Diversity in Medicine

When Marisha Burden, MD, division head of hospital medicine at the University of Colorado at Denver, Aurora, would go to medical conferences, it seemed as if very few women were giving talks. She wondered if she could be wrong.

“I started doing my own assessments at every conference I would go to, just to make sure I wasn’t biased in my own belief system,” she said in a session at SHM Converge 2021, the annual conference of the Society of Hospital Medicine.

She wasn’t wrong.

In 2015, only 35% of all speakers at the SHM annual conference were women, and only 23% of the plenary speakers were women. In the years after that, when the society put out open calls for speakers, the numbers of women who spoke increased substantially, to 47% overall and 45% of plenary speakers.

The results – part of the SPEAK UP study Dr. Burden led in 2020 – show how gender disparity can be improved with a systematic process that is designed to improve it. The results of the study also showed that as the percentages of female speakers increased, the attendee ratings of the sessions did, too.

“You can do these things, and the quality of your conference doesn’t get negatively impacted – and in this case, actually improved,” Dr. Burden said.

That study marked progress toward leveling a traditionally uneven playing field when it comes to men and women in medicine, and the panelists in the session called on the field to use a variety of tools and strategies to continue toward something closer to equality.

Sara Spilseth, MD, MBA, chief of staff at Regions Hospital, in St. Paul, Minn., said it’s well established that although almost 50% of medical school students are women, the percentage shrinks each step from faculty to full professor to dean – of which only 16% are women. She referred to what’s known as the “leaky pipe.”

In what Dr. Spilseth said was one of her favorite studies, researchers in 2015 found that only 13% of clinical department leaders at the top 50 U.S. medical schools were women – they were outnumbered by the percentage of department leaders with mustaches, at 19%, even though mustaches are dwindling in popularity.

“Why does this exist? Why did we end up like this?” Part of the problem is a “respect gap,” she said, pointing to a study on the tendency of women to use the formal title of “doctor” when introducing male colleagues, whereas men who introduce women use that title less than half the time.

The COVID-19 pandemic has only made these disparities worse. Women are responsible for childcare much more frequently than men, Dr. Burden said, although the pandemic has brought caregiving duties to the forefront.

Dr. Spilseth said mentoring can help women navigate the workplace so as to help overcome these disparities. At Regions, the mentoring program is robust.

“Even before a new hire steps foot in the hospital, we have established them with a mentor,” she said. Sponsoring – the “ability of someone with political capital to use it to help colleagues” – can also help boost women’s careers, she said.

Her hospital also has a Women in Medicine Cooperative, which provides a way for women to talk about common struggles and to network.

Flexible work opportunities – working in transitional care units, being a physician advisor, and doing research – can all help boost a career as well, Dr. Spilseth said.

She said that at the University of Colorado, leaders set out to reach salary equity in a year and a half – and “it was a painful, painful process.” They found that different people held different beliefs about how people were paid, which led to a lot of unnecessary stress as they tried to construct a fairer system.

“On the back end of having done that, while it was a rough year and half, it has saved so much time – and I think built a culture of trust and transparency,” she said.

Recruiting in a more thoughtful way can also have a big impact, Dr. Spilseth said. The manner in which people are told about opportunities could exclude people without intending to.

“Are you casting a wide net?” she asked.

Adia Ross, MD, MHA, chief medical officer at Duke Regional Hospital, Durham, N.C., said that even in the face of obvious disparities, women can take steps on their own to boost their careers. She encouraged taking on “stretch assignments,” a project or task that is a bit beyond one’s current comfort level or level of experience or knowledge. “It can be a little scary, and sometimes there are bumps along the way,” she said.

All of these measures, though incremental, are the way to make bigger change, she said. “We want to take small steps but big strides forward.”

A version of this article first appeared on Medscape.com.

When Marisha Burden, MD, division head of hospital medicine at the University of Colorado at Denver, Aurora, would go to medical conferences, it seemed as if very few women were giving talks. She wondered if she could be wrong.

“I started doing my own assessments at every conference I would go to, just to make sure I wasn’t biased in my own belief system,” she said in a session at SHM Converge 2021, the annual conference of the Society of Hospital Medicine.

She wasn’t wrong.

In 2015, only 35% of all speakers at the SHM annual conference were women, and only 23% of the plenary speakers were women. In the years after that, when the society put out open calls for speakers, the numbers of women who spoke increased substantially, to 47% overall and 45% of plenary speakers.

The results – part of the SPEAK UP study Dr. Burden led in 2020 – show how gender disparity can be improved with a systematic process that is designed to improve it. The results of the study also showed that as the percentages of female speakers increased, the attendee ratings of the sessions did, too.

“You can do these things, and the quality of your conference doesn’t get negatively impacted – and in this case, actually improved,” Dr. Burden said.

That study marked progress toward leveling a traditionally uneven playing field when it comes to men and women in medicine, and the panelists in the session called on the field to use a variety of tools and strategies to continue toward something closer to equality.

Sara Spilseth, MD, MBA, chief of staff at Regions Hospital, in St. Paul, Minn., said it’s well established that although almost 50% of medical school students are women, the percentage shrinks each step from faculty to full professor to dean – of which only 16% are women. She referred to what’s known as the “leaky pipe.”

In what Dr. Spilseth said was one of her favorite studies, researchers in 2015 found that only 13% of clinical department leaders at the top 50 U.S. medical schools were women – they were outnumbered by the percentage of department leaders with mustaches, at 19%, even though mustaches are dwindling in popularity.

“Why does this exist? Why did we end up like this?” Part of the problem is a “respect gap,” she said, pointing to a study on the tendency of women to use the formal title of “doctor” when introducing male colleagues, whereas men who introduce women use that title less than half the time.

The COVID-19 pandemic has only made these disparities worse. Women are responsible for childcare much more frequently than men, Dr. Burden said, although the pandemic has brought caregiving duties to the forefront.

Dr. Spilseth said mentoring can help women navigate the workplace so as to help overcome these disparities. At Regions, the mentoring program is robust.

“Even before a new hire steps foot in the hospital, we have established them with a mentor,” she said. Sponsoring – the “ability of someone with political capital to use it to help colleagues” – can also help boost women’s careers, she said.

Her hospital also has a Women in Medicine Cooperative, which provides a way for women to talk about common struggles and to network.

Flexible work opportunities – working in transitional care units, being a physician advisor, and doing research – can all help boost a career as well, Dr. Spilseth said.

She said that at the University of Colorado, leaders set out to reach salary equity in a year and a half – and “it was a painful, painful process.” They found that different people held different beliefs about how people were paid, which led to a lot of unnecessary stress as they tried to construct a fairer system.

“On the back end of having done that, while it was a rough year and half, it has saved so much time – and I think built a culture of trust and transparency,” she said.

Recruiting in a more thoughtful way can also have a big impact, Dr. Spilseth said. The manner in which people are told about opportunities could exclude people without intending to.

“Are you casting a wide net?” she asked.

Adia Ross, MD, MHA, chief medical officer at Duke Regional Hospital, Durham, N.C., said that even in the face of obvious disparities, women can take steps on their own to boost their careers. She encouraged taking on “stretch assignments,” a project or task that is a bit beyond one’s current comfort level or level of experience or knowledge. “It can be a little scary, and sometimes there are bumps along the way,” she said.

All of these measures, though incremental, are the way to make bigger change, she said. “We want to take small steps but big strides forward.”

A version of this article first appeared on Medscape.com.

When Marisha Burden, MD, division head of hospital medicine at the University of Colorado at Denver, Aurora, would go to medical conferences, it seemed as if very few women were giving talks. She wondered if she could be wrong.

“I started doing my own assessments at every conference I would go to, just to make sure I wasn’t biased in my own belief system,” she said in a session at SHM Converge 2021, the annual conference of the Society of Hospital Medicine.

She wasn’t wrong.

In 2015, only 35% of all speakers at the SHM annual conference were women, and only 23% of the plenary speakers were women. In the years after that, when the society put out open calls for speakers, the numbers of women who spoke increased substantially, to 47% overall and 45% of plenary speakers.

The results – part of the SPEAK UP study Dr. Burden led in 2020 – show how gender disparity can be improved with a systematic process that is designed to improve it. The results of the study also showed that as the percentages of female speakers increased, the attendee ratings of the sessions did, too.

“You can do these things, and the quality of your conference doesn’t get negatively impacted – and in this case, actually improved,” Dr. Burden said.

That study marked progress toward leveling a traditionally uneven playing field when it comes to men and women in medicine, and the panelists in the session called on the field to use a variety of tools and strategies to continue toward something closer to equality.

Sara Spilseth, MD, MBA, chief of staff at Regions Hospital, in St. Paul, Minn., said it’s well established that although almost 50% of medical school students are women, the percentage shrinks each step from faculty to full professor to dean – of which only 16% are women. She referred to what’s known as the “leaky pipe.”

In what Dr. Spilseth said was one of her favorite studies, researchers in 2015 found that only 13% of clinical department leaders at the top 50 U.S. medical schools were women – they were outnumbered by the percentage of department leaders with mustaches, at 19%, even though mustaches are dwindling in popularity.

“Why does this exist? Why did we end up like this?” Part of the problem is a “respect gap,” she said, pointing to a study on the tendency of women to use the formal title of “doctor” when introducing male colleagues, whereas men who introduce women use that title less than half the time.

The COVID-19 pandemic has only made these disparities worse. Women are responsible for childcare much more frequently than men, Dr. Burden said, although the pandemic has brought caregiving duties to the forefront.

Dr. Spilseth said mentoring can help women navigate the workplace so as to help overcome these disparities. At Regions, the mentoring program is robust.

“Even before a new hire steps foot in the hospital, we have established them with a mentor,” she said. Sponsoring – the “ability of someone with political capital to use it to help colleagues” – can also help boost women’s careers, she said.

Her hospital also has a Women in Medicine Cooperative, which provides a way for women to talk about common struggles and to network.

Flexible work opportunities – working in transitional care units, being a physician advisor, and doing research – can all help boost a career as well, Dr. Spilseth said.

She said that at the University of Colorado, leaders set out to reach salary equity in a year and a half – and “it was a painful, painful process.” They found that different people held different beliefs about how people were paid, which led to a lot of unnecessary stress as they tried to construct a fairer system.

“On the back end of having done that, while it was a rough year and half, it has saved so much time – and I think built a culture of trust and transparency,” she said.

Recruiting in a more thoughtful way can also have a big impact, Dr. Spilseth said. The manner in which people are told about opportunities could exclude people without intending to.

“Are you casting a wide net?” she asked.

Adia Ross, MD, MHA, chief medical officer at Duke Regional Hospital, Durham, N.C., said that even in the face of obvious disparities, women can take steps on their own to boost their careers. She encouraged taking on “stretch assignments,” a project or task that is a bit beyond one’s current comfort level or level of experience or knowledge. “It can be a little scary, and sometimes there are bumps along the way,” she said.

All of these measures, though incremental, are the way to make bigger change, she said. “We want to take small steps but big strides forward.”

A version of this article first appeared on Medscape.com.

As manifestations of overt racism and macroaggressions have gained increased visibility, there is a need for discussion of another expression of racism: microaggressions. Although racism classically is viewed as blatant structural, attitudinal, and behavioral prejudice, experts pose that the face of racism has evolved into a more covert insidious form. This form of racism was originally coined racial microaggressions by psychiatrist Chester M. Pierce, MD, 50 years ago.^1,2 Since that time, microaggressions have further expanded to describe “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial, gender, sexual-orientation, and religious slights and insults to the target person or group.” ³ This article aims to define and depict examples of microaggressions in medicine, discuss the resulting harmful effects, and offer strategies to minimize and counter these negative ramifications.

What are microaggressions?

Microaggressions are behaviors that stem from implicit bias and occur at an interpersonal level. Implicit bias refers to unconscious stereotypes, assumptions, and beliefs held about an individual’s identity. One of the earliest microaggressions—invisibility—was characterized by Ralph Ellison in his novel Invisible Man. Ellison states, “I am invisible, understand, simply because people refuse to see me . . . When they approach me they see only my surroundings, themselves, or figments of their imagination—indeed, everything and anything except me.”⁴ This concept of invisibility is a primary microaggression faced by people of color.

In medicine, microaggressions and implicit bias may be encountered throughout medical training and clinical practice in interactions with colleagues, superiors, patients, and patients’ families.^5,6 Examples of microaggressions in medicine include demeaning comments, nonverbal disrespect, generalizations of social identity, assumption of nonphysician status, role- or credential-questioning behavior, explicit epithets, rejection of care, questioning or inquiries of ethnic/racial origin, and sexual harassment.⁷

An example of microaggressions in medicine was fully displayed when physician Tamika Cross described her experience of being turned away from helping an unresponsive passenger during a flight emergency.

[T]he flight attendant yells “call overhead for a physician on board.” I raised my hand to grab her attention. She said to me “oh no sweetie put [your] hand down, we are looking for actual physicians or nurses or some type of medical personnel, we don’t have time to talk to you” . . . Another “seasoned” white male approaches the row and says he is a physician as well. She says to me “thanks for your help but he can help us, and he has his credentials.”⁸

What are the effects of microaggressions?

Although microaggressions may be unconscious and unintentional by the offender, the negative ramifications are notable. Recent studies report that women and underrepresented minority (URM) medical students, residents, and physicians experience microaggressions and implicit bias at a higher prevalence and frequency compared with their male and non-URM counterparts.^7,9 Repetitive microaggressions are harmful to the health and safety of women and URM medical students, residents, physicians, other providers, and patients. The Table provides example scenarios of microaggressions in medicine categorized according to Berk.¹⁰

Microaggressions negatively impact physical, mental, and emotional well-being. Current data support that medical students and residents who experience microaggressions are more likely to report associated symptoms of burnout, depression, and suicidal thoughts.^11,12 Subjection to persistent bias can lead to minority status stress and racial battle fatigue, creating feelings of invisibility, isolation, exclusion, and loneliness for those impacted.^13,14

In the book Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine, Damon Tweedy, MD, reflects on race in medicine. Tweedy notes his experience as a medical student when a professor mistakenly assumed he was a maintenance worker in the classroom. Tweedy describes how he internalized the exchange and, despite his success throughout the course of his medical training, combatted feelings of anxiety, self-doubt, and implied inferiority.¹⁵

Although microaggressions are harmful to one’s health, they also undermine the learning and teaching experience for students, residents, and faculty, and they detract from the larger goal of providing care for patients.¹¹ Frequent devaluing and questioning of an individual’s contributions, qualifications, and credentials based on identity can lower productivity and problem-solving abilities. These behaviors cultivate an unwelcome and hostile work/learning environment that is stressful and polarizing for the recipient.

Despite the heavy burden of microaggressions, most students, residents, and faculty physicians do not report incidents to their institutions and feel that training, resources, and policies to respond to bias adequately are lacking.⁷ As a result of implicit bias and microaggressions, women and URM medical students and providers are unable to focus solely on the practice of medicine. They are tasked with the additional burden of shouldering the emotional and cognitive complexities that microaggressions produce.¹⁶

What are strategies to reduce microaggressions in medicine?

To minimize the harmful effects of microaggressions, intervention strategies must be implemented that reduce the likelihood of the occurrence of microaggressions and challenge the stereotypes that undergird implicit bias. These strategies include cultivating allies, followed by demanding structural accountability. Allies are members of the majority group who collectively collaborate with members of the nonmajority group to effect change through the promotion of diversity, equity, and inclusion efforts.¹⁷ Cultivating allies involves building a network of collaboration among these groups and emphasizes education. Education is critical for allies to address microaggressions at the interpersonal level. This process of education involves personal reflection and self-awareness in exploring one’s biases, fears, and assumptions. Integral to this step is broadening one’s acceptance of different cultures, racial/ethnic groups, and identities. There must be a willingness to engage in difficult or uncomfortable conversations and a readiness to actively listen to concerns rather than perpetuating further harm through avoidance and dismissive or defensive behavior.¹⁸

Demanding structural accountability facilitates deconstruction of bias and microaggression at the larger systemic level. This strategy involves implicit bias and antiracism training, development of retention plans, and identification of mentors for women and URM providers and students. Implicit bias and microaggression training and policies should be incorporated into medical education and resident curriculums. Similarly, educational resources and training must be made available to practicing physicians, faculty, and other providers through their institutions and places of employment. Equipping students and providers with the tools needed when microaggressions are witnessed or experienced demonstrates systemic-level accountability and communicates the importance of the issue. Furthermore, the development of retention plans and identification of mentors provide a support system and foster a culture of inclusion where recipients of microaggressions feel protected and valued. Increased feelings of inclusivity and belonging help bridge the gap created through microaggressions and implicit bias.

Final Thoughts

Despite an often covert nature, the detrimental effects of microaggressions are tangible and far reaching. As providers, we must strive to understand all categories of racism and expose the many ways prejudice manifests within medical training and clinical practice. It is our obligation to undertake the challenge of “making the ‘invisible’ visible” as we confront microaggressions and implicit bias to promote a safer and more inclusive medical community and workforce.¹⁹

As manifestations of overt racism and macroaggressions have gained increased visibility, there is a need for discussion of another expression of racism: microaggressions. Although racism classically is viewed as blatant structural, attitudinal, and behavioral prejudice, experts pose that the face of racism has evolved into a more covert insidious form. This form of racism was originally coined racial microaggressions by psychiatrist Chester M. Pierce, MD, 50 years ago.^1,2 Since that time, microaggressions have further expanded to describe “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial, gender, sexual-orientation, and religious slights and insults to the target person or group.” ³ This article aims to define and depict examples of microaggressions in medicine, discuss the resulting harmful effects, and offer strategies to minimize and counter these negative ramifications.

What are microaggressions?

Microaggressions are behaviors that stem from implicit bias and occur at an interpersonal level. Implicit bias refers to unconscious stereotypes, assumptions, and beliefs held about an individual’s identity. One of the earliest microaggressions—invisibility—was characterized by Ralph Ellison in his novel Invisible Man. Ellison states, “I am invisible, understand, simply because people refuse to see me . . . When they approach me they see only my surroundings, themselves, or figments of their imagination—indeed, everything and anything except me.”⁴ This concept of invisibility is a primary microaggression faced by people of color.

In medicine, microaggressions and implicit bias may be encountered throughout medical training and clinical practice in interactions with colleagues, superiors, patients, and patients’ families.^5,6 Examples of microaggressions in medicine include demeaning comments, nonverbal disrespect, generalizations of social identity, assumption of nonphysician status, role- or credential-questioning behavior, explicit epithets, rejection of care, questioning or inquiries of ethnic/racial origin, and sexual harassment.⁷

An example of microaggressions in medicine was fully displayed when physician Tamika Cross described her experience of being turned away from helping an unresponsive passenger during a flight emergency.

[T]he flight attendant yells “call overhead for a physician on board.” I raised my hand to grab her attention. She said to me “oh no sweetie put [your] hand down, we are looking for actual physicians or nurses or some type of medical personnel, we don’t have time to talk to you” . . . Another “seasoned” white male approaches the row and says he is a physician as well. She says to me “thanks for your help but he can help us, and he has his credentials.”⁸

What are the effects of microaggressions?

Although microaggressions may be unconscious and unintentional by the offender, the negative ramifications are notable. Recent studies report that women and underrepresented minority (URM) medical students, residents, and physicians experience microaggressions and implicit bias at a higher prevalence and frequency compared with their male and non-URM counterparts.^7,9 Repetitive microaggressions are harmful to the health and safety of women and URM medical students, residents, physicians, other providers, and patients. The Table provides example scenarios of microaggressions in medicine categorized according to Berk.¹⁰

Microaggressions negatively impact physical, mental, and emotional well-being. Current data support that medical students and residents who experience microaggressions are more likely to report associated symptoms of burnout, depression, and suicidal thoughts.^11,12 Subjection to persistent bias can lead to minority status stress and racial battle fatigue, creating feelings of invisibility, isolation, exclusion, and loneliness for those impacted.^13,14

In the book Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine, Damon Tweedy, MD, reflects on race in medicine. Tweedy notes his experience as a medical student when a professor mistakenly assumed he was a maintenance worker in the classroom. Tweedy describes how he internalized the exchange and, despite his success throughout the course of his medical training, combatted feelings of anxiety, self-doubt, and implied inferiority.¹⁵

Although microaggressions are harmful to one’s health, they also undermine the learning and teaching experience for students, residents, and faculty, and they detract from the larger goal of providing care for patients.¹¹ Frequent devaluing and questioning of an individual’s contributions, qualifications, and credentials based on identity can lower productivity and problem-solving abilities. These behaviors cultivate an unwelcome and hostile work/learning environment that is stressful and polarizing for the recipient.

Despite the heavy burden of microaggressions, most students, residents, and faculty physicians do not report incidents to their institutions and feel that training, resources, and policies to respond to bias adequately are lacking.⁷ As a result of implicit bias and microaggressions, women and URM medical students and providers are unable to focus solely on the practice of medicine. They are tasked with the additional burden of shouldering the emotional and cognitive complexities that microaggressions produce.¹⁶

What are strategies to reduce microaggressions in medicine?

To minimize the harmful effects of microaggressions, intervention strategies must be implemented that reduce the likelihood of the occurrence of microaggressions and challenge the stereotypes that undergird implicit bias. These strategies include cultivating allies, followed by demanding structural accountability. Allies are members of the majority group who collectively collaborate with members of the nonmajority group to effect change through the promotion of diversity, equity, and inclusion efforts.¹⁷ Cultivating allies involves building a network of collaboration among these groups and emphasizes education. Education is critical for allies to address microaggressions at the interpersonal level. This process of education involves personal reflection and self-awareness in exploring one’s biases, fears, and assumptions. Integral to this step is broadening one’s acceptance of different cultures, racial/ethnic groups, and identities. There must be a willingness to engage in difficult or uncomfortable conversations and a readiness to actively listen to concerns rather than perpetuating further harm through avoidance and dismissive or defensive behavior.¹⁸

Demanding structural accountability facilitates deconstruction of bias and microaggression at the larger systemic level. This strategy involves implicit bias and antiracism training, development of retention plans, and identification of mentors for women and URM providers and students. Implicit bias and microaggression training and policies should be incorporated into medical education and resident curriculums. Similarly, educational resources and training must be made available to practicing physicians, faculty, and other providers through their institutions and places of employment. Equipping students and providers with the tools needed when microaggressions are witnessed or experienced demonstrates systemic-level accountability and communicates the importance of the issue. Furthermore, the development of retention plans and identification of mentors provide a support system and foster a culture of inclusion where recipients of microaggressions feel protected and valued. Increased feelings of inclusivity and belonging help bridge the gap created through microaggressions and implicit bias.

Final Thoughts

Despite an often covert nature, the detrimental effects of microaggressions are tangible and far reaching. As providers, we must strive to understand all categories of racism and expose the many ways prejudice manifests within medical training and clinical practice. It is our obligation to undertake the challenge of “making the ‘invisible’ visible” as we confront microaggressions and implicit bias to promote a safer and more inclusive medical community and workforce.¹⁹

As manifestations of overt racism and macroaggressions have gained increased visibility, there is a need for discussion of another expression of racism: microaggressions. Although racism classically is viewed as blatant structural, attitudinal, and behavioral prejudice, experts pose that the face of racism has evolved into a more covert insidious form. This form of racism was originally coined racial microaggressions by psychiatrist Chester M. Pierce, MD, 50 years ago.^1,2 Since that time, microaggressions have further expanded to describe “brief and commonplace daily verbal, behavioral, and environmental indignities, whether intentional or unintentional, that communicate hostile, derogatory, or negative racial, gender, sexual-orientation, and religious slights and insults to the target person or group.” ³ This article aims to define and depict examples of microaggressions in medicine, discuss the resulting harmful effects, and offer strategies to minimize and counter these negative ramifications.

What are microaggressions?

Microaggressions are behaviors that stem from implicit bias and occur at an interpersonal level. Implicit bias refers to unconscious stereotypes, assumptions, and beliefs held about an individual’s identity. One of the earliest microaggressions—invisibility—was characterized by Ralph Ellison in his novel Invisible Man. Ellison states, “I am invisible, understand, simply because people refuse to see me . . . When they approach me they see only my surroundings, themselves, or figments of their imagination—indeed, everything and anything except me.”⁴ This concept of invisibility is a primary microaggression faced by people of color.

In medicine, microaggressions and implicit bias may be encountered throughout medical training and clinical practice in interactions with colleagues, superiors, patients, and patients’ families.^5,6 Examples of microaggressions in medicine include demeaning comments, nonverbal disrespect, generalizations of social identity, assumption of nonphysician status, role- or credential-questioning behavior, explicit epithets, rejection of care, questioning or inquiries of ethnic/racial origin, and sexual harassment.⁷

An example of microaggressions in medicine was fully displayed when physician Tamika Cross described her experience of being turned away from helping an unresponsive passenger during a flight emergency.

[T]he flight attendant yells “call overhead for a physician on board.” I raised my hand to grab her attention. She said to me “oh no sweetie put [your] hand down, we are looking for actual physicians or nurses or some type of medical personnel, we don’t have time to talk to you” . . . Another “seasoned” white male approaches the row and says he is a physician as well. She says to me “thanks for your help but he can help us, and he has his credentials.”⁸

What are the effects of microaggressions?

Although microaggressions may be unconscious and unintentional by the offender, the negative ramifications are notable. Recent studies report that women and underrepresented minority (URM) medical students, residents, and physicians experience microaggressions and implicit bias at a higher prevalence and frequency compared with their male and non-URM counterparts.^7,9 Repetitive microaggressions are harmful to the health and safety of women and URM medical students, residents, physicians, other providers, and patients. The Table provides example scenarios of microaggressions in medicine categorized according to Berk.¹⁰

Microaggressions negatively impact physical, mental, and emotional well-being. Current data support that medical students and residents who experience microaggressions are more likely to report associated symptoms of burnout, depression, and suicidal thoughts.^11,12 Subjection to persistent bias can lead to minority status stress and racial battle fatigue, creating feelings of invisibility, isolation, exclusion, and loneliness for those impacted.^13,14

In the book Black Man in a White Coat: A Doctor’s Reflections on Race and Medicine, Damon Tweedy, MD, reflects on race in medicine. Tweedy notes his experience as a medical student when a professor mistakenly assumed he was a maintenance worker in the classroom. Tweedy describes how he internalized the exchange and, despite his success throughout the course of his medical training, combatted feelings of anxiety, self-doubt, and implied inferiority.¹⁵

Although microaggressions are harmful to one’s health, they also undermine the learning and teaching experience for students, residents, and faculty, and they detract from the larger goal of providing care for patients.¹¹ Frequent devaluing and questioning of an individual’s contributions, qualifications, and credentials based on identity can lower productivity and problem-solving abilities. These behaviors cultivate an unwelcome and hostile work/learning environment that is stressful and polarizing for the recipient.

Despite the heavy burden of microaggressions, most students, residents, and faculty physicians do not report incidents to their institutions and feel that training, resources, and policies to respond to bias adequately are lacking.⁷ As a result of implicit bias and microaggressions, women and URM medical students and providers are unable to focus solely on the practice of medicine. They are tasked with the additional burden of shouldering the emotional and cognitive complexities that microaggressions produce.¹⁶

What are strategies to reduce microaggressions in medicine?

To minimize the harmful effects of microaggressions, intervention strategies must be implemented that reduce the likelihood of the occurrence of microaggressions and challenge the stereotypes that undergird implicit bias. These strategies include cultivating allies, followed by demanding structural accountability. Allies are members of the majority group who collectively collaborate with members of the nonmajority group to effect change through the promotion of diversity, equity, and inclusion efforts.¹⁷ Cultivating allies involves building a network of collaboration among these groups and emphasizes education. Education is critical for allies to address microaggressions at the interpersonal level. This process of education involves personal reflection and self-awareness in exploring one’s biases, fears, and assumptions. Integral to this step is broadening one’s acceptance of different cultures, racial/ethnic groups, and identities. There must be a willingness to engage in difficult or uncomfortable conversations and a readiness to actively listen to concerns rather than perpetuating further harm through avoidance and dismissive or defensive behavior.¹⁸

Demanding structural accountability facilitates deconstruction of bias and microaggression at the larger systemic level. This strategy involves implicit bias and antiracism training, development of retention plans, and identification of mentors for women and URM providers and students. Implicit bias and microaggression training and policies should be incorporated into medical education and resident curriculums. Similarly, educational resources and training must be made available to practicing physicians, faculty, and other providers through their institutions and places of employment. Equipping students and providers with the tools needed when microaggressions are witnessed or experienced demonstrates systemic-level accountability and communicates the importance of the issue. Furthermore, the development of retention plans and identification of mentors provide a support system and foster a culture of inclusion where recipients of microaggressions feel protected and valued. Increased feelings of inclusivity and belonging help bridge the gap created through microaggressions and implicit bias.

Final Thoughts

Despite an often covert nature, the detrimental effects of microaggressions are tangible and far reaching. As providers, we must strive to understand all categories of racism and expose the many ways prejudice manifests within medical training and clinical practice. It is our obligation to undertake the challenge of “making the ‘invisible’ visible” as we confront microaggressions and implicit bias to promote a safer and more inclusive medical community and workforce.¹⁹

In February, an article published by the American Medical Association pointed out that income inequality is likely the cause for health disparity among races.¹ The topic of health disparities was also the subject of the editorial published in the January/February issue, “Systemic racism and health disparities: a statement from editors of family medicine journals” (J Fam Pract. 2021;70:3-5).

It would be interesting to compare health outcomes among Blacks, Latinos, and Whites stratified by income/poverty levels. I suspect that much of the racial inequality would fade with that. There are so many questions to ask in relation to these issues rather than chalk everything up to racism. Does education, dietary choices, exercise, substance abuse, or cultural priorities factor into the differences? If everyone suddenly had equal access to care and equal financial resources, would there be any difference, or would behavior patterns remain unchanged?

I would hope we could avoid groupthink and be willing to intelligently and critically evaluate these issues so that the underlying problems can be effectively addressed.

Steven Mull, MD
Rockford, IL

In February, an article published by the American Medical Association pointed out that income inequality is likely the cause for health disparity among races.¹ The topic of health disparities was also the subject of the editorial published in the January/February issue, “Systemic racism and health disparities: a statement from editors of family medicine journals” (J Fam Pract. 2021;70:3-5).

It would be interesting to compare health outcomes among Blacks, Latinos, and Whites stratified by income/poverty levels. I suspect that much of the racial inequality would fade with that. There are so many questions to ask in relation to these issues rather than chalk everything up to racism. Does education, dietary choices, exercise, substance abuse, or cultural priorities factor into the differences? If everyone suddenly had equal access to care and equal financial resources, would there be any difference, or would behavior patterns remain unchanged?

