Unconscious Bias and Lower Expectations

By Christina Johnson MD, PhD

Christina Johnson MD, PhD
Clinical Faculty, Overlook Family Medicine

I remember how excited we felt about starting college. At the minority prefreshman program, we met with the new director of multicultural student services and the new African-American chaplain, who were both deeply interested in our success. This is because we were the largest class of Black and Hispanic students the school had ever seen. We had all grown up in the hip hop 1980’s, but we also represented the last cultural vestiges of the 1960’s and 1970’s. Most of us were active members of student committees and groups that promoted cultural pride and educational success. We had watched Eyes on the Prize in school or with our parents and understood the significance of struggle. We knew the Fresh Prince, Parliament Funkadelic and Nirvana. Our experiences ranged from public schools to exclusive boarding schools. We felt that we were culturally ready for college.

The problem was that the school had not yet been prepared for us. We sat one day in the Unity House meeting room with several deans and administrators who were deeply concerned. They heard that many of us intended to go into health careers. They welcomed us to the campus and told us that we should feel at home. Then they encouraged us to consider other careers, because it was not likely that we would make it into medical school (the odds were so low), and it would be more realistic to consider other options. This is before any of us wrote a paper, fretted over a chemistry calculation, or dissected a frog. We understood that they were well intentioned. What they meant was that there was unlimited potential for growth and learning in college and that we should be open to the possibilities of exploring all our interests. What they didn’t know was that we had met them before. 

I met them when I sat in front of a panel for a scholarship interview, and they expressed their surprise at my great scores—for a minority, public school student. I would meet them again while arriving for a research training program at the National Institutes of Health and being mistaken as the new secretary. Then again, when interviewing for medical school with a medical director who thought I must be interested in the MD/PhD program only because of the money involved—surely my interests weren’t purely academic. They were the same professors who encouraged me to consider traveling around Europe to “find myself” when I told them I was interested in medicine. These were gatekeepers to the realm of academic possibilities, and they knew that we were unlikely to succeed.

What they did not realize was that I had prayed about what I was supposed to do in life, having been urged to decide by the ever-looming threat of preteen pregnancy and the dropout rates in my neighborhood. I made the decision to become a doctor when I was 12 years old, and it was then that I decided I belonged to that community. The concurrent presence of negative voices along my journey did not dissuade me, but they affirmed my belonging to the shared struggle experienced by my family, friends, and community in pursuing our collective dreams. Their attempt to advise us to make decisions based on our putative limitations were already a part of our lived experience. It is true that during college many of us found our niche in other fields. However, those decisions arose freely as a part of the normal exploration of interest and identity that occurs in the college environment. Indeed, many of us did become medical professionals.

Much of my journey to becoming a physician and a researcher has been marked by academic curiosity and perseverance, incredible mentorship, and family support.  Medicine is where my community focus and intellectual fervor align. However, it is the thread of rejection that has been a constant motivator. It is the reason why I am not just a clinician, but a community educator, an advocate, and a mentor. It has allowed me to see belonging to this community as both an earned privilege and a gateway for others to adopt a posture of belonging as they pursue their goals.

Improving Culturally Competent and Inclusive Health Care for LGBT Patients Through Resident and Staff Education

By Jennifer Hammonds,LCSW and Alicia Markley, MPAS, PA-C

Bob arrived to establish receive care in our rural site clinic. As the nurse was going through the rooming process with the patient, she noticed he seemed very apprehensive about answering questions. Bob began to open up to the nurse about a recent negative experience he had at a local emergency room. He had presented to the ER for abdominal pain. Throughout the visit, Bob could hear the ER staff at the nurse’s station, laughing, joking about him, and speaking negatively about him and his concerns. This experience was traumatic, and fear of having this happen again had caused him to put off seeking medical care for some time. The nurse was rightfully upset on the patient’s behalf and wanted to put him at ease in our clinic.

This is a glaring example of health disparity, but why was Bob treated differently? Bob is a transgender individual. Bob’s legal name is Barb.

Research has shown that LGBTQ patients experience higher levels of discrimination, stigma, and stress and are at higher risk for poor health outcomes. Our primary goal is to provide quality patient care for our patients. All our patients. This nurse took a step back and looked at her ability to provide culturally competent care for this patient. She naturally wanted to treat this, and every patient respectfully, but she knew that she had some obvious questions about how to address certain situations.

This incident sparked a conversation between the two of us. As a whole, the clinics seem to be adept at being LGBTQ sensitive toward our adolescent patients, but we weren’t sure about our adult population. How comfortable is our nursing staff in asking patients for pertinent, though sensitive, health information? Do our front desk staff know how to address patients when their insurance card information differs from the information provided by the patient? Is our clinic known in the community as being LGBTQ friendly, or are we missing the big picture? We quickly realized that we were uncertain about many of these things. Questions often spark the need for answers, so we decided to embark on a project, one that would, hopefully, highlight our strengths, as well as areas in need of improvement.

We decided to begin simply, with a survey of all staff, nurses, faculty, residents, and social workers, to determine our comfort level, knowledge base, and understanding of LGBTQ patients and their healthcare needs. We used a SurveyMonkey tool, knowing full well that this was a less-than-scientific method of data collection.It nonetheless served our purpose of information gathering.

The responses were quite interesting. Many professionals expressed having only basic knowledge of LGBTQ patient needs but were willing to learn anything we could teach them. A few identified as being a member of the LGBTQ population and were delighted to learn of our project intent. The feedback received engaged us fully, and we made it our goal to find the best resources to educate ourselves and provide the best quality care to all patients in our community.

