in all clinical specialties and geographic locations to be redeployed within their health systems to COVID-specific teams. Not long into the pandemic, providers and epidemiologists began noticing a startling trend: Black and Hispanic/Latinx patients were more likely to not only contract COVID-19, but also to die from it. At Brigham and Women’s Hospital (BWH) and others, new committees and task forces were assembled to address these inequities; the electronic medical record was enhanced with reminders to screen patients for social determinants of health; a comprehensive educational and support campaign was launched in at-risk neighborhoods. These efforts, although important, cannot reach their full potential if a disconnect exists between providers and patients.
For decades, minority groups have sustained a deep-seated mistrust of our healthcare system – a system which historically subjected them to unfair procedures and withheld life-saving treatments. A system which forgets that not every patient can read beyond a 4th grade level. A system that dismisses alternative and spiritual medicine. Instead of ignoring these issues or providing care in spite of them, why not reflect on our own implicit bias and partner with patients to better understand how their backgrounds influence their interaction with the healthcare system?
As the dual pandemics of COVID-19 and racial inequity continue to dominate the national conversation, there is an escalating call from the medical community to improve the healthcare and lives of minority patients. Hospitals across the country have mandated implicit bias training for employees. We have received emails requesting broader dissemination of the PACTS curriculum to non-surgical specialties. Colleagues have reached out with personal anecdotes about their experiences caring for minority patients. Some of these stories speak excitedly of the successful implementation of skills learned in PACTS; others recount feelings of disappointment, embarrassment, and outrage when things did not go as intended. Now, more than ever, it is a moral imperative that we educate ourselves on providing culturally dexterous care. The impetus is on not only the residency programs to provide time and support for this education, but also on the residents to realize what is an increasingly obvious truth: it doesn’t matter how well you can read a CT scan or suture an anastomosis if patients are avoiding the hospital because they can’t trust or understand you.
TRANSFORMING POLICY & PRACTICE
The COVID-19 pandemic has initiated a broader national recognition of racial and ethnic disparities in healthcare that that existed pre-pandemic and has highlighted the need for cultural dexterity. The Accreditation Council for Graduate Medical Education (ACGME) oversees most training programs in the US and currently requires residents to “demonstrate competence in… respect and responsiveness to diverse patient populations.” Our policy recommendation is to go a step further: