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Paths Forward for Diversity, Equity, and Inclusion in Healthcare
- 1. Paths Forward for Diversity, Equity, and Inclusion in Healthcare Andrea Sikora, PharmD, MSCR, BCCCP, FCCM Clinical Associate Professor, University of Georgia College of Pharmacy @AndreaSikora
- 2. PAGE 2 Learning Objectives •Review core concepts of diversity, equity, and inclusion Discuss current disparities in the healthcare profession Identify steps towards expanding diversity, equity, and inclusion in healthcare
- 4. Definitions Image adapted from: https://dei360.org/blog/ Diversity difference regarding cultural, racial, religion, age, sex/gender, disability, etc. Equity fair treatment, access, and opportunities Inclusion All individuals have a say or voice and can impact decision- making; the practice of providing equal access and opportunities to all
- 5. Diversity Presence of differences that may include race, gender, religion, sexual orientation, ethnicity, nationality, socioeconomic status, language, (dis)ability, age, religious commitment, or political perspective “Diversity, Equity, and Inclusion.” Diversity Equity and Inclusion. Image taken from: https://www.constantinealexander.net/2016/11/the-more-connected-we-feel-to-others-the-more-socially-responsible-we-are.html
- 6. PAGE 4 Layers of Diversity 6 Gardenwartz, L., Rowe, A. (2008). Emotional Intelligence for Managing Results in a Diverse World. Image taken from: https://www.gardenswartzrowe.com/why-g-r Level 1: Personality Level 2: Internal Dimensions Level 3: External Dimensions Level 4: Organizational Dimensions
- 7. PAGE 7 What is an internal dimension of diversity? A. Management Status B. Physical Ability C. Income D. Appearance Assessment Question
- 8. PAGE 8 What is an internal dimension of diversity? A. Management Status B. Physical Ability C. Income D. Appearance Assessment Question
- 9. PAGE 9
- 10. Promoting justice, impartiality, and fairness within the procedures, processes, and distribution of resources by institutions or systems Requires an understanding of the root cause of outcome disparities within our society Equality ≠ Equity “Diversity, Equity, and Inclusion.” Diversity Equity and Inclusion. Image taken from: https://interactioninstitute.org/illustrating-equality-vs-equity/
- 11. PAGE Inclusion 11 “Diversity, Equity, and Inclusion.” Diversity Equity and Inclusion. Image taken from: https://medium.com/@angelamhkim/i-shared-this-picture-on-my-facebook-feed-earlier-this-week-e294cc75232b An outcome to ensure those that are diverse actually feel and are welcomed To the degree to which diverse individuals are able to participate fully in the decision-making processes and development opportunities within an organization or group
- 12. Relationships Between Diversity, Equity, and Inclusion Krys, B. (2019). Belonging: A conversation about equity, diversity, and inclusion. Diversity Inclusion Equity Belonging: structure that engages full potential of all the individuals, where innovation thrives, and beliefs and values are incorporated into the whole
- 13. PAGE 13 System 1 and System 2 Thinking Kahneman, D. (2011). Thinking, fast and slow. Macmillan.
- 14. PAGE Implicit Bias “An attitude or internalized stereotype that affects an individual’s perception, action, or decision making in an unconscious manner and often contributes to unequal treatment of people based on race, ethnicity, nationality, gender, gender identity, sexual orientation, religion, socioeconomic status, age, disability, or other characteristic.” 14 FAQs for Implicit Bias Training September 24, 2021. https://www.michigan.gov/documents/lara/Implicit_Bias_FAQs_FINAL_7.22.2021_731300_7.pdf. Image taken from: Porterfield, S. (2021) “10 Diversity & Inclusion Statistics That Will Change How You Do Business.” Employee Recognition and Company Culture.
- 15. PAGE Biases 15 Implicit Bias • Attitudes and beliefs that occur outside of our conscious awareness and control • Example of System 1 thinking, such that we are not even aware they exist • May play a role in patient marginalization Explicit Bias • Biases we are aware of on a conscious level • Example of System 2 thinking • Implicit biases can become explicit bias when you become consciously aware of the prejudices and beliefs you possess Greenwald, A., & Krieger, L. (2006). Implicit bias: Scientific foundations. California Law Review, 94(4), 945-967.
- 16. PAGE 16 What feature does not describe implicit bias? A. Overt awareness B. Outside of conscious thought C. System 1 Thinking D. Plays a role in patient care Assessment Question
- 17. PAGE 17 What feature does not describe implicit bias? A. Overt awareness B. Outside of conscious thought C. System 1 Thinking D. Plays a role in patient care Assessment Question
- 19. 1. The millennial and Gen Z generations are the most diverse in history 2. 67% of job seekers consider workplace diversity an important factor when considering employment opportunities, and more than 50% of current employees want their workplace to do more to increase diversity 3. Workers are seeking more diverse and inclusive workplaces because 45% of American workers experienced discrimination and/or harassment in the past year 4. Majority of women in the workforce feel excluded from decision making, do not feel comfortable expressing their opinions, and do not feel as though they can succeed 5. 78% of employees who responded to a Harvard Business Review study said they work at organizations that lack diversity in leadership positions Why should we prioritize diversity, equity, & inclusion? Porterfield, S. (2021) “10 Diversity & Inclusion Statistics That Will Change How You Do Business.” Employee Recognition and Company
- 20. Tangible Benefits Porterfield, S. (2021) “10 Diversity & Inclusion Statistics That Will Change How You Do Business.” Employee Recognition and Company 1. Higher representation of women in C-suite level positions results in 24% greater returns to shareholders 2. Organizations with above-average gender diversity and levels of employee engagement outperform companies with below-average diversity and engagement by 46-58% 3. Companies with higher-than-average diversity had 19% higher innovation revenues 4. According to a 2015 McKinsey report, companies in the top quarter for racial/ethnic diversity are 35% more likely to surpass peers, while those in the same bracket for gender diversity are 15% more likely to do the same DEI initiatives make workplaces smarter and more successful, while also contributing to increased job satisfaction, employee retention, and revenue
- 21. PAGE Fostering and Managing Diversity in Schools of Pharmacy 21 Demographic profile of health- related professions falls short of mirroring the population • Traditionally focused on benefit of diversity from patient care standpoint • Interpretations of diversity can be broadened (e.g., experiential diversity, defined as intellectual depth efrom faculty members possessing varying disciplines/fields, professional, and research experiences) • Fewer women and minorities possess leadership roles such as dean-level rank at schools of pharmacy • Underrepresented minority enrollment in colleges and schools of pharmacy has been increasing Diversity benefits learning outcomes • Provides students with a setting allowing further psychosocial development throgh exploration of new ideas, relationships, and roles • Fosters respect and appreciation of different cultures, lifestyles, professional experiences, and intellectual abilities, which are imperative for faculty and students to successfully collaborate • Strides to increase student, faculty, and staff diversity can lead to increased interest in researching understudied areas in healthcare (e.g., healthcare disparities, access to care, effectiveness of outreach programs), increased diversity in the pharmacy workplace, and increased access to healthcare for the public Nkansah NT, Youmans SL, Agness CF, Assemi M. Am J Pharm Educ. 2009;73(8):152. doi:10.5688/aj7308152 Image taken from: Porterfield, S. (2021) “10 Diversity & Inclusion Statistics That Will Change How You Do Business.” Employee Recognition and Company Culture. Alonzo N, Bains A, Rhee G, et al. Am J Pharm Educ. 2019;83(7):6925. doi:10.5688/ajpe6925
- 22. PAGE Developing and Implementing Diversity in Schools of Pharmacy 22 Nkansah NT, Youmans SL, Agness CF, Assemi M. Am J Pharm Educ. 2009;73(8):152. doi:10.5688/aj7308152 • Vision of diversity demonstrated and communicated • Diversity integrated into mission and vision Leadership commitment • Criteria for diversity defined and included in recruitment and hiring • Criteria established to define and demonstrate how individuals fit into overall mission and vision • Ongoing strategic planning to retain diverse composition of individuals Diversity linked to recruitment and retention • Perform a baseline needs assessment, then begin strategic planning and designing of diversity program to focus on building and maintaining a diverse academic environment • Systematically implement diversity initiatives and activities according to allocated budget and resources • Ensure accountability by continuously defining metrics to measure program (and its individual activities) success and development of communication vehicles Developing and Implementing a Diversity Program for Schools of Pharmacy • Develop mentoring, coaching, and sponsorship programs with outreach to diverse individuals • Start mentorship programs early! (PCAT review, pre-pharmacy clubs, leadership in student organizations, etc.) Increase Diverse Mentorship Opportunities
- 23. Gender Inequity & Sexual Harassment in the Pharmacy Profession Bissell BD, Johnston JP, Smith RR, et al. Am J Health Syst Pharm. 2021;78(22):2059-2076. doi:10.1093/ajhp/zxab275 • 90% of awards between 1981 and 2014 were given to male recipients • Women experience significantly higher rates of workplace harassment (online rates range 20-40%) • Little data surrounding harassment in the workplace exist in the pharmacy profession 60% of the profession identifies as female • Build national infrastructure that promotes diversity and gender equity • Scoping the problem and establishing a baseline with plans for improvement • Developing organizational initiatives to promote diversity in leadership and recognition Recommendations • Creation of a national resource center specific to gender bias and sexual harassment to serve as central repository of tools and resources • Inventory organization's current membership to create plans for improving representation and proactive strategies to identify and cultivate potential female leaders • Support female membership through diverse mentorship and sponsorship • Candidates nominated for national awards will be thoroughly reviewed to ensure character evaluations and review and recall processes established for those engaged in reproachful behaviors • Develop organizational transparent reporting system and grievance processes • Develop mitigation strategies at local levels to identify conscious and unconscious biases in the workplace and education Implementation
- 25. Chapman EN, Kaatz A, Carnes M. J Gen Intern Med. 2013;28(11):1504-1510. doi:10.1007/s11606-013-2441-1 Hoffman KM, Trawalter S, Axt JR, Oliver MN. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113 Examples of Implicit Biases in Healthcare Research has shown that Black patients are undertreated for pain not only relative to white patients, but relative to World Health Organization Guidelines Hispanic patients are less likely to receive pain medications and when prescribed, they are prescribed lower doses than white patients African-Americans are less likely than white patients to receive evidence-based care for stroke, myocardial infarction, and heart failure Physicians are less likely to treat suicidal ideation in elderly patients Women are 3x less likely to be referred for total knee replacement than men even when clinically indicated
- 26. Cerdeña JP, Plaisime MV, Tsai J. Lancet. 2020;396(10257):1125-1128. doi:10.1016/S0140-6736(20)32076-6 Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740 The Practice of Race-Based Medicine System by which research characterizing race as an essential, biological variable, translates into clinical practice, leading to inequitable care. Race is a poor proxy for human variation. Genetic research shows that humans cannot be divided into biologically distinct subcategories, however race is repeatedly used as a shortcut in clinical medicine. Common Race-Based Algorithms: • Kidney stone risk (STONE Score) • Kidney Donor Risk Index 9KDRI) • American Heart Association (AHA) Get with the Guidelines- Heart Failure Risk Score • Society of Thoracic Surgeons Risk Calculators • Vaginal Birth after Cesarean (VBAC) algorithm • Pulmonary Function Tests • Urinary Tract Infection Calculator for pediatric patients • Rectal Cancer Survival Calculator • National Cancer Institute Breast Cancer Risk Assessmen Tool • Breast Cancer Surveillance Consortium Risk Calculator • Osteoporosis Risk Score • Fracture Risk Assessment Tool (FRAX)
- 27. Cerdeña JP, Plaisime MV, Tsai J. Lancet. 2020;396(10257):1125-1128. doi:10.1016/S0140-6736(20)32076-6 The Practice of Race-Based Medicine How race is used Rationale for race-based management Potential harm Race-conscious approach eGFR EGFR for Black patients is multiplied by 1.16-1.21 the eGFR for white patients depending on the equation Black patients are presumed to have higher muscle mass and creatinine generation Black patients may experience delayed dialysis and transplant referral due to higher eGFR estimation Use eGFR equations that do not adjust for race (e.g., 2021 CKD-EPI, Cystatin C) BMI risk for diabetes Asian patients considered at risk for diabetes at BMI > 23 vs 25 for patients of other races Asian patients are presumed to develop more visceral than peripheral adiposity than patients of other races at similar BMI levels, increasing the risk for insulin resistance Asian patients screened for diabetes despite absence of other risk factors might experience increased stigma and distrust of medical providers Screen patients with lower BMIs on the basis of indications of increased body fat (eg, body roundness,12 body fat percentage), not based on race JNC 8 Hypertension Guidelines Treatment algorithm provides alternate pathways for Black and non-Black patients ACE-inhibitor use associated with higher risk of stroke and poorer control of blood pressure in Black patients than in patients of other races Black patients may be less likely to achieve hypertension control and require multiple antihypertensive agents Consider all antihypertensive options for blood pressure control in Black patients, adjust as needed to achieve goals and manage adverse effects ASCVD risk estimation Race-specific equations included to estimate ASCVD risk ASCVD events higher for Black patients than patients of other races with otherwise equivalent risk burden Black patients might experience more adverse effects from recommended statin therapy, including persistent muscle damage Recommend preventative therapy on the basis of clinical metrics and comorbidities; consider pathways by which structural racism might increase cardiovascular risk among Black patients and promote resources to reduce racial stress and trauma
- 28. PAGE Understanding Health Equity 28 Healthcare is constantly evolving, yet these advances are not benefitting everyone equally Gaps persist based on race, income, education, and other social factors Health Disparity: differences in health that are preventable, rather than biological or natural Improving Health Equity. IHI Open School. 2021.
- 29. PAGE Health Disparities vs Health Differences 29 Improving Health Equity. IHI Open School. 2021. Health Disparities • Stem from unfair social systems • For example: •Unsafe employment •Low-quality education Health Differences • Related to biological causes • For example: •Genetics •Age • Differences in healthcare may be clinically appropriate if they accommodate unique patient needs or preferences
- 30. Social Determinants of Health Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion.
- 31. Disparities in Health and Health Care. Kaiser Family Foundation. 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/ A broad array of factors within and beyond the healthcare system drive disparities in health and healthcare
- 32. “Short distances to large gaps in health.” https://www.rwjf.org/en/library/interactives/whereyouliveaffectshowlongyoulive.html
- 33. Disparities in Health and Health Care. Kaiser Family Foundation. 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/ Longstanding disparities in healthcare
- 34. Impact of COVID-19 “The pandemic has amplified earlier inequities” • Women face disproportionate stress • For LGBTQ+ employees, fears of isolation and losing ground at work loom large • People of color single out work safety and career prospects Ellingrud, K., et al. (2021). “Diverse Employees Are Struggling the Most during COVID-19--Here's How Companies Can Respond.” McKinsey & Company.
- 35. PAGE Racial Disparities in ICU Outcomes 35 McGowan SK, Sarigiannis KA, Fox SC, Gottlieb MA, Chen E. Crit Care Med. 2022;50(1):1-20. doi:10.1097/CCM.0000000000005269 Image taken from: https://www.commonwealthfund.org/publications/podcast/2020/jun/why-are-more-black-americans-dying-covid-19 Compared to White patients, Black patients have higher mortality rates Black patients experienced greater financial impacts during ICU admissions, were less likely to receive early tracheostomy, and less likely to received timely antibiotics than White patients Black patients also had worse end-of-life care including lower rates on quality of dying, less advanced care planning, and higher intensity of interventions at end of life Highlights structural inequalities on racial differences in mortality in the ICU
- 36. Racial/Ethnic Differences in Emergency Department Outcomes Zhang X, Carabello M, Hill T, Bell SA, Stephenson R, Mahajan P. Front Med (Lausanne). 2020;7:300. Published 2020 Jun 25. doi:10.3389/fmed.2020.00300 Image taken from: https://www.youthventuresjpa.org/post/covid-19-racial-disparities-task-force Upon arrival to the ED, minority populations have been found to receive disparate treatment for a number of common symptoms including chest pain, acute coronary events, trauma, stroke symptoms and brain injury, pain management for bone fractures, migraines, and back pain as compared to white patients. Black patients were 10% less likely to receive immediate or emergent (as opposed to semi- or non-urgent) ESI scores, while Hispanic patients were 8% more likely to receive immediate or urgent scores and Asian patients were 19% more likely to receive immediate and emergent or urgent care compared to white patients. Black and Hispanic patients were 10% less likely than white patients to be admitted to the hospital. Black patients were 1.26 times more likely to die in hospital. Hispanic patients were 1.12 times more likely to die in hospital, and Asian patients were 1.64 times more likely to die in hospital. Black patients were 16% less likely to receive any imaging and 4% less likely to have a blood test during an ED visit than white patients. Waiting times in the ED were significantly longer for all minorities.
- 37. PAGE Consequences & Impact of Race-Based Medicine on Learners 37 Race is often learned as an independent risk factor for disease, rather than as a mediator of structural inequalities Moves efforts away from identifying and focusing on social determinants of health that impact disease Health disparities are presented without context Students learn to associate race with disease conditions, reinforcing that race is a biological trait or that ancestry is interchangeable with race Students learn that race is relevant to treatment decisions and have inadequate power to question the racialized assumptoms of their supervisors Cerdeña JP, Plaisime MV, Tsai J. Lancet. 2020;396(10257):1125-1128. doi:10.1016/S0140-6736(20)32076-6 Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740
- 38. PAGE 38 38 L G B T + And more!
- 39. PAGE 39 39 L G B T + Lesbian • Woman who is attracted to other women Gay • Man who is attracted to other men • OR • Anyone with primary attractions to people of the same sex Bisexual • A person who is attracted to people of their own sex, as well as, another sex Transgend er (Trans) • Individuals whose gender identity does not align with the sex assigned at birth Asexual • A person who generally has no or little sexual attraction to any group of people. May still have romantic or emotional attractions Intersex • A person born with chromosomes , genitalia, and/or secondary sexual characteristic s that are inconsistent with the understanding of a male or female body Queer • People who have a non- normative gender identity, sexual orientation, or sexual anatomy -- can include lesbians, gay men, transgender, and other identities And more!
- 40. PAGE 40 40 • Different LGBT+ identities are not necessarily related • For example: Gender identity and sexual orientation are separate identities Hunt L, Vennat M, Waters JH. Health and Wellness for LGBTQ. Adv Pediatr. 2018 Aug;65(1):41-54. doi: 10.1016/j.yapd.2018.04.002. Epub 2018 May 21. PMID: 30053929.
- 41. PAGE 41 41 Historical Medical Marginalization 1973 • Gay removed as mental illness by DSM/APA 2012 • Trans removed as mental illness by DSM/APA 2013 • Asexual removed as mental illness by DSM/APA 2019 • Trans removed as mental illness by ICD/WHO Present • Surgeries that are not medically necessary are still routinely performed on intersex kids before they can give meaningful consent
- 42. PAGE 42 42 42 Health Disparities Compared to Heterosexual Counterparts Physical Illness • Lesbian and bisexual women have twice the odds of heart attack and stroke • Gay men have higher rates of arthritis and cancer • Gay men have higher rates of angina pectoris Mental Illness • Gay people have twice the rates of anxiety disorders, major depression, PTSD • Gay and bisexual men have twice the rate of substance use disorder • Lesbian and bisexual women have twice the rate of substance use disorder HIV • 70% of new HIV cases in the US are in gay and bisexual men • Trans women are at higher risk for HIV • New HIV cases disproportionately affect African American and Hispanic/Latino gay and bisexual men and trans women STDs • Syphilis – 43% of cases occur in gay and bisexual men • 50% of gay men with syphilis also co- infected with HIV • Higher rates of hepatitis A and B in gay and bisexual men • Higher rates of genital warts in gay men https://www.cdc.gov/std/Syphilis/STDFact-MSM-Syphilis.htm Jin F, Prestage GP, Kippax SC, et al. Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study. Sex Transm Dis 2007;34:488–93. Wallace SP, Cochran SD, Durazo EV, Ford CL. UCLA Center for Policy Research. 2011. http://healthpolicy.ucla.edu/publications/Documents/PDF/aginglgbpb.pdf Terra T, Schafer JL, Pan PM, Costa AB, Caye A, Gadelha A, Miguel EC, Bressan RA, Rohde LA, Salum GA. Mental health conditions in Lesbian, Gay, Bisexual, Transgender, Queer and Asexual youth in Brazil: A call for action. J Affect Disord. 2022 Feb 1;298(Pt A):190- 193. doi: 10.1016/j.jad.2021.10.108. Epub 2021 Oct 26. PMID: 34715179. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213009/#:~:text=The%20prevalence%20of%20drug%20use,h eterosexual%20men%20and%20women%2C%20respectively. https://www.cdc.gov/hiv/group/index.html
- 43. PAGE 43 43 Health Disparities Compared to Heterosexual Counterparts: Physical Illness • Lesbian and bisexual women have twice the odds of heart attack and stroke • Gay men have higher rates of arthritis and cancer • Gay men have higher rates of angina pectoris Mental Illness • Gay people have twice the rates of anxiety disorders, major depression, PTSD • Gay and bisexual men have twice the rate of substance use disorder • Lesbian and bisexual women have twice the rate of substance use disorder HIV • 70% of new HIV cases in the US are in gay and bisexual men • Trans women are at higher risk for HIV • New HIV cases disproportionately affect African American and Hispanic/Latino gay and bisexual men and trans women STDs • Syphilis – 43% of cases occur in gay and bisexual men • 50% of gay men with syphilis also co-infected with HIV • Higher rates of hepatitis A and B in gay and bisexual men • Higher rates of genital warts in gay men https://www.cdc.gov/std/Syphilis/STDFact-MSM-Syphilis.htm Jin F, Prestage GP, Kippax SC, et al. Risk factors for genital and anal warts in a prospective cohort of HIV-negative homosexual men: the HIM study. Sex Transm Dis 2007;34:488–93. Wallace SP, Cochran SD, Durazo EV, Ford CL. UCLA Center for Policy Research. 2011. http://healthpolicy.ucla.edu/publications/Documents/PDF/aginglgbpb.pdf Terra T, Schafer JL, Pan PM, Costa AB, Caye A, Gadelha A, Miguel EC, Bressan RA, Rohde LA, Salum GA. Mental health conditions in Lesbian, Gay, Bisexual, Transgender, Queer and Asexual youth in Brazil: A call for action. J Affect Disord. 2022 Feb 1;298(Pt A):190- 193. doi: 10.1016/j.jad.2021.10.108. Epub 2021 Oct 26. PMID: 34715179. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8213009/#:~:text=The%20prevalence%20of%20drug%20use,h eterosexual%20men%20and%20women%2C%20respectively. https://www.cdc.gov/hiv/group/index.html
- 44. PAGE 44 Trans 101 44 Why is it important for medical professionals to know? Gender dysphoria • Marked unease when one's gender identity does not match their lived experience Gender affirming care • Treatment for gender dysphoria Experiences • 1/3 of trans people report negative experiences with healthcare providers related to being trans • Refused treatment • Verbal harassment • Having to teach the provider about transgender care Providers should be familiar with treating trans patients to: • Provide optimal care • Make patients feel comfortable https://transequality.org/sites/default/files/docs/usts/USTS-Executive-Summary-Dec17.pdf
- 45. PAGE 45 45 Basics of Gender-Affirming Care Hormone-replacement therapy (HRT) aligns a person's sex hormones with the gender they identify as HRT causes bodily changes that help alleviate gender dysphoria Non-binary (NB) care is more individualized than other gender affirming care May include surgeries, but not desired by all individuals Certain lab values and risks for certain diseases change with HRT Gender-affirming care may also include counseling
- 46. PAGE 46 46 Trans Health Disparities Income • 29% living in poverty • 15% unemployment rate in trans population • 30% experienced homelessness at some point in time due to transgender Mental Health • 39% of respondents in survey experienced serious psychological distress in past month • Compared to 5% of US population • 40% attempted suicide at least once in lifetime Access to healthcare • 23% did not seek healthcare in year prior to survey for fear of mistreatment • 33% did not seek healthcare when needed due to being unable to afford it Discrimination • Trans people of color three times as likely to be living in poverty • Black trans women 20% likely to be living with HIV • Compared to 1.4% of all trans respondents on survey • 42% of trans people with disabilities reported mistreatment by healthcare provider James, Sandy E., Herman, Jody, Keisling, Mara, Mottet, Lisa, and Anafi, Ma’ayan. 2015 U.S. Transgender Survey (USTS). Inter-university Consortium for Political and Social Research [distributor], 2019-05-22. https://doi.org/10.3886/ICPSR37229.v1
- 47. PAGE 47 47 How to Promote Inclusivity Pronouns • Display yours to encourage others to share (can be on your name tag, in your email signature, etc) Names • Ask what name people prefer to go by Display ally symbols • Pin on your collar or nametag • Pride flag in your office Open, honest dialogue Ask!
- 48. PAGE 48 48 Promoting Healthy Conversations with LGBT+ patients Respect their identity • Use their chosen pronouns and name Keep it pertinent • If not relevant to their health issues, do not call attention to it Be professional • Don't make judgments on their lifestyle or identity
- 49. PAGE 49 49 How do I present myself as an ally? Mind your business! • Don't ask someone their sexual preferences or identity • Allow them to bring it up naturally Don't assume • Avoid using pronouns or 'sir/ma'am' if you don't know Ask what their pronouns are • You can start by offering yours
- 50. PAGE 50 50 Patient Case Scenarios – Case #1 JS comes into the pharmacy to pick up medications. The pharmacy tech notices that JS is designated as 'male' in the computer but is picking up estradiol—a feminine hormone. JS has also requested that insurance not be billed for the prescriptions and to instead bill them to a discount card. How should the tech approach this transaction? Treat JS like any other patient • Don’t call attention to any perceived differences Avoid using pronouns or gendered titles when greeting JS • Misgendering JS, especially when they're picking up potentially gender-affirming medications, can damage their self-image Don't ask probing questions about the prescription • Don't ask why they don't want it on insurance
- 51. PAGE 51 51 Patient Case Scenarios – Case #2 CM comes to her primary care visit for a yearly check-up. Her patient profile notes she is a trans woman, with her preferred name/pronouns listed. At the visit, she states she recently bought a home blood pressure monitor and is concerned because her BP is "always in the 140s." At today's visit, it was 140/78. How should the clinician approach the situation? Treat CM like any other patient Recognize if being trans would affect your recommendation • Only ask questions that are relevant to the current situation • Evaluate risk factors Make appropriate recommendations as you typically would
- 52. PAGE Suggestions for Improving LGBT+ Outcomes 52 Inclusion of LGBT+ topics in primary healthcare curricula Post-degree education • Continuing education • Guidelines • Articles Promoting alternate avenues of healthcare • Clinics for uninsured/underinsured LGBT patients Preventative health • PrEP • Vaccines • Prophylactics
- 53. PAGE Suggestions for Improving LGBT+ Outcomes: 53 Inclusion of LGBT+ topics in primary healthcare curricula Post-degree education • Continuing education • Guidelines • Articles Promoting alternate avenues of healthcare • Clinics for uninsured/underinsured LGBT patients Preventative health • PrEP • Vaccines • Prophylactics
- 54. PAGE Expansion of Diversity, Equity, and Inclusion in Healthcare
- 55. PAGE Cultural Competence 55 Buckley T. Cultural competency: How to communicate effectively across cultural boundaries. Drug Topics. 2012;7:24‐33. Clark, K. Achieving Cultural Competency and Its Role in Pharmacy. Having the ability to provide care to patients with diverse values, beliefs and behaviors, and to tailor that care to patients’ social, cultural, and linguistics needs Attitudes, knowledge, and skills that allow integration and translation of knowledge about various cultures into the practice of healthcare A set of behaviors, attitudes, and policies that come together that enables effective work in cross- cultural situations A skill that is learned over time and evolves over time with the changing environment
- 56. PAGE 56 Communication Models Squarely face the patient Open posture Lean Eye contact Relax Listen Explain Acknowledge Recommend Negotiate The SOLER Model The LEARN Model
- 57. PAGE 57 Awareness and Recognition Adjust your perspective Training Communication Tools Education Reflection Know your resources How can we overcome implicit bias?
- 58. PAGE 58 How can we overcome implicit bias? Recognize Individual > Group Empathize Check your stress level
- 59. PAGE Becoming Race Conscious 59 Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740 Consider abandoning or questioning race-based analytics Reconsider approach in which you "present" patients, rather than classifying by race, consider indictors of structural vulnerability Distinguish race and genetic ancestry Do not narrow diagnosis or assume management on basis of race, and ensure treatment plans are culturally inclusive Use a combination of genetics, ancestry, and social determinants to identify the appropriate treatment pathway See each person’s individuality and cultivate empathy
- 60. PAGE 60 Fear Zone Fear Zone Learning Zone Growth Zone Becoming an ally
- 61. PAGE 61 References • “Diversity, Equity, and Inclusion.” Diversity Equity and Inclusion. Image taken from: https://www.constantinealexander.net/2016/11/the-more- connected-we-feel-to-others-the-more-socially-responsible-we-are.html • Gardenwartz, L., Rowe, A. (2008). Emotional Intelligence for Managing Results in a Diverse World. Image taken from: https://www.gardenswartzrowe.com/why-g-r • “Diversity, Equity, and Inclusion.” Diversity Equity and Inclusion. Image taken from: https://interactioninstitute.org/illustrating-equality-vs-equity/ • “Diversity, Equity, and Inclusion.” Diversity Equity and Inclusion. Image taken from: https://medium.com/@angelamhkim/i-shared-this-picture- on-my-facebook-feed-earlier-this-week-e294cc75232b • Krys, B. (2019). Belonging: A conversation about equity, diversity, and inclusion. • Kahneman, D. (2011). Thinking, fast and slow. Macmillan. • FAQs for Implicit Bias Training September 24, 2021. https://www.michigan.gov/documents/lara/Implicit_Bias_FAQs_FINAL_7.22.2021_731300_7.pdf. • Greenwald, A., & Krieger, L. (2006). Implicit bias: Scientific foundations. California Law Review, 94(4), 945-967. • Porterfield, S. (2021) “10 Diversity & Inclusion Statistics That Will Change How You Do Business.” Employee Recognition and Company Culture. • Nkansah NT, Youmans SL, Agness CF, Assemi M. Am J Pharm Educ. 2009;73(8):152. doi:10.5688/aj7308152 • Porterfield, S. (2021) “10 Diversity & Inclusion Statistics That Will Change How You Do Business.” Employee Recognition and Company Culture. • Alonzo N, Bains A, Rhee G, et al. Am J Pharm Educ. 2019;83(7):6925. doi:10.5688/ajpe6925 • Bissell BD, Johnston JP, Smith RR, et al. Am J Health Syst Pharm. 2021;78(22):2059-2076. doi:10.1093/ajhp/zxab275
- 62. PAGE 62 References • Chapman EN, Kaatz A, Carnes M. J Gen Intern Med. 2013;28(11):1504-1510. doi:10.1007/s11606-013-2441-1 • Hoffman KM, Trawalter S, Axt JR, Oliver MN. Proc Natl Acad Sci U S A. 2016;113(16):4296-4301. doi:10.1073/pnas.1516047113 • Cerdeña JP, Plaisime MV, Tsai J. Lancet. 2020;396(10257):1125-1128. doi:10.1016/S0140-6736(20)32076-6 • Vyas DA, Eisenstein LG, Jones DS. N Engl J Med. 2020;383(9):874-882. doi:10.1056/NEJMms2004740 • Improving Health Equity. IHI Open School. 2021. • Healthy People 2030, U.S. Department of Health and Human Services, Office of Disease Prevention and Health Promotion. • Disparities in Health and Health Care. Kaiser Family Foundation. 2021. https://www.kff.org/racial-equity-and-health-policy/issue-brief/disparities-in-health-and-health-care-5-key-question-and-answers/ • Ellingrud, K., et al. (2021). “Diverse Employees Are Struggling the Most during COVID-19--Here's How Companies Can Respond.” McKinsey & Company. • McGowan SK, Sarigiannis KA, Fox SC, Gottlieb MA, Chen E. Crit Care Med. 2022;50(1):1-20. doi:10.1097/CCM.0000000000005269 • Image taken from: https://www.commonwealthfund.org/publications/podcast/2020/jun/why-are-more-black-americans-dying-covid-19 • Zhang X, Carabello M, Hill T, Bell SA, Stephenson R, Mahajan P. Front Med (Lausanne). 2020;7:300. Published 2020 Jun 25. doi:10.3389/fmed.2020.00300 • Image taken from: https://www.youthventuresjpa.org/post/covid-19-racial-disparities-task-force • Buckley T. Cultural competency: How to communicate effectively across cultural boundaries. Drug Topics. 2012;7:24‐33. • Clark, K. Achieving Cultural Competency and Its Role in Pharmacy.
- 63. Thank you! Paths Forward for Diversity, Equity, and Inclusion in Healthcare Andrea Sikora, PharmD, MSCR, BCCCP, FCCM Clinical Associate Professor, University of Georgia College of Pharmacy @AndreaSikora Evaluation Access Code: 8126
Notes de l'éditeur
- Diversity – difference regarding cultural, racial, religion, age, sex/gender, disability, etc. Equity – fair treatment, access, and opportunities. **Equity is different than equality in that equality implies treating everyone as if their experiences are exactly the same** Inclusion – all individuals have a say or voice and can impact decision-making; the practice of providing equal access and opportunities to all
- - Presence of difference and variability within differences - Populations that have been and remain underrepresented among practitioners in the field and marginalized in broader society Prior to engaging in a productive discussion on diversity, it is essential to agree upon a definition. Simply defined, diversity means variety or multiformity.4 A common misconception is the notion that the term diversity relates only to racial/ethnic or gender differences. Cox proposed a broader definition of diversity to be “a group of individuals in one social system who have distinctly different, socially-relevant group affiliations.” A socially-relevant group affiliation is defined further as one to which some meaning is attached when people interact.6 In this context, diversity can refer to gender, nationality, age, religion, racial/ethnic identity, sexuality, and physiological abilities/disabilities. There may be diversity within group affiliations depending on social and cultural norms. Chisholm-Burns proposed an even broader interpretation of diversity for postsecondary educational institutions. In addition to demographic diversity, she presents the concept of experiential diversity, defined as the intellectual depth developed from faculty members possessing varying disciplines/fields, professional, and research experiences.7
- 4 layers of diversity has influenced and broadened the conversation about diversity & sets the tone for inclusion by reflecting each person’s reality in the organization Personality- openness, conscientiousness, extraversion, agreeableness, neuroticism Internal Dimensions- age, gender, sexual orientation, physical ability, ethnicity, race External Dimensions- geographic location, income, personal habits, recreational habits, religion, educational background, work experience, appearance, parental status, marital status Organizational Dimensions- functional level, work content field, division/departments/units/group, seniority, work location, union affiliation, management status Breadth of this model makes it easier to see that the current dialogue around DEI is mostly focused on most of the internal dimensions (e.g., race, ethnicity, gender, sexual orientation) and a handful of the external dimensions Intersectionality is viewed as pertaining only to this subset of attributes Yet, discrimination, bias, and power dynamics exist, in varying degrees, across all attributes and the promise of true diversity exists across all of them as well
- Facilitation of opportunities for full participation & contribution of all people Inclusion outcomes are met when you, your institution, and your program are truly inviting to all
- Each element represents a different piece of the full human experience. Addressing only one or two of these falls short on gaining, what I think is the full human experience — a sense of belonging. .