I would hope we could avoid groupthink and be willing to intelligently and critically evaluate these issues so that the underlying problems can be effectively addressed.

Steven Mull, MD
Rockford, IL

In February, an article published by the American Medical Association pointed out that income inequality is likely the cause for health disparity among races.¹ The topic of health disparities was also the subject of the editorial published in the January/February issue, “Systemic racism and health disparities: a statement from editors of family medicine journals” (J Fam Pract. 2021;70:3-5).

It would be interesting to compare health outcomes among Blacks, Latinos, and Whites stratified by income/poverty levels. I suspect that much of the racial inequality would fade with that. There are so many questions to ask in relation to these issues rather than chalk everything up to racism. Does education, dietary choices, exercise, substance abuse, or cultural priorities factor into the differences? If everyone suddenly had equal access to care and equal financial resources, would there be any difference, or would behavior patterns remain unchanged?

I would hope we could avoid groupthink and be willing to intelligently and critically evaluate these issues so that the underlying problems can be effectively addressed.

Steven Mull, MD
Rockford, IL

It was encouraging to see your editorial, “Systemic racism and health disparities: a statement from editors of family medicine journals” (J Fam Pract. 2021;70:3-5), because to solve a problem you must first recognize the problem exists. There was a publication several years ago that went deeply into this subject.¹ I worked with the Medicaid population for 20 years, and I observed things similar to what was described in that paper.

Health disparities should be looked at as if structured around zip codes. People who live in low-income/­poverty areas usually have to deal with at least 3 main problems. The first issue involves lack of healthy food options. In low-income areas, food choice is often limited, forcing many to purchase their meals from fast food restaurants, dollar stores, or a “corner store.” In addition to being a food desert, a low-income area may have a poor public school system, and studies have shown that good health outcomes are linked to higher education. Poor medical intelligence is another problem connected to low-income patients. These patients tend to have a hard time keeping up with what medicine they are taking and cannot offer much insight into their medical condition. Furthermore, it is possible that in a busy practice, patient education is not what it should be, and a patient’s silence during a visit should not be accepted as an understanding of what a doctor has told them.

Hopefully, recognizing these issues will help provide a starting point for each doctor to gain better awareness into this problem.

Robert W. Sessoms, MD
Daytona Beach, FL

It was encouraging to see your editorial, “Systemic racism and health disparities: a statement from editors of family medicine journals” (J Fam Pract. 2021;70:3-5), because to solve a problem you must first recognize the problem exists. There was a publication several years ago that went deeply into this subject.¹ I worked with the Medicaid population for 20 years, and I observed things similar to what was described in that paper.

Health disparities should be looked at as if structured around zip codes. People who live in low-income/­poverty areas usually have to deal with at least 3 main problems. The first issue involves lack of healthy food options. In low-income areas, food choice is often limited, forcing many to purchase their meals from fast food restaurants, dollar stores, or a “corner store.” In addition to being a food desert, a low-income area may have a poor public school system, and studies have shown that good health outcomes are linked to higher education. Poor medical intelligence is another problem connected to low-income patients. These patients tend to have a hard time keeping up with what medicine they are taking and cannot offer much insight into their medical condition. Furthermore, it is possible that in a busy practice, patient education is not what it should be, and a patient’s silence during a visit should not be accepted as an understanding of what a doctor has told them.

Hopefully, recognizing these issues will help provide a starting point for each doctor to gain better awareness into this problem.

Robert W. Sessoms, MD
Daytona Beach, FL

It was encouraging to see your editorial, “Systemic racism and health disparities: a statement from editors of family medicine journals” (J Fam Pract. 2021;70:3-5), because to solve a problem you must first recognize the problem exists. There was a publication several years ago that went deeply into this subject.¹ I worked with the Medicaid population for 20 years, and I observed things similar to what was described in that paper.

Health disparities should be looked at as if structured around zip codes. People who live in low-income/­poverty areas usually have to deal with at least 3 main problems. The first issue involves lack of healthy food options. In low-income areas, food choice is often limited, forcing many to purchase their meals from fast food restaurants, dollar stores, or a “corner store.” In addition to being a food desert, a low-income area may have a poor public school system, and studies have shown that good health outcomes are linked to higher education. Poor medical intelligence is another problem connected to low-income patients. These patients tend to have a hard time keeping up with what medicine they are taking and cannot offer much insight into their medical condition. Furthermore, it is possible that in a busy practice, patient education is not what it should be, and a patient’s silence during a visit should not be accepted as an understanding of what a doctor has told them.

Hopefully, recognizing these issues will help provide a starting point for each doctor to gain better awareness into this problem.

Robert W. Sessoms, MD
Daytona Beach, FL

The American Heart Association and the American College of Cardiology have issued a new report on medical ethics and professionalism in cardiovascular medicine.

The report addresses a variety of topics including diversity, equity, inclusion, and belonging; racial, ethnic and gender inequities; conflicts of interest; clinician well-being; data privacy; social justice; and modern health care delivery systems.

The 54-page report is based on the proceedings of the joint 2020 Consensus Conference on Professionalism and Ethics, held Oct. 19 and 20, 2020. It was published online May 11 in Circulation and the Journal of the American College of Cardiology .

The 2020 consensus conference on professionalism and ethics came at a time even more fraught than the eras of the three previous meetings on the same topics, held in 1989, 1997, and 2004, the writing group notes.

“We have seen the COVID-19 pandemic challenge the physical and economic health of the entire country, coupled with a series of national tragedies that have awakened the call for social justice,” conference cochair C. Michael Valentine, MD, said in a news release.

“There is no better time than now to review, evaluate, and take a fresh perspective on medical ethics and professionalism,” said Dr. Valentine, professor of medicine at the Heart and Vascular Center, University of Virginia, Charlottesville.

“We hope this report will provide cardiovascular professionals and health systems with the recommendations and tools they need to address conflicts of interest; racial, ethnic, and gender inequities; and improve diversity, inclusion, and wellness among our workforce,” Dr. Valentine added. “The majority of our members are now employed and must be engaged as the leaders for change in cardiovascular care.”
 

Road map to improve diversity, achieve allyship

The writing committee was made up of a diverse group of cardiologists, internists, and associated health care professionals and laypeople and was organized into five task forces, each addressing a specific topic: conflicts of interest; diversity, equity, inclusion, and belonging; clinician well-being; patient autonomy, privacy, and social justice in health care; and modern health care delivery.