Herein lies the rub—the two clinics within our residency program provide two vastly different perspectives. One is located within the University City limits with a significantly diverse population. The other resides in a homogenous, rural area that has limited exposure to people of different backgrounds. As our goal of education began to take shape, it was necessary to consider our audience as well. Luckily for us, the National LGBTQ Health Education Center had a tremendous amount of learning material, PowerPoint presentations, and seminars available for use. Both clinics were receptive and engaged with the material presented, and subsequent nonscientific polling suggested that the exercise was a beneficial one.

Throughout this process, we both deepened our own intellectual and emotional understanding of our patients and cemented our belief that our colleagues were dedicated to providing the most positive and beneficial care to our patients, no matter their gender or orientation. We plan to revisit these training materials yearly with hope that we can continue to grow and fulfill our mission of meeting health care needs through education, patient care, research, and service to the community.

Another Uncommon Ethical Dilemma We Must Now Consider

Alison Huffstetler, MD

Claudia Allen, PhD, JD

The myriad challenges posed by the COVID-19 pandemic are immense. We face shortages in personal protective equipment, brisk reallocation of clinicians, management of novel telehealth visits, and a looming increase in physician burnout. The family medicine community has engaged in remarkable efforts to ensure patients continue to receive necessary care. But as the pandemic begins to impact places like Washington, DC,  two imminent ethical questions arise: How will we balance care for the urban underserved of DC and the political figures, both of whom are sure to be affected by COVID-19? And how will we maintain professionalism while caring for our own medical colleagues?

Boris Johnson, Prime Minster of the UK, was admitted to the intensive care unit at St Thomas’s Hospital in London on April 5th.1 On the day of Johnsons’ ICU admission, there were 799 ICU beds available in the UK but 9,646 were needed.2 According to his physicians, Johnson clearly needed ICU-level care, but what about the other 8,850 patients who also needed ICU-level care? What ethical considerations exist when caring for high-powered officials? And even closer to home, how will we responsibly care for our colleagues, our nurses, and our families?

We will not presume to have a definitive answer, nor will we be able to solve the ventilator crisis in this post. But we will offer an evidence-based approach to the ethics of caring for very important patients (VIPs). 

  1. First, do no harm. Avoid the trap of protecting the VIP from an invasive or uncomfortable treatment if it is the standard of care. In the past, VIPs have suffered from lapses in quality care due to poor adherence to standards.3 Conversely, resist the urge to bend the rules toward overuse and avoid unnecessary tests, inappropriate medications, or delayed discharge.4 
  2. Acknowledge the situation. Opt for an up-front conversation with VIPs. Let the patient and family know that you will treat them as you treat all of your patients. Recognize that your feelings and decision making may be affected by the VIPs status. As a human reminder, it is ok (and warranted!) to show empathy for your friends, colleagues, and public figures. However, remind yourself that decisions should be rooted in the clinical picture and evidence base.
  3. Keep the right team in place. VIPs, families, or hospital staff might place pressure for a more senior, administrator-clinician to care for the VIP. This is often known as “chairman syndrome,” which refers to a demand to have care from the department chair, an individual who may be removed from frequent clinical care. Instead, the patient should be cared for by the team at the appropriate level of care and with the most expertise. Residents should not be removed from these teams as they consistently care for hospitalized patients and are equipped with tools to remain up to date on management. Do not escalate care without the appropriate clinical indications.5 
  4. Thoughtfully manage communication. There are two concepts here. First, ensure that you are speaking with the VIP and family routinely and honestly; aim to maintain an open line of communication with necessary boundaries. Second, patient case discussions and management decisions should only take place with direct team members. Consider a hospital pseudonym that can be used during verbal discussions and in the chart/nursing boards to reduce the likelihood of a confidentiality breech.
  5. Enlist the team to maintain these standards. It is not possible to avoid an effect on our mentality as we care for a patient who is prominent or personally close to us. What we can do is acknowledge the potential for confusing feelings, clarify them in our own minds by putting them into words, and enlisting the whole team to hold one another accountable. Give the whole team the task of keeping an eye on whether professional standards are being adhered to, and permission to hold one another accountable when anyone notices standards slipping.

We face unprecedented numbers of critically ill patients in the hospital. Family physicians are taking this opportunity to expand our presence and provide excellent care to patients. These patients will begin to include other physicians, administrators, hospital staff, friends, and well-known figures. We argue all of these are VIPs and all deserve our attention. Take time now to plan for and discuss what your team will do when caring for one another. Anticipate that these plans will change and acknowledge flexibility in the plan. Our patients will more equitably benefit from the strategies we put into place today. 

References

  1. Booth W, Adam K. Boris Johnson heads into second night in intensive care unit. The Washington Post. https://www.washingtonpost.com/world/boris-johnson-receives-oxygen-support-as-he-battles-covid-19/2020/04/07/0f21fa86-7885-11ea-a311-adb1344719a9_story.html. Published April 7, 2020. Accessed April 8, 2020.
  2. Institute for Health Metrics and Evaluation.| COVID-19 Projections. https://covid19.healthdata.org/projections. Accessed April 8, 2020.
  3. Lerner BH. Revisiting the death of Eleanor Roosevelt: was the diagnosis of tuberculosis missed? Int J Tuberc Lung Dis Off J Int Union Tuberc Lung Dis. 2001;5(12):1080-1085.
  4. Allen-Dicker J, Auerbach A, Herzig SJ. Perceived safety and value of inpatient “very important person” services. J Hosp Med. 2017;12(3):177-179. https://doi.org/10.12788/jhm.2701
  5. Guzman JA, Sasidhar M, Stoller JK. Caring for VIPs: nine principles. Cleve Clin J Med. 2011;78(2):90-94. https://doi.org/10.3949/ccjm.78a.10113