Second in a series addressing implicit bias in health care

In the aftermath of the unsettling tragedy that unfolded in Orlando last month, we are again reminded about the issue of discrimination and the challenges that lie ahead on multiple fronts. Discrimination is as pervasive in health care as it is other aspects of society, and ultimately undermines the values of justice and equality that we as a country depend on and fight so hard to protect. LGBTQ communities, in particular, continue to face alarming disparities in health that reflect the unfortunate impact of bigotry and prejudice. For example, research found 42 percent of transgender adults reported verbal harassment, physical assault or explicit denial of equal treatment in a hospital or doctor’s office.

Last month, the Department of Health and Human Services (HHS) took a pivotal step forward in prohibiting discrimination in health coverage by releasing a final rule implemented under Section 1557 of the Affordable Care Act. Section 1557 provisions are undoubtedly a victory for all Americans as they prohibit discrimination on the basis of an individual’s race, color, national origin, age, disability or sex for all health programs or activities receiving financial assistance through HHS. The final rule is especially critical for LGBTQ people because banning sex discrimination includes protections on the basis of gender identity and sex stereotypes, which  has the increased potential to reduce health disparities. Still, there are concerns about how some providers are held accountable for service delivery and health outcomes if they are financially exempt.

There is also an additional opportunity to look beyond the policy scope referenced in Section 1557 to address less visible, but equally serious forms of discrimination that still influence policies and practices. As we highlighted in our April blog addressing implicit bias in health care, several studies show that bias among health care providers is one major factor contributing to disparities in access to high quality care. The disparities evident in research may reflect that traditional training current health care providers receive does not adequately address the health needs of historically marginalized communities. New approaches are therefore needed to integrate practices, standards, and policies for how health care services are delivered in hopes of producing more equitable outcomes.

Last year, the University of Louisville took an initiative to improve the essential health care needs of LGBTQ populations by piloting a medical school curriculum called eQuality Project. The program embeds formal implicit bias training directly into the curriculum, which includes a requirement that first year medical students, complete Implicit Association Tests (IATs). Students participating in the program must complete three IATs before beginning the curriculum as a baseline and are encouraged to complete additional post-tests. Post-test results are then matched to baseline results to determine differences. The rationale for exploring bias at early stages in the curriculum is that doing so will establish a framework of accountability for students in their approach to the work both within the program and beyond.

While IATs are the core of the curriculum at the University of Louisville, health systems like Kaiser Permanente place a larger emphasis on identifying opportunities for physicians to directly engage with vulnerable populations outside of the exam room. Dr. Ted Eytan, who works with Kaiser Permanente as a longtime advocate for equal benefits to the transgender population, maintains a collection of resources that helps break down hidden power dynamics in patient and provider interactions. He acknowledges that biases may not be erased but can be changed through exposure by building awareness and sensitivity about the unique challenges of patients who physicians work with. Through his work with Kaiser Permanente, Dr. Eytan also encourages auditing the day to day environment as a provider, and reports how simply taking a few minutes to ask questions not only humanizes a patient, but also changes a dynamic where bias may otherwise enter. 

The University of Louisville and Kaiser Permanente are leading efforts to disrupt existing patterns in health disparities by encouraging health care providers to understand health factors that are strongly influenced by different, often unequal, interactions that individuals have with the larger society. We must strive to intentionally promote a culture of knowledge where social variations are not treated as invisible, illegitimate, or negative, but instead as opportunities to learn and grow. The provisions under Section 1557 are an important step in the right direction, and also present a challenging but critical opportunity for us to look beyond the policy scope to practice. We will need to move forward on both fronts by changing discriminatory policies in the provision of care and also encouraging, equipping and supporting health care providers with the knowledge and resources needed to tackle discrimination and bias as barriers to achieving health equity.

Stay tuned for the third and final blog of this series, which will focus on examining policy recommendations that are needed at different levels of the healthcare system.