The report serves as a road map to achieve equity, inclusion, and belonging among cardiovascular professionals and calls for ongoing assessment of the professional culture and climate, focused on improving diversity and achieving effective allyship, the writing group says.

The report proposes continuous training to address individual, structural, and systemic racism, sexism, homophobia, classism, and ableism.

It offers recommendations for championing equity in patient care that include an annual review of practice records to look for differences in patient treatment by race, ethnicity, zip code, and primary language.

The report calls for a foundation of training in allyship and antiracism as part of medical school course requirements and experiences: A required course on social justice, race, and racism as part of the first-year curriculum; school programs and professional organizations supporting students, trainees, and members in allyship and antiracism action; and facilitating immersion and partnership with surrounding communities.

“As much as 80% of a person’s health is determined by the social and economic conditions of their environment,” consensus cochair Ivor Benjamin, MD, said in the release.

“To achieve social justice and mitigate health disparities, we must go to the margins and shift our discussions to be inclusive of populations such as rural and marginalized groups from the perspective of health equity lens for all,” said Dr. Benjamin, professor of medicine, Medical College of Wisconsin, Milwaukee.

The report also highlights the need for psychosocial support of the cardiovascular community and recommends that health care organizations prioritize regular assessment of clinicians’ well-being and engagement.

It also recommends addressing the well-being of trainees in postgraduate training programs and calls for an ombudsman program that allows for confidential reporting of mistreatment and access to support.

The report also highlights additional opportunities to:

• improve the efficiency of health information technology, such as electronic health records, and reduce the administrative burden
• identify and assist clinicians who experience mental health conditions, , or 
• emphasize patient autonomy using shared decision-making and patient-centered care that is supportive of the individual patient’s values
• increase privacy protections for patient data used in research
• maintain integrity as new ways of delivering care, such as telemedicine, team-based care approaches, and physician-owned specialty centers emerge
• perform routine audits of electronic health records to promote optimal patient care, as well as ethical medical practice
• expand and make mandatory the reporting of intellectual or associational interests in addition to relationships with industry

The report’s details and recommendations will be presented and discussed Saturday, May 15, at 8:00 AM ET, during ACC.21. The session is titled Diversity and Equity: The Means to Expand Inclusion and Belonging.

The AHA will present a live webinar and six-episode podcast series (available on demand) to highlight the report’s details, dialogue, and actionable steps for cardiovascular and health care professionals, researchers, and educators.

This research had no commercial funding. The list of 40 volunteer committee members and coauthors, including their disclosures, are listed in the original report.

A version of this article first appeared on Medscape.com.

The American Heart Association and the American College of Cardiology have issued a new report on medical ethics and professionalism in cardiovascular medicine.

The report addresses a variety of topics including diversity, equity, inclusion, and belonging; racial, ethnic and gender inequities; conflicts of interest; clinician well-being; data privacy; social justice; and modern health care delivery systems.

The 54-page report is based on the proceedings of the joint 2020 Consensus Conference on Professionalism and Ethics, held Oct. 19 and 20, 2020. It was published online May 11 in Circulation and the Journal of the American College of Cardiology .

The 2020 consensus conference on professionalism and ethics came at a time even more fraught than the eras of the three previous meetings on the same topics, held in 1989, 1997, and 2004, the writing group notes.

“We have seen the COVID-19 pandemic challenge the physical and economic health of the entire country, coupled with a series of national tragedies that have awakened the call for social justice,” conference cochair C. Michael Valentine, MD, said in a news release.

“There is no better time than now to review, evaluate, and take a fresh perspective on medical ethics and professionalism,” said Dr. Valentine, professor of medicine at the Heart and Vascular Center, University of Virginia, Charlottesville.

“We hope this report will provide cardiovascular professionals and health systems with the recommendations and tools they need to address conflicts of interest; racial, ethnic, and gender inequities; and improve diversity, inclusion, and wellness among our workforce,” Dr. Valentine added. “The majority of our members are now employed and must be engaged as the leaders for change in cardiovascular care.”
 

Road map to improve diversity, achieve allyship

The writing committee was made up of a diverse group of cardiologists, internists, and associated health care professionals and laypeople and was organized into five task forces, each addressing a specific topic: conflicts of interest; diversity, equity, inclusion, and belonging; clinician well-being; patient autonomy, privacy, and social justice in health care; and modern health care delivery.

The report serves as a road map to achieve equity, inclusion, and belonging among cardiovascular professionals and calls for ongoing assessment of the professional culture and climate, focused on improving diversity and achieving effective allyship, the writing group says.

The report proposes continuous training to address individual, structural, and systemic racism, sexism, homophobia, classism, and ableism.

It offers recommendations for championing equity in patient care that include an annual review of practice records to look for differences in patient treatment by race, ethnicity, zip code, and primary language.

The report calls for a foundation of training in allyship and antiracism as part of medical school course requirements and experiences: A required course on social justice, race, and racism as part of the first-year curriculum; school programs and professional organizations supporting students, trainees, and members in allyship and antiracism action; and facilitating immersion and partnership with surrounding communities.

“As much as 80% of a person’s health is determined by the social and economic conditions of their environment,” consensus cochair Ivor Benjamin, MD, said in the release.

“To achieve social justice and mitigate health disparities, we must go to the margins and shift our discussions to be inclusive of populations such as rural and marginalized groups from the perspective of health equity lens for all,” said Dr. Benjamin, professor of medicine, Medical College of Wisconsin, Milwaukee.

The report also highlights the need for psychosocial support of the cardiovascular community and recommends that health care organizations prioritize regular assessment of clinicians’ well-being and engagement.

It also recommends addressing the well-being of trainees in postgraduate training programs and calls for an ombudsman program that allows for confidential reporting of mistreatment and access to support.

