EDUCATION CORNER

Educational Update: Self-reflection: Consideration of the social determinants of health, history, and our implicit bias to better serve our patients

Priscilla Nelson, M.D. & Angele Theard, M.D.

Recent years have brought immense political and social change, and as a profession we should capitalize on this to advocate for our patients. To do this we need to consider how our patients’ health is comprised of not only their biology and social issues, but also impacted by the biased perceptions held by their healthcare providers. The interface of these topics has become a focus of healthcare and public health and is referred to as social determinants of heath (SDoH).​

Angele Theard M.D.

Priscilla Nelson, M.D.

What are social determinants of heath?

In the simplest terms, SDoH are a way of acknowledging that the conditions in which people live affect their health and life chances. These circumstances, which are often nonmedical in nature, include early childhood development, educational achievement, occupational status, job security, housing availability, food security, income, access to and quality of health services, discrimination, and levels of social support. The framework of SDoH is a way to think about how social and economic circumstances impact the heath of individuals and populations.

SDoH research suggests that they may have more impact than healthcare or lifestyle choices on overall health. Language barriers, for example, an issue facing members of our international communities worldwide can impact health. According to the US census (2007), fifty-five million Americans speak a language other than English at home with Spanish being the most common (62%) followed by other Indo-European languages, (19%), and Asian and Pacific Islander (15%). Impaired communication, lower patient satisfaction, adverse outcomes, and compromised patient safety are problems identified as at least partially consequent to language barriers. Results of a nationwide sample of the parents of over 100,000 children aged 0-17 revealed that children in non-English -primary-language households experienced multiple disparities in medical and oral health and access to care. Qualitative studies and interviews will be important to help better delineate the breadth of underlying reasons for such disparities. As physicians, we must take the time to understand these SoDH to deliver care more effectively.

How do we start?

The first place to start when we discuss SDoH is to reflect upon our own culture and the personal assumptions that we make about different racial and socioeconomic groups. Stereotypes and biases, commonly subconscious, may influence our practice. In a review of fifteen studies examining implicit bias measured using the implicit association test (IAT) in health care workers, most demonstrated some level of pro-White bias. Our goal is to recognize these stereotypes and biases and actively resist them. Dr. Cohan, a gynecologist contemplates her own bias in a self-reflection piece in her NEJM are: Racist like me – a call to self-reflection and action for White physicians. While she explains that her dedication to caring for underserved women of color and her score on the IAT test are evidence that she is not racist, she questions why sometimes she might spend just a little more time with a White patient, she wondered how she mistook one Black resident for another who is also Black, and how she may have ordered more drug screens for patients with preterm labor who were Black.  Discovering your own unconscious or implicit bias is free and available online. Implicit Association Test (IAT): https://implicit.harvard.edu/implicit/takeatest.html

Do you understand the history of structural racism?

In 2017, as part of a Lancet series on equity and equality in health, authors from the New York City Department of health and Harvard TH Chan School of Public Health defined structural racism as “…the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, healthcare, and criminal justice.”  This article provides an excellent overview and foundation for learning. Several books and articles have been published on this topic, like “How Structural Racism Works — Racist Policies as a Root Cause of U.S. Racial Health Inequities” by Zinzi D. Bailey et al. In The Color of Law, Richard Rothstein provides us an understanding of how the history of laws, rules, and practices, implemented by government has assured the continual denial of the social determinants of health to marginalized groups. Dr. Rafael Ortega, an anesthesiologist at Boston University School of Medicine, focuses on anesthesia’s history in America’s South, racial disparities in medicine and how these disparities have translated into some of healthcare’s challenges today. Understanding how our biases may be supporting the system of structural racism is a necessary step toward ensuring equitable care. Taking the time to read and understand this history is integral to recognizing the experiences of our diverse patients. This together with our continued efforts to diversify our healthcare care workforce will undoubtedly help us provide more effective individualized care.

How can we at SNACC incorporate SDoH into the care we provide?

The SNACC educational committee will begin to incorporate SDoH into our educational efforts specifically as they apply to neurosurgical anesthesia. We plan to incorporate these topics in the monthly quizzes and short reviews. Our goal is to have neuroanesthesiologists understand and consider some of the social factors in the treatment and care of the neurosurgical patient. We hope that these enhancements to our educational programs can be used as thought generators to create quality and improvement projects in your institution. In the perioperative period are your patients optimized similarly? Does your underrepresented population present with consistently elevated blood pressures that have gone untreated or undertreated? Has non-compliance been because of lack of access to care or lack of education? We are great at establishing rapport with patients when it comes to awake craniotomies. Do you establish the same rapport with your patients of all cultural backgrounds? Or do you have unconscious biases that hinders you from asking the questions, educating, and getting to know your patients? In the post-operative period, are we controlling for pain similarly? These are just some ideas to get you started.

Take the time to reflect on your practice, understand history, the social determinants of health, your patients, and as the late John P. Bunker founding chair of the Department of Anesthesia at Stanford University School of Medicine in 1960 once said,

“Be the internist of the operating room. “

References

Braveman P, Gottlieb L. The social determinants of health: it’s time to consider the causes of the causes. Public Health Rep. 2014 Jan-Feb;129 Suppl 2(Suppl 2):19-31.

Jaiswal D, To MJ, Hunter H, Lane C, States C, Cameron B, Clarke SK, Cox C, MacLeod A. Twelve tips for medical students to facilitate a Photovoice project. Med Teach. 2016 Oct;38(10):981-986. doi: 10.3109/0142159X.2016.1170779. Epub 2016 Apr 13. PMID: 27076182.

Flores G. Language barriers to health care in the United States.

NEJM. 2006;355(3):229–231

Flores G, Tomany-Korman SC. The language spoken at home and disparities in medical and dental health, access to care, and use of services in US children. Pediatrics. 2008 Jun;121(6):e1703-14. doi: 10.1542/peds.2007-2906.

Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among healthcare professional and its influence on health care outcomes: a systematic review. Am J. Public Health. 2015;105(12):e60-076

Cohan D. Racist Like Me – A Call to Self-Reflection and Action for White Physicians. NEJM. 2019 Feb 28;380(9):805-807.

Baily Z, Kreiger N, Agenor M, et al. America: equity and equality in health 3. Structural racism and health inequities in the USA: evidence and interventions. Lancet, 2017;389:1453-63

Bailey ZD, Feldman JM, Bassett MT. How Structural Racism Works – Racist Policies as a Root Cause of U.S. Racial Health Inequities. NEJM. 2021 Feb 25;384(8):768-773. doi: 10.1056/NEJMms2025396. Epub 2020 Dec 16. PMID: 33326717.

Rothstein R. The Color of Law: history of how our government segregated America: New York: Liveright Publishing, 2017

Ortega R, Achu RA. On anesthesia and race. J Natl Med Assoc. 2021 Oct;113(5):541-545. doi: 10.1016/j.jnma.2021.05.007. Epub 2021 Jun 7. PMID: 34112524.

Callaway W. Operating Room Partners. The anesthesiologist and the surgeon: partners in the operating room by John P. Bunker (review). JAMA Dec 4, 1972. Vol 222, No 10, p 1315.

The Anesthesiologists and the Surgeon: Partners in the operating room, Bunker John P. Little Brown, and Co, 1972.)