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Features  |   June 2019
‘Where Are You From?’
Author Affiliations
  • Rekha K. Chandrabose, M.D.
    Ad Hoc Committee on Women in Anesthesia
Article Information
Central and Peripheral Nervous Systems / Education / CPD / Pain Medicine / Advocacy and Legislative Issues / Quality Improvement / Features
Features   |   June 2019
‘Where Are You From?’
ASA Monitor 6 2019, Vol.83, 12-14.
ASA Monitor 6 2019, Vol.83, 12-14.
Rekha K. Chandrabose, M.D., is Assistant Clinical Professor, Department of Anesthesiology, University of California, San Diego. She is Founder, Women in Anesthesiology.
Rekha K. Chandrabose, M.D., is Assistant Clinical Professor, Department of Anesthesiology, University of California, San Diego. She is Founder, Women in Anesthesiology.
Rekha K. Chandrabose, M.D., is Assistant Clinical Professor, Department of Anesthesiology, University of California, San Diego. She is Founder, Women in Anesthesiology.
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My husband and I purchased a house in a beach community in San Diego in 2014. The house next door to ours is a short-term rental, and when I was standing in the street getting the house inspected, a renter came out to me and said, “Are you buying this house?” When I answered that we were in the process, he said, “How does someone like you afford something like this?” I was silent, and my realtor hustled me away from him, seeing her 3 percent sales commission disappear before her eyes. Had the older-appearing, white male chair of my department been standing on the sidewalk, such a question would not have been asked.
It’s been five years since that happened, and it turns out that those people are repeat renters. They are next door several weeks at a time, every year. The man’s wife brings their granddaughter over to play with our children when she comes to visit. This “inciting event” plays out in my head every time I see the man, and the last time we talked about it, my husband, who is white, attempted to steer me to think about it more positively. Obviously, this man is not scared of us, and we have never seen any sign of racism from his grand-daughter or wife. Essentially, my spouse suggested that maybe I could start letting this one go. The suggestion did not go over well, although the conversation was brief.
“Honey, when was the last time someone asked you where you are from, and then after you answered said, ‘No, where are you really from?’ Never, right? It happens to me every week.” People often respond to this idea of “Where are you from?” as actually just an attempt to connect with their physician, and sometimes it is. People who have travelled toIndia want to share that experience with me. For what it’s worth, I was born in England and raised in North Carolina. If you really want to connect with me, when I answer North Carolina, ask me more about my beloved home state of 31 years, not insist on delving deeper into my personal background. It’s not relevant to patient care and is no one else’s business.
As anesthesiologists, we are often in power positions in relation to our patients. We (hopefully) strive for partnership, but it is vulnerable to place your life in the hands of someone you just met. And yet, even with that dynamic present, the underpinning of being entitled to the knowledge of not just what I will do but who I actually am, one of my core identities, colors my patient-doctor relationship. I am in power and it negatively affects me. So, imagine then, the effect of the unconscious bias of their physician on the black or Latina patient, the transgender patient, the vulnerable religious minority.
Medical social media and lay literature are bursting at the seams with words like equity, diversity, inclusion, ally, microaggression and bias. It’s an explosion of terminology to the point of inundation. We all trained for this job for a minimum of eight years, making it the largest investment of our lives. Aren’t we all just there to do our best work every day, for every patient? It turns out that we are not meeting that goal. We are not benchmarking and achieving what is best for our patients, our colleagues and, ultimately, ourselves. Cultural competence is both required for good patient care and lacking in medical training.
Cultural competence is defined as the ability of providers and organizations to effectively deliver health care services that meet the social, cultural and linguistic needs of patients.1  There is a multitude of evidence that shows physician behaviors are profoundly affected by bias. Not because we are different than everyone else, but because we are the same. All behavior is affected by bias, deep conscious or unconscious associations made about people based on their group identities (primary language, race, religion, sexual orientation, gender, etc.). Patient care is affected and often compromised by these biases.
“In the U.S., racial and ethnic minorities have higher rates of chronic disease, obesity and premature death than white people. Black patients, in particular, have among the worst health outcomes, experiencing higher rates of hypertension and stroke. And black men have the lowest life expectancy of any demographic group, living on average 4.5 fewer years than white men.”2  In a community-based study, researchers found that “[n]early 65 percent of black respondents and 70 percent of white respondents reported that a doctor of the same race would understand their concerns best.”3  The researchers are careful to point out that the take-away message here is not to avoid treating people who have different cultural identities than you. Rather it is to be aware that these barriers exist and to take steps to ameliorate potential negative effects on your relationship with the patient and on their treatment plan. Due to multifactorial issues, including bias, only about 4 percent of doctors are black. Patient preference notwithstanding, we simply do not have enough black doctors in this country to address these preferences. The pipeline for black medical graduates remains relatively flat (about 6 percent for the last decade). That means white patients who prefer same-race doctors (at a higher rate than black patients) are much more likely to feel understood by their physician. Fairness aside, the purpose of this study was undertaken to understand the financial impact of patient satisfaction, preventative care usage and recommendation compliance. In a nutshell, cultural respect and competence have a multimillion-dollar impact. In a world where health care economics is driving both patient and physician satisfaction, this data is invaluable.
Anesthesiology has not undertaken specific study of the impact of bias on anesthesia care. However, groundbreaking (and heart-breaking) research was recently published out of the University of Virginia’s Department of Psychology and School of Medicine. Hoffman et al. published an article titled “Racial Bias in Pain Assessment and Treatment Recommendations, and False Beliefs about Biological Differences between Blacks and Whites.” The article “provides the first evidence that racial bias in pain perception is associated with racial bias in pain treatment recommendations. Taken together, this work provides evidence that false beliefs about biological differences between blacks and whites continue to shape the way we perceive and treat black people – they are associated with racial disparities in pain assessment and treatment recommendations .... These findings suggest that individuals with at least some medical training hold and may use false beliefs about biological differences between blacks and whites to inform medical judgments, which may contribute to racial disparities in pain assessment and treatment.”4  We are not exempt, but we have the ability to address these deficits.
In an environment both financial and cultural, in which nurse anesthetists have come to label their care superior to physician-led care, we should be taking the lead on studying and changing the perception of doctors and cultural and racial bias. Yet a Google search of cultural competence in anesthesia/anesthesiology reveals almost an entire first page of hits from CRNA schools and the American Association of Nurse Anesthetists!
What can we do about bias? It is not enough to acknowledge its existence. Simply discussing bias and unconscious bias “training” does not work. In fact, forced bias training in employees may actually exacerbate bias.5  As noted by Glenn Llopis, a Forbes contributor, “Companies are not investing in strategies that are most effective – namely those that solve for inclusion. And unconscious bias is not one of those strategies. If only because revealing unconscious biases is not a strategy – it is a tactic in the service of diversity training, which the Harvard study found among the least effective.”6  So, what steps can we take in anesthesiology to solve for inclusion as it pertains to patient care?
First, we must acknowledge that gaining cultural competence is a process, not an end goal. Competence has no pinnacle. Current understanding of cultural competency is a reflection of decades of work. Twenty years ago, mandatory diversity training was cutting edge, yet we see that it did not work. Program implementation must be designed and developed using what we know might work and excluding what we know doesn’t work, but makes people feel better for “trying.” In other words, the process is dynamic. In my opinion, the best efforts are carefully designed training plans using the current literature and regular assessment for impact with data tracking.
The Georgetown University Health Policy Institute has a list of steps that can be implemented to help us be the best physicians we can be. Some are more directly applicable to anesthesiology than others, but the list is provided in its entirety:
  1. Provide interpreter services