- System 1 is the brain’s fast, emotional, unconscious thinking mode. This type of thinking requires little effort, but is often error prone. Most everyday activities (like driving, talking, cleaning, etc.) make heavy use of the type 1 system. System 2 is the slow, logical, effortful, conscious thought, where reason dominates.
- Unconscious attitude and stereotypes that can manifest in the criminal justice system, workplace, school setting, and healthcare system Also known as unconscious bias or implicit social cognition Examples: race, gender, sexuality Biases often arise as a result of trying to find patterns and navigate the overwhelming stimuli in this very complicated world Culture, media, upbringing can also contribute to development of such biases Removing these biases is a challenge, especially because we often don’t even know they exist, but research reveals potential interventions and provides hope that levels of implicit biases in the US are decreasing First coined in 1995 by psychologists Mahzarin Banaji and Anthony Greenwald Argued social behavior is largely influenced by unconscious associations and judgments Since the 1990s, psychologists have extensively researched implicit biases, revealing that without even knowing it, we all possess our own implicit biases. (https://www.simplypsychology.org/implicit-bias.html)
- They surface in your conscious mind leading you to choose whether to act on or against them Implicit Association Test (IAT)- measures attitudes and beliefs that people may be unwilling or unable to report – may show that you have an implicit attitude that you did not know about
- Workplace Younger folks are seeking out workplaces that are focused on and committed to creating workplaces the reflect the country’s demographics and in which they feel welcome and respected Creating a diverse and inclusive workplace is central to attracting talented employees and setting your company up for success Only 40% of women feel satisfied with the decision-making process at their organization (vs 70% of men), which leads to job dissatisfaction and poor employee retention rate. This combined with the fact that only 2/3 of women feel they can voice a dissenting opinion without fear of repercussion (vs 80% of men) means that 60% of women feel that people from diverse backgrounds can succeed in their organization. Without diverse leadership, women are 20% less likely than straight white men to win endorsement for their ideas, people of color are 24% less likely, and those who identify as LGBTQ+ are 21% less likely
- Workplace Companies with more women in leadership positions consistently outperform companies with less than half of their leadership positions filled by women. A look at the Fortune 1000 list of companies shows how important female CEOs are for a company’s success: while only 5% of companies are run by women, those organizations contribute 7% of the total revenue of the Fortune 1000 list. Those companies also outperform the S&P 500 index—in short, women in leadership are good for business. Creating an inclusive culture and a workplace where employees feel respected, valued, and comfortable being themselves isn’t just good common sense—it’s also good for your company’s bottom line. A 2018 study by Harvard Business Review found that the most diverse companies were also the most innovative, allowing them to market a greater range of products to consumers. McKinsey’s report looked at 366 companies throughout the Americas and the United Kingdom and found that there’s a strong correlation between a company’s higher-than-average diversity (racial/ethnic and gender) and higher-than-average profits, as compared to similar organizations. In contrast to health professions, corporate settings have long focused on studying the effects of diversity and implementing programs to capitalize on its benefits.3 A study surveying human resource executives from the top 15 Fortune 500 companies cites several compelling reasons for engaging in diversity management which include: better utilization of talent (93%), increasing marketplace understanding (80%), enhanced breadth of understanding in leadership positions (60%), enhanced creativity (53%), and increased quality of team problem solving (40%).13 Employee retention is financially beneficial as well. Employment turnover among women and minorities can be expensive; one study projected the cost of turnover at $5,000 - $10,000 for an hourly employee, and $75,000 - $221,000 for an executive with an annual salary of $100,000.13 Multiple benefits of diversity are documented in business literature. An organization that fosters an environment of inclusiveness yields a greater return on investment in human capital.14 Organizations that employ individuals with diverse backgrounds and abilities have an increased level of job satisfaction and commitment among employees, which increases productivity. As a result, these organizations expend fewer resources on grievances, mediation, and turnover. In the higher education context, Gurin et al published data demonstrating the benefit of diversity on learning outcomes (eg, active-thinking skills, intellectual engagement/motivation) and democracy outcomes (eg, perspective-taking, citizenship, engagement) for all students despite race/ethnicity. Diverse higher learning environments provide students with a setting allowing further psychosocial development through the exploration of new ideas, relationships, and roles.9 A diverse organization has the competitive advantage of harnessing a highly capable and satisfied workforce if it is able to “hire, retain, and promote top performers, regardless of their racial or gender status.”12,14 Academic institutions are uniquely positioned to champion principles of diversity. Thoroughly understanding diversity from an organizational standpoint can help academicians and administrators develop diversity programs that meet the needs of faculty members, students, staff members, and the public. Promoting the benefits of diversity fosters respect and appreciation of different cultures, lifestyles, professional experiences, and intellectual abilities.7,12 These values are imperative for faculty members and students working in practice environments that depend on successful collaboration among people. In a survey conducted at an American Association of Colleges of Pharmacy (AACP) meeting, attendees of a Pharmacy Practice Department Round Table session were asked, “How do you define diversity in the departmental or team environment?” A common response was, “valuable differences in members of the team contributed by culture and experiences,” suggesting that many participants positively valued diversity.7 The presence of diverse viewpoints fosters collaboration, creative problem solving, innovation, and identification of financial resources that otherwise might be unrecognized.7,12 In addition, strides to increase student, faculty, and staff diversity can lead to increased interest in researching understudied areas in pharmacy (eg, health care disparities, access to care, effectiveness of outreach programs), increased diversity in the pharmacy workforce, and increased access to health care for the public.
- ASHP published a statement in 2007 stressing the importance of diversity towards reducing racial/ethnic healthcare disparities ACPE standards and guidelines address the inclusion of diversity goals in pharmacy colleges/school values; consideration in recruiting faculty members, staff, and students; and as a significant factor influencing curriculum, teaching, and learning methodologies Despite national awareness of the importance of diversity, demographic profile of health-related professions (including pharmacy) falls short of mirroring the population Traditionally focused on benefit of diversity from patient care standpoint --> necessary but eliminating healthcare disparities is not the sole reason to promote student, faculty, and staff diversity Higher education literature defines (1) structural diversity, (2) informal interactional diversity, and (3) classroom diversity as the 3 types of diversity experiences in the educational setting. Structural diversity is defined as the number of diverse groups represented, to increase the probability that students will be exposed to others of diverse backgrounds.8 Informal interactional diversity describes the frequency and quality of interactions among diverse groups of students outside the classroom setting. Classroom diversity describes the experience of learning about a diverse group of people from a curriculum content and classroom interactional standpoint.9 These 3 definitions of diversity are specific to the academic learning environment for students and/or postgraduate trainees; however, these concepts of diversity are also relevant when considering interactions among faculty members, staff members, and students. Based on the 2008-2009 AACP faculty demographic tables, of 444 dean-level rank faculty members (ie, dean, associate/assistant dean), 21% were female, 7% African American, 2% Hispanic/Latino, and 3% Asian/Native Hawaiian or Other Pacific Islander.16 These proportions have changed minimally (at most, 1 percentage point) since 2003-2004.17 The proportion of leadership made up of female faculty members may suggest a trend of women rising within the ranks of chair and assistant/associate dean. Data has not been published about persons with disabilities in faculty positions in colleges/schools of pharmacy; such data, along with other demographic parameters (eg, sexual orientation, religious affiliation) would be useful. Underrepresented minority enrollment in colleges and schools of pharmacy has increased from 10.6% to 14.0% between 1988 and 2002. Of 9,040 first professional doctor of pharmacy (PharmD) degrees nationally conferred in 2005-2006, underrepresented minorities received 12% (African American, 7.4%; Hispanic, 4.2% and Native American, 0.4%).24 Based on data from 2006, however, approximately 54% of these students are distributed among 11 colleges/schools of pharmacy, 4 being historically black colleges and universities (HBCUs).23 Currently no data exists within pharmacy literature assessing diversity in other respects (eg, physical/learning ability, sociocultural/economic disadvantage, sexual orientation). Depending on a school's definition of diversity, such data suggests that most colleges/schools can potentially recruit a more diverse student body. Diversity benefits learning and democracy outcomes In higher education context, diversity improves learning outcomes (e.g., active-thinking skills, intellectual engagement/motivation) and democracy outcomes (e.g., perspective-taking, citizenship, engagement) for all students despite race/ethnicity Provides students with a setting allowing further psychosocial development throgh exploration of new ideas, relationships, and roles Fosters respect and appreciation of different cultures, lifestyles, professional experiences, and intellectual abilities, which are imperative for faculty and students to successfully collaborate among people Strides to increase student, faculty, and staff diversity can lead to increased interest in researching understudied areas in pharmacy (e.g., healthcare disparities, access to care, effectiveness of outreach programs), increased diversity in the pharmacy workplace, and increased access to healthcare for the public **Mentorship can Aid in residency candidacy- GPA, Leadership, posters/publications, LOR, review letter of intent, review CV, selection of programs to apply to, interview prep **Mentorship can impact mentees- increased confidence, job satisfaction, influence career decisions, increase competency/skills, professional development, increase pub success/academic promotsons, beneficial by students, residents, pharmacists
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2828313/#B16
- Hypotheses involving race are frequently implicit and circular --> relying on conventional wisdom that Black and Brown people are genetically distinct from White people, this common knowledge descends from European colonization at which time race was developed as a tool to divide and control populations Rely on conventional wisdom that people from different races are genetically, and biologically different When in fact, race is a social construct and race and genes are not the same thing Insert this picture: https://www.npr.org/sections/health-shots/2016/02/05/465616472/is-it-time-to-stop-using-race-in-medical-research
- Examples of race based medicine, potential harm to patients, and race-conscious alternatives (SO INTERESTING... MY MIND IS BLOWN) EGFR- MDRD commonly used; drug dosing also impacted Others: FRAX: measures probaility of fracture is adjusted according to geography or minority status or both – Black women are less likely to be screened PFT: reference values for pulmonary function are adjusted for race and ethnicity – Black patients may experience increased difficulty obtaining disability support for pulmonary disease The majority of these algorithms never defined race There is no standard to including race in these tools or no justification for why we include race in estimation tools The burden of proof is on those who are challenging these algorithms to move away from race-based medicine
- Health disparity refers to a higher burden of illness, injury, disability, or mortality experienced by 1 group relative to another driven by social and economic factors or inequalities Health disparities: product of both low-quality medical care and social circumstances beyond the purview of the traditional health care system Phrase “health inequities” can be helpful to communicate the idea of avoidable, unjust differences Examples?
- Health disparities that result in poor outcomes for people of color exist bc of structural/systemic racism
- Conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality of life outcomes and risks
- Summarizes a lot of the individuals factors a patient or a whole patient population may have to overcome in order to have the same access or opportunities as another patient or group of people. All of these translate into health outcomes Can be linked to anti-black racism and poor health outcomes
- Example: Location The Center on Society and Health at Virginia Commonwealth University is an academic research center that studies the health implications of social factors—such as education, income, neighborhood and community environmental conditions, and public policy. So they did this project – “mapping life expectancy” – which illustrate that opportunities to lead a long and healthy life can vary dramatically by neighborhood. These maps show and compare these issues among different neighborhoods throughout the country. Here we have a map of Atlanta - You can see here that there is a 13 year difference between those who live in Bankhead vs those who live in Buckhead. Unfortunately, significant gaps in life expectancy persist across many United States cities, towns, ZIP codes and neighborhoods. They have an interactive map available on their website, so I plugged in the address of AUMC and here’s what I found: The US average age = 77.30 years (bottom) Georgia - as a whole - aligns closely at 77.20 years, but around the area here our average age is significantly less at 67.7 years
- Left: Prior to the COVID19 pandemic, people of color and other underserved groups faced longstanding disparities in health Despite the recognition and documentation of disparities for decades and overall improvements in population health over time, many disparities have persisted, and, in some cases, widened.6 Recent data from before the COVID-19 pandemic showed that people of color fared worse compared to their White counterparts across a range of health measures, including infant mortality, pregnancy-related deaths, prevalence of chronic conditions, and overall physical and mental health status (Figure 2). As of 2018, life expectancy among Black people was four years lower than White people, with the lowest expectancy among Black men. Research also documents disparities across other factors. For example, low-income people report worse health status than higher income individuals,7 and lesbian, gay, bisexual, and transgender (LGBT) individuals experience certain health challenges at increased rates. Right: The Affordable Care Act health coverage expansions led to large gains in coverage across groups. Despite these gains, however, people of color and low-income individuals remain at increased risk of being uninsured (Figure 3), contributing to greater barriers to accessing health care. Further, starting in 2017, coverage gains stalled and began reversing, reflecting a range of actions by the Trump administration, including decreased funding for outreach and enrollment assistance, approval of state waivers to add new eligibility restrictions for Medicaid coverage, and immigration policy changes that increased fears among immigrant families about participating in Medicaid and CHIP. These coverage losses eroded some of the previous coverage gains under the ACA, particularly among Hispanic people, who already were at increased risk of being uninsured. Coverage losses have likely continued due to the COVID-19 pandemic as people have lost jobs and experienced declining income. Beyond disparities in coverage, people of color and lower income individuals also receive poorer quality of care. Recent KFF/The Undefeated survey data find that Black adults are more likely than White adults to report certain negative health care experiences, such as a provider not believing them and refusing them a test, treatment, or pain medication they thought they needed.
