Overcoming racism and unconscious bias in ob/gyn

Dr. Rogers: Like many Americans, I watched the video of the killing of George Floyd with horror. In the days that followed, I found myself thinking, 'What can I do to improve the problem of racism in America?'

Racism is so prevalent that we as individuals cannot wait for someone else to solve the problem. We must each set out to do our part starting in our own community, specifically our own clinical space.

I reached out to a physician I greatly admire, Dr. Nesbitt. As the Associate Dean of Student Diversity and Inclusion, she has provided me mentorship on racism and bias in medical education before.

I sat down with Dr. Nesbitt to discuss what obstetricians and gynecologists can do to reduce racism and unconscious bias in their practice.

Dr. Rogers: I want my Black patients to feel understood, cared for, and safe. Are there practical ways I can send that message to my patients?

Dr. Nesbitt: It is important for all patients to feel heard and seen by their health care provider. Because of life experiences, Black patients will see a White physician with some degree of distrust. Therefore, physicians must train themselves to see their patients differently.

That may mean setting aside longer appointment times so there can be better communication. It is also helpful to have staff in the office that reflect the patient population you see so patients feel more comfortable.

The importance of the office staff cannot be understated. A patient’s first experience with the physician is through the staff. If the staff does not make the patient feel comfortable, it will affect how the patient interacts with the physician.

Dr.Rogers: What is the role of positive imagery? Certainly, when people are exposed to positive ideas related to a minority group, it will affect how they see that group as a whole. What do you think about having materials in the office that celebrate the contributions and achievements of Black people and other underrepresented groups in America?

Dr. Nesbitt: Positive imagery is very important. Physicians should look at the materials they are handing out in the office to make sure that those materials reflect the patient receiving them. Perception is critical, and positive imagery can increase patient trust.

Dr. Rogers: There are well-documented racial disparities in pain management. The myth that Black people are resistant to injury and pain has been carried through medical history. False beliefs are still present today, and contemporary studies have shown that it causes health care providers to undertreat the pain experienced by Black patients.^1-3

As ob/gyns, pain management is an important part of what we do. There has been a great deal of attention given to following a standard multimodal approach to pain management.⁴ How do we recognize and prevent racial bias while remaining mindful of opiate misuse?

Dr. Nesbitt: Knowing that such bias exists is the first step. A self-audit of your own practice may also be very helpful.⁵ Looking at how you prescribe pain medication to patients of different races can make you aware of what you may be doing unconsciously so you can correct it.

Specifically, reviewing trends in both inpatient and outpatient prescribing, dosages given in relation to pain scores, patient functionality, and patient education regarding pain expectations can help the physician ensure that all patients are receiving the highest quality care.

Dr. Rogers: There are studies documenting bias in contraception.^6-8 Contraceptive choices are complex, influenced by cultural and societal values as well as access.

There is a risk that we could allow our unconscious bias to influence our contraception counseling. Trust is a huge factor in all patient encounters, no less so in family planning. However, in a country where Black Americans have been victimized in medicine, how do ob/gyns build that trust?

Dr. Nesbitt: The experiences of Black people in medicine has been seen as its own topic when really it is an integral part of American history. So it’s not taught the same way, and people are therefore largely unaware. There are subtle ways for physicians to acknowledge this history.

Action is, of course, more important than words. It is not for the physician to provide a history lesson. Rather, it is for the physician to demonstrate an appreciation for how their patients may feel.⁹ 

Dr. Rogers: The rate of maternal mortality is 3 to 4 times higher in Black women than in White women. This holds true for severe morbidity as well.^10,11 It is a complicated issue with many contributing factors. We need to address this, and it must be a priority.

The Black Maternal Health Caucus has introduced legislation that will do just that. Patient-centered care and increased access to services helps, but what can general ob/gyns do in their offices to improve the experience for pregnant Black patients?

Dr. Nesbitt: Each ob/gyn needs to ask themselves the question, “How is systemic racism manifested in this office?” Systemic racism is a difficult concept to understand. It is not a problem with an individual.

It is embedded in processes that affect one group disproportionately. So physicians can look at their practices and see how the system in place affects certain patients in a negative way.

Difficulties with childcare and transportation disproportionately affect minority patients.^12,13 That might be something that the practice can address by partnering with a childcare service, for example.

Dr. Rogers: Another area that every ob/gyn must be aware of and address is the impact of race on gynecologic cancers. When you control for how many patients have undergone a hysterectomy, endometrial and cervical cancer are of significantly higher incidence in Black women.

Poverty, a lack of insurance, loss to follow-up, and other health comorbidities are all issues. In addition, a number of studies have shown that Black women do not get the same level of surgical treatment as White women.¹⁴

What is the role of the ob/gyn in fostering health equity in the context of cancer? Is it patient-centered navigation?

Dr. Nesbitt: Patient navigators are very helpful. The navigators should reflect the ethnicity and culture of the patients. They do not have to be health care providers, although one can transition someone in the office into this role.

They could be someone from the community. Physicians should look at their own office outcomes to define what the best approach would be. You cannot do everything, but you can focus on a few of the biggest barriers to care that you find.

Giving a questionnaire to the patients, either in person or by phone, can also provide important information.

Dr. Rogers: Howard Ross talks about power and micro-inequities in an organizational group.¹⁵ I have received reports before from residents and faculty of instances when they experienced negative interactions that were small but incredibly hurtful.

How do we eliminate them in the office setting? How do I address my colleague who I witness in the act of micro-inequity?

Dr. Nesbitt: Micro-inequities are not easy. Addressing them requires some degree of risk, which is why they have probably lasted so long. Physicians may witness them but they do not feel comfortable taking the risk of addressing it because they do not see a benefit to doing so.

