Clinicians need to improve care for patients in under-resourced communities
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Dr. Francis Wels Peabody, MD, once wrote “The secret of the care of the patient is caring for the patient.”
Today, the burden of advanced stages of chronic kidney disease in the United States falls heavily on those who may lack the caring that Dr. Peabody talks about: people of color, as well as those with low socioeconomic status (SES).1
These disparities in CKD are not new, but the recent COVID-19 pandemic has highlighted the burden of health disparities in low SES and historically underrepresented groups. This and the increase in racial tensions due to a discriminatory criminal justice system, and increased visible advocacy for social justice, have led to a broader examination of inequities in the health care system beyond the few clinicians and researchers for whom this has been their career focus.
The prevailing questions for many are: How did we get here and what is the path forward?
Impact of health disparities
Health disparities are defined as group differences that would not exist if all things in society were equal. The pattern of racial and ethnic health in our nation follows the inequitable distribution of and access to societal resources that influence health, such as education, housing, employment, wealth, access to and quality of health care and more. These are commonly called the social determinants of health.2-6
Lack of access to high-quality social determinants of health has led to a cascade of health risks such as toxic environmental exposures, poor nutrition, uninsured or underinsured people, psychosocial stress and depression,2-6 as well as weathering: the health disadvantage from the cumulative lifetime exposure to adverse socioeconomic conditions and discrimination.7
Structural racism
An aphorism commonly attributed to former CMS Administrator Donald Berwick, PhD, is “Every system is perfectly designed to achieve the results it gets.” The design of the system that created and maintains inequities in the social determinants of health in the United States is called structural racism.8 It is commonly defined as the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, earnings, benefits, credit, media, health care, criminal justice and more. The race-based structured disadvantage along with marginalization from the majority of society and cultural conflicts clarifies that it is racism, and not race, that drives and maintains racial and ethnic disparities in CKD and its risk factors and many other disease states.1, 4, 8-12
As a profession, we often lament the lack of progress in reducing health disparities.
But should we be surprised? The reality is structural racism can and does persist in governmental and institutional policies even in the absence of individuals who are explicitly racially prejudiced.13
However, there is a fear of discussing racism and its roots in slavery, despite no one reading this article having owned a slave or created structural racism. Until structural racism is dismantled, we will continue to get the results we are getting.
In medicine, we believe our call to care for and heal the sick will lead us to rise above individual prejudices as we strive to provide the best care to all of our patients. The results from the Harvard Project Implicit say otherwise.14 While doctoral level researchers and lawyers score an average of medium on the implicit or unconscious racial bias, physicians score high for implicit or unconscious racial bias. Yet, nary a physician believes he or she has any such biases or that it could impact the care he or she delivers.
Moving forward
Maybe we can take heed from three sources. First, the WHO has identified three major principles to achieve health equity by addressing injustices that influence the social determinants of health.15 These include the following:
improve living and working conditions so all persons can achieve their full health potential;
re-organize societies to equitably distribute power, money and resources; and educate the health care community and wider society on the social determinants of health and how social inequity drives health disparities.
A second source is from our patients. They want to be treated as respected human beings. This includes eye contact and recognizing their humanity; forming a partnership with patients because they want doctors to do things with them and not to them; communication, ie, a bi-directional exchange and not being talked to or talked at; time, because patients want their doctor to be able to explain things and have things explained to them and appointments, to get to see their doctor within a reasonable time.16
The third source is the 5Rs of cultural humility (Table).17 It is a tool that brings awareness to the reality that everyone has implicit biases and provides a platform to address these biases through our use of cultural humility, mindfulness, compassion and empathy to reduce our biases and a self-reflection question. The 5Rs are reflection, respect, regard, relevance and resiliency.
By treating all patients with respect and compassion in a partnership, we can start to break down many of the barriers that are under our most immediate control and start a movement toward truly reducing disparities in care. If we bring these same values to our choices in molding the society in which we want to live, we may have a chance at dismantling structural racism and ensure all communities are appropriately resourced. Then, we can start to truly eliminate health disparities.
- References:
- Smedley BD, et al. Institute of Medicine, Committee on understanding and eliminating racial and ethnic disparities in health care. Unequal treatment: Confronting racial and ethnic disparities in healthcare. Washington, DC: National Academies Press; 2003.
- Laster M, et al. Am J Kidney Dis. 2018;doi:10.1053/j.ajkd.2018.06.021.
- Crews DC, et al. Semin Nephrol. 2013;doi:10.1016/j.semnephrol.2013.07.008.
- Norton JM, et al. J Am Soc Nephrol. 2016;doi:10.1681/asn.2016010027.
- Hall YN. Am J Kidney Dis.2018;doi:10.1053/j.ajkd.2017.12.016.
- Nicholas SB, et al. Adv Chronic Kidney Dis. 2015;doi:10.1053/j.ackd.2014.07.002.
- Geronimus AT, et al. Am J Public Health.2006;doi:10.2105/AJPH.2004.060749.
- Bailey ZD, et al. Lancet. 2017;doi:10.1016/s0140-6736(17)30569-x.
- Norris K, et al. J Am Soc Nephrol. 2008;doi:10.1681/asn.2008030276.
- Norris KC, et al. Kidney Int. 2005;doi:10.1111/j.1523-1755.2005.00485.x.
- Nicholas SB, et al. Semin Nephrol. 2013;doi:10.1016/j.semnephrol.2013.07.002.
- Crews DC, J Am Soc Nephrol. 2020;doi:10.1681/asn.2020060809.
- Williams DR, et al. Annu Rev Public Health.2019;doi:10.1146/annurev-publhealth-040218-043750.
- Sabin J, et al. Journal of Health Care for the Poor and Underserved. 2009;doi:10.1353/hpu.0.0185.
- Organization WH. Closing the gap in a generation: Health equity through action on the social determinants of health. WHO; 2008.
- Stone M. BMJ (Clinical research ed). 2003;doi:10.1136/bmj.326.7402.1294.
- Masters C, et al. Journal of General Internal Medicine. 2019;doi:10.1007/s11606-018-4814-y.
- For more information:
- Keith C. Norris, MD, is with the department of medicine at UCLA School of Medicine in Los Angeles and can be reached at knorris@ucla.edu.
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