- Women face disproportionate stress Women are 1.5x as likely as men to cite challenges point to a “double shift”: acute challenges with mental health and increased household responsibilities Women are 1.2x as likely to cite acute difficulties with workload increases, connectivity and belonging in the workplace, having a healthy and safe worksite, performance reviews, and physical health In emerging economies, women have it far worse- >60% of women in emerging economies are suffering from acute or moderate challenges (China, India, Brazil are 2-3x as likely to say they are facing acute challenges from mental health as their peers in the US and European countries) For LGBTQ+ employees, fears of isolation and losing ground at work loom large Compared with straight and cisgender employees, LGBTQ+ respondents are 1.4 times as likely to cite acute challenges with fair performance reviews and workload increases and are struggling similarly with a loss of workplace connectivity and belonging. It’s perhaps not surprising then that two out of three LGBTQ+ employees report either acute or moderate challenges with mental health. People of color single out work safety and career prospects For people of color across the survey, acute challenges are more commonly felt across workplace health and safety, career progression, and household responsibilities. Concerns over workplace health and safety are perhaps unsurprising given the disproportionate health impacts experienced by people of color. POC in the United States are more likely to cite acute challenges than white Americans. Particular pain points include concerns related to career progression (2.2 times as likely) and household responsibilities (2.1 times). https://www.mckinsey.com/featured-insights/diversity-and-inclusion/diverse-employees-are-struggling-the-most-during-covid-19-heres-how-companies-can-respond.
- Racial disparities in the United States healthcare system are well described across a variety of clinical settings. The ICU is a clinical environment with a higher acuity and mortality rate, potentially compounding the impact of disparities on patients. Non white patients are less likely to receive cancer screenings, have control of BP/cholesterol, A1c, and black patients are more likely to be rehospitalized for common medical conditions like asthma or HF Some studies show black patietns may be twice as likely to develop sepsis as white patients, have higher rates of acute lung injury (not seen in other studies) Barnato AE, Alexander SL, Linde-Zwirble WT, Angus DC. Racial variation in the incidence, care, and outcomes of severe sepsis: analysis of population, patient, and hospital characteristics. Am J Respir Crit Care Med. 2008;177(3):279-284. doi:10.1164/rccm.200703-480OC Plurad DS, Lustenberger T, Kilday P, et al. The association of race and survival from sepsis after injury. Am Surg. 2010;76(1):43-47. doi:10.1177/000313481007600109 Erickson SE, Shlipak MG, Martin GS, et al. Racial and ethnic disparities in mortality from acute lung injury. Crit Care Med. 2009;37(1):1-6. doi:10.1097/CCM.0b013e31819292ea The most common confounders were age, socioeconomic status, severity of illness at admission, and hospital type. These results suggest that although Black and Hispanic patients may have an increased mortality in the ICU, the difference may relate more to changes that predate their ICU admission, instead of difference in care delivered in the ICU itself. Nevertheless, multiple studies showed that racial differences were eliminated when hospital type was controlled for, but these factors are unlikely to be independent of one another, because research shows that Black patients are more likely to be admitted to lower performing hospitals Black patients were less likely to have engaged in advanced care planning, which may explain why in some instances they were found to prefer life-extending care such as CPR or reversing a DNR status (37). Mortality differences could be explained by accompanying demographic and patient factors differences in many other outcomes, including palliative care measures, appropriate use of antibiotics, and rates of sepsis, persisted despite controlling for similar variables.
- The Institute of Medicine IOM report noted that minority groups, including black and Hispanic populations, face critical differences in healthcare access owing to higher rates of uninsurance, reduced choice in where to receive care, and a variety of structural, cultural, and linguistic barriers as compared to white people (2). Further, black and Hispanic individuals are less likely than whites to have a primary care provider for routine and preventive health needs and are more likely to seek care in a hospital emergency department (ED) Such disparities are alarming in light of the strong association between emergency care quality and mortality risk and the heightened threat of racial biases affecting providers' decision-making in the fast-paced, information-poor ED context During the 12-year study period between 2005 and 2016, NHAMCS collected data on 247,989 adult (> 18 years old) ED encounters with a discrete race categorization, providing a weighted sample of 1,065,936,835 for analysis (Table 1 and Supplement Table 2). The analysis was stratified by racial/ethnic groups in the following proportions: white patients, 64.3%; black patients, 22.1%; Hispanic patients, 11.0%; Asian patients, 1.7%; and other, 0.01%. Rates of uninsurance were highest for Hispanic patients (24.2%) and black patients (22.4%) and lowest for white (15.2%) and Asian patients (13.7%). Compared to Asian and white patients, a greater proportion of black patients, Hispanic patients, and other racial/ethnic minority ED patients belonged to the 18–39 age group. In terms of symptoms, black patients presented with the highest proportion of respiratory issues (11.6% of visits), and Hispanic patients presented with the highest proportion of digestive issues (18.4% of visits). The emergency care of black patients was characterized by disparities in multiple dimensions of care. Namely, black patients received lower ESI scores, were less likely to receive tests in the ED, were less likely to be admitted to the hospital and/or ICU, and had a higher death rate in the ED and hospital. Some of these findings were in contrast to Hispanic and Asian patients, who, in general, received equivalent or greater ED resources compared to white patients.
- Racial disparities in med use med cost a barrier for black, Hispanic/ also lack health insurance and pay more for medications compared to white americans Translates into worse med adherence rates Unequal access to pharmacists and pharmacists services (less in minority neighborhoods)
- https://www.simplypsychology.org/implicit-bias.html ASHP task force provides actionable recommendations for new or enhanced efforts that ASHP and our practice community may undertake in areas of racial diversity, equity, and inclusion, as they related to issues facing BIPOC americans
- Recognize that you have implicit bias- and that is doesn’t mean you’re a bad person, and commit to overcoming it Focus on thinking of people as individuals, not as members of a group based on race, age, or gender. You may try asking personal questions that go beyond their group identity, for example, about their hobbies, interests, or family Empathize with the other person and think about what their life might be like and try to walk a mile in their shoes Stretch yourself to notice and focus on the ways people differ from the stereotypes in their group identities ** Be conscious of your stress level when you’re working under time pressure and handling a particularly complex problem. Biases can affect our thinking more when we’re in these conditions (often the case in healthcare).