When it comes to Diversity, Equity and Inclusion (DEI) we have a politically charged landscape that changes as our culture matures. Which means that what worked a few years ago needs to change today. And I’m certain what we’re doing today will need to evolve again in the future. Some of the people that work with me at CareAlign have begged and pleaded with me to share aspects of DEI that have affected me personally. While it is true that I am a woman and I’m not white, talking about this subject doesn’t come easily to me. So I will start with an amusing anecdote.
I never thought I’d spend a lot of time worrying what I look like on a zoom call. But one day I was on a call with a woman of color and she looked fabulous. I could actually see her features and her smile instead of the harsh contrast I typically see between darker skin tones and backgrounds, where the person’s skin appears hazy and undefined. I asked what she had done and was shocked as I learned that starting from film, cameras have been optimized for lighter skin tones. That means that those of us with a darker complexion look like we are sitting in a dark shadow, because the camera doesn’t know how to process the contrast between us and the room around us. In case you’re thinking “oh, no, I have a Mac, my camera’s awesome” – I’m a Mac user too, and I’ve gone ahead and swapped out the camera for one that actually knows how to process a wide range of skin tones, and am much happier!
Words matter: DEI initiatives can help us improve patient care
Unfortunately, this systematic bias exists everywhere. For example, in rounds if someone says “no” to anything, we tend to write that they’ve “refused” whatever it is they were offered. However this often isn’t the case. I have seen situations where a patient was doing something as simple and private as using the restroom, and when someone on the healthcare team came to see them, they asked to be seen later. What was communicated to the team and written in the chart? That the patient “refused” treatment that day. Unfortunately, that one word has drastic ripple effects. When others then read or hear that the patient “refused” something, assumptions are made and a variety of other words about the patient, like “difficult”, “non-cooperative”, or “hard-to-deal-with” start bubbling up. This is classic bias and is terribly unfair. After one particularly enlightening conversation with a patient last summer, I now use the word “declined” plus an explanation to keep from sending the patient down a path of bias that is hard to come back from. After all, it is easy to copy forward a word in the chart, but it is incredibly hard to remove one. In fact, colleagues and I are now starting to research how the use of language affects how we treat and care for patients.
An uphill battle, but one worth pushing forward
Then there’s the comic situation of the yet-to-graduate white male medical student being confused as my attending when we’re seeing a patient. I feel for the student when they are flustered and start squirming when this happens, hoping to take attention away from themselves. All too often, the patient rarely figures out the mistake unless it’s spelled out for them. This has happened so often in fact, that while I used to use my first name to introduce myself to patients, it would always result in a call from the nurse saying that the patient had not yet seen the attending. So now I always introduce myself as Dr. Airan-Javia and explain the roles of everyone else in the room to help everyone understand what’s going on.
Working towards a more inclusive world
One person who really impresses me is Dr. Dana Thompson, a woman of color who has an impressive list of firsts on her resume: First African-American female consultant in surgery; first African-American woman to serve as division chief in otolaryngology; first African-American president of an otolaryngology academic surgery society. I recently had the good fortune of seeing her give grand rounds. She recounted hard-to-listen-to examples of how some patients have refused her as a doctor because of her color and/or gender. I was impressed when I learned some of the ways she has dealt with these situations. One example was when she asked a colleague who better fit the patient’s bias of what a doctor “should” look like to accompany her to see the patient and show that they are a team, colleagues, on the same level, and trust each other. She reminded us that we are all products of our experiences, and sometimes we can use these instances as opportunities to expose someone to another point of view. Sometimes it works, and sometimes it doesn’t. But we can still try. One thing I like about this strategy is that it helps nudge biases back to neutral without creating even more discomfort for someone who came to the hospital because they are already suffering. That kind of generosity of spirit in the face of such a direct and unapologetic insult is truly inspirational.
I know that I’m at my best when I remove all of my pre-set ideas and look at the situation for what it is. But I can’t always do that and it takes enormous effort. What I can do is try. I’m fascinated about what we can learn about bias from the research we are doing on language and clinical documentation and – even better – how we can use that information to improve care. But that’s for another post!