  2. Recruit and retain minority staff

  3. Provide training to increase cultural awareness, knowledge and skills

  4. Coordinate with traditional healers

  5. Use community health workers

  6. Incorporate culture-specific attitudes and values into health promotion tools

  7. Include family and community members in health care decision-making

  8. Locate clinics in geographic areas that are easily accessible for certain populations

  9. Expand hours of operation

  10. Provide linguistic competency that extends beyond the clinical encounter to the appointment desk, advice lines, medical billing and other written materials.7 

In my assessment, steps 2, 3, 6, 7 and 10 are directly applicable to hospital-based anesthesia practice, as well as vital to our growth as a specialty. Each step will take a varying amount of intentional effort, investment and continued assessment for success. Physicians should be leaders in studying bias and its impact on the patient-physician relationship in the context of anesthesiology.
For me, my own cultural competency homework may be to understand why patients root their understanding of me in my skin tone and gender. It turns out, there is some data to suggest that gently opening myself to letting them know me as a person may be one of the few (proven) ways to reduce bias.
References:
Betancourt JR, Green AR, Carrillo JE . Cultural Competence in Health Care: Emerging Frameworks and Practical Approaches. New York, NY: The Commonwealth Fund; 2002.
Torres N. Research: having a black doctor led black men to receive more-effective care. Harvard Business Review. August 10, 2018. https://hbr.org/2018/08/research-having-a-black-doctor-led-black-men-to-receive-more-effective-care. Last accessed April 10, 2019.
Alsan M, Garrick O, Graziani G. Does diversity matter for health? Experimental evidence from Oakland. http://www.nber.org/papers/w24787. National Bureau of Economic Research working paper 24787. Published June 2018. Last accessed April 15, 2019.
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;113(16):4296-4301. [Article] [PubMed]
Dobbin F, Kalev A. Why diversity programs fail. Harvard Business Review. July 2016. https://hbr.org/2016/07/why-diversity-programs-fail. Last accessed April 10, 2019.
Llopis G. Unsconscious bias training perpetuates the problems America strives to fix. Forbes. October 21, 2017. https://www.forbes.com/sites/glennllopis/2017/10/21/unconscious-bias-training-perpetuates-the-problems-america-strives-to-fix/#7b701cc96224. Last accessed April 10, 2019.
Cultural competence in health care: is it important for people with chronic conditions. Georgetown University McCourt School of Public Policy website. https://hpi.georgetown.edu/cultural/#. Last accessed April 10, 2019.
Rekha K. Chandrabose, M.D., is Assistant Clinical Professor, Department of Anesthesiology, University of California, San Diego. She is Founder, Women in Anesthesiology.
Rekha K. Chandrabose, M.D., is Assistant Clinical Professor, Department of Anesthesiology, University of California, San Diego. She is Founder, Women in Anesthesiology.
Rekha K. Chandrabose, M.D., is Assistant Clinical Professor, Department of Anesthesiology, University of California, San Diego. She is Founder, Women in Anesthesiology.
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