However, physicians owe it to their staffs, when they see something to say something. If the leader of the practice won’t do it, the rest of the practice won’t either. The leader must also make it clear to the staff that taking the risk of saying something will not result in them losing their job. It must come from the top so everyone feels comfortable expressing their concerns.¹⁶

It is hard for one physician to give that feedback to another physician. We don’t like to confront our peers. You want to say it in a congenial way, and you have to accept that you may get a negative response. However, you offend more people by not saying anything.I think what you can say to that colleague is, “You may not be aware, but people had a negative response to what you said.”

Dr. Rogers: Recent world events have highlighted racism in America. It is on the news and social media constantly. When the White staff in the workplace do not acknowledge what is happening in the world to Black people, the Black staff are going to feel like the White staff don’t care.

With this in mind, how do ob/gyns address recent events, like the killing of George Floyd, with their coworkers?

Dr. Nesbitt: Black people often feel unheard. Acknowledgment is really important. It says that you hear them and see them. But that is just the first step. It should be followed by action. Asking the staff what the office can do to make changes is also important.

This is not a political issue. If it is, it will never be fixed because the political parties will never agree. Conversely, by it not being a political issue, we are free to talk about it in a meaningful way.

Dr. Rogers: Communication is an important first step in addressing race relations in the United States, but how does one do that in the workplace?

Physicians may fear that they do not know enough about the topic to address it properly. They may not understand that the discomfort they are feeling over this topic is but the smallest window into how their Black colleagues feel every day as they try to “fit in” at work.

Dr. Nesbitt: Black people have been socialized to live two lives. They do feel like they are expected to make White people feel more comfortable so they will be accepted. It is an interesting topic because it was not really addressed before now despite it being discussed among Black people frequently.

Even among Black people who have the benefits of education and resources, it is not easy. Discrimination still exists. It comes back to acknowledgment. To do that, you have to break down the barriers to communication. Asking questions is a good way to start.

Allowing Black people to become more comfortable increases the dialogue about what their lives are like, their customs, and homelife. This can help normalize the conversations.

Dr. Rogers: We have a long way to go in America. Racism is not a new concept. Its origins date back to the dawn of America. By acknowledging the issue, understanding what our role is, seeking insight into our own influences, and building communication with our colleagues and patients, we can do our part to create a community based in equality.

Related: Watch the full, extended video interview with Drs. Rogers and Nesbitt

__

References

1. Hoffman KM, Trawalter S, Axt JR, Oliver MN. racial bias in pain assessment and treatment recommendations, and false beliefs about biological differences between Blacks and Whites. Proc Natl Acad Sci U S A. 2016 Apr 19; 113(16): 4296-4301.
2. Badreldin N, Grobman WA, Yee LM. Racial Disparities in postpartum pain management. Obstet Gynecol. 2019 Dec; 134(6): 1147-1153.
3. Lee P, Le Saux M, Siegel R, Goyal M, Chen C, Ma Y, et al. Racial and ethnic disparities in the management of acute pain in us emergency departments: meta-analysis and systematic review. Am J Emerg Med. 2019 Sep; 37(9): 1770-1777.
4. Lian X, Adsumelli R, Girffin TR, Gan TJ. Clinical updates in women’s health care summary: perioperative pain management: primary and preventative care review. Obstet Gynecol. 2018 Nov; 132(5): 1321.
5. Pulver LK, Oliver K, Tett SE. Innovation in hospital quality improvement activities—acute postoperative pain management (APOP) self-help toolkit audits as an example. J Healthc Qual. 2012 July-Aug; 34(4): 45-59.
6. Higgins JA, Kramer RD, Ryder KM. Provider bias in long-acting reversible contraception (LARC) promotion and removal: perceptions of young adult women. Am J Public Health. 2016 Nov; 106(11): 1932-1937.
7. Dehlendorf C, et al. Disparities in family planning. Am J Obstet Gynecol. 2010 Mar; 202(3): 214-220.
8. Kramer RD, Higgins JA, Godecker AL, Ehrenthal DB. Racial and ethnic differences in patterns of long-acting reversible contraceptive use in the United States, 2011-2015. Contraception. 2018 May; 97(5): 399-404.
9. Diangelo R. White Fragility. Boston, Massachusetts: Beacon Press; 2018.
10. Howell EA. Reducing disparities in severe maternal morbidity and mortality. Clin Obstet Gynecol. 2018 Jun; 61(2): 387-399.
11. Black Maternal Health Caucus. About the Black Maternal Health Momnibus Act of 2020. https://Blackmaternalhealthcaucus-underwood.house.gov/Momnibus. Accessed July 3, 2020.
12. Roman LA, Raffo JE, Dertz K, Agee B, Evans D, Penninga K, et al. Understanding perspectives of african american medicaid-insured women on the process of perinatal care: an opportunity for systems improvement. Matern Child Health J. 2017 Dec; 21(Suppl 1): 81-92.
13. Heaman MI, Moffatt M, Elliott L, Sword W, Helewa ME, Morris H, et al. Barriers, motivators and facilitators related to prenatal care utilization among inner-city women in Winnipeg, Canada: a case-control study. BMC Pregnancy Childbirth. 2014 July; 14: 227.
14. Temkin SM, Rimel BJ, Bruegl AS, Gunderson CC, Beavis AL, Doll KM. A contemporary framework of health equity applied to gynecologic cancer care: A Society of Gynecologic Oncology evidenced-based review. Gynecol Oncol. 2018 April; 149(1): 70-77.
15. Ross HJ. Everyday Bias. Lanham, Maryland: Rowman & Littlefied; 2014.
16. Winters MF. We Can’t Talk About That At Work! Oakland, California: Berrett-Koehler Publishers, Inc.; 2017.