The report also highlights additional opportunities to:

• improve the efficiency of health information technology, such as electronic health records, and reduce the administrative burden
• identify and assist clinicians who experience mental health conditions, , or 
• emphasize patient autonomy using shared decision-making and patient-centered care that is supportive of the individual patient’s values
• increase privacy protections for patient data used in research
• maintain integrity as new ways of delivering care, such as telemedicine, team-based care approaches, and physician-owned specialty centers emerge
• perform routine audits of electronic health records to promote optimal patient care, as well as ethical medical practice
• expand and make mandatory the reporting of intellectual or associational interests in addition to relationships with industry

The report’s details and recommendations will be presented and discussed Saturday, May 15, at 8:00 AM ET, during ACC.21. The session is titled Diversity and Equity: The Means to Expand Inclusion and Belonging.

The AHA will present a live webinar and six-episode podcast series (available on demand) to highlight the report’s details, dialogue, and actionable steps for cardiovascular and health care professionals, researchers, and educators.

This research had no commercial funding. The list of 40 volunteer committee members and coauthors, including their disclosures, are listed in the original report.

A version of this article first appeared on Medscape.com.

The American Heart Association and the American College of Cardiology have issued a new report on medical ethics and professionalism in cardiovascular medicine.

The report addresses a variety of topics including diversity, equity, inclusion, and belonging; racial, ethnic and gender inequities; conflicts of interest; clinician well-being; data privacy; social justice; and modern health care delivery systems.

The 54-page report is based on the proceedings of the joint 2020 Consensus Conference on Professionalism and Ethics, held Oct. 19 and 20, 2020. It was published online May 11 in Circulation and the Journal of the American College of Cardiology .

The 2020 consensus conference on professionalism and ethics came at a time even more fraught than the eras of the three previous meetings on the same topics, held in 1989, 1997, and 2004, the writing group notes.

“We have seen the COVID-19 pandemic challenge the physical and economic health of the entire country, coupled with a series of national tragedies that have awakened the call for social justice,” conference cochair C. Michael Valentine, MD, said in a news release.

“There is no better time than now to review, evaluate, and take a fresh perspective on medical ethics and professionalism,” said Dr. Valentine, professor of medicine at the Heart and Vascular Center, University of Virginia, Charlottesville.

“We hope this report will provide cardiovascular professionals and health systems with the recommendations and tools they need to address conflicts of interest; racial, ethnic, and gender inequities; and improve diversity, inclusion, and wellness among our workforce,” Dr. Valentine added. “The majority of our members are now employed and must be engaged as the leaders for change in cardiovascular care.”
 

Road map to improve diversity, achieve allyship

The writing committee was made up of a diverse group of cardiologists, internists, and associated health care professionals and laypeople and was organized into five task forces, each addressing a specific topic: conflicts of interest; diversity, equity, inclusion, and belonging; clinician well-being; patient autonomy, privacy, and social justice in health care; and modern health care delivery.

The report serves as a road map to achieve equity, inclusion, and belonging among cardiovascular professionals and calls for ongoing assessment of the professional culture and climate, focused on improving diversity and achieving effective allyship, the writing group says.

The report proposes continuous training to address individual, structural, and systemic racism, sexism, homophobia, classism, and ableism.

It offers recommendations for championing equity in patient care that include an annual review of practice records to look for differences in patient treatment by race, ethnicity, zip code, and primary language.

The report calls for a foundation of training in allyship and antiracism as part of medical school course requirements and experiences: A required course on social justice, race, and racism as part of the first-year curriculum; school programs and professional organizations supporting students, trainees, and members in allyship and antiracism action; and facilitating immersion and partnership with surrounding communities.

“As much as 80% of a person’s health is determined by the social and economic conditions of their environment,” consensus cochair Ivor Benjamin, MD, said in the release.

“To achieve social justice and mitigate health disparities, we must go to the margins and shift our discussions to be inclusive of populations such as rural and marginalized groups from the perspective of health equity lens for all,” said Dr. Benjamin, professor of medicine, Medical College of Wisconsin, Milwaukee.

The report also highlights the need for psychosocial support of the cardiovascular community and recommends that health care organizations prioritize regular assessment of clinicians’ well-being and engagement.

It also recommends addressing the well-being of trainees in postgraduate training programs and calls for an ombudsman program that allows for confidential reporting of mistreatment and access to support.

The report also highlights additional opportunities to:

• improve the efficiency of health information technology, such as electronic health records, and reduce the administrative burden
• identify and assist clinicians who experience mental health conditions, , or 
• emphasize patient autonomy using shared decision-making and patient-centered care that is supportive of the individual patient’s values
• increase privacy protections for patient data used in research
• maintain integrity as new ways of delivering care, such as telemedicine, team-based care approaches, and physician-owned specialty centers emerge
• perform routine audits of electronic health records to promote optimal patient care, as well as ethical medical practice
• expand and make mandatory the reporting of intellectual or associational interests in addition to relationships with industry

The report’s details and recommendations will be presented and discussed Saturday, May 15, at 8:00 AM ET, during ACC.21. The session is titled Diversity and Equity: The Means to Expand Inclusion and Belonging.

The AHA will present a live webinar and six-episode podcast series (available on demand) to highlight the report’s details, dialogue, and actionable steps for cardiovascular and health care professionals, researchers, and educators.

This research had no commercial funding. The list of 40 volunteer committee members and coauthors, including their disclosures, are listed in the original report.

A version of this article first appeared on Medscape.com.

The health disparities seen in today’s high rates of Black infant and maternal morbidity and mortality are rooted in health inequities and generational stress dating back centuries in the United States, but today’s obstetricians can make changes in their own practices to address this inequity, according to Haywood L. Brown, MD, professor of ob.gyn. and associate dean of diversity at the Morsani College of Medicine and vice president of institutional equity at the University of South Florida, Tampa.

Dr. Brown delivered his remarks during the Benson and Pamela Harer Seminar on History at the annual meeting of the American College of Obstetricians and Gynecologists on May 2. His talk focused on the origins of perinatal and maternal health inequities and how those original factors play out today in increased maternal and neonatal morbidity and mortality among Black women and their babies.

“Racial and ethnic disparities and inequity in maternal and child health are prevalent and persistent. We have to move beyond the documentation,” Dr. Brown told attendees. “We have to adopt uniform care standards, recognizing our own biases and understanding that the contribution of social determinants of health are important in the care and outcome of women. And we have to work on decreasing the stress of women who give birth.”

Evelyn Nicole Mitchell, MD, faculty chair of the ob.gyn. diversity and inclusion committee at the University of Southern California, found Dr. Brown’s talk compelling and hopes it opens the eyes of others who attended.

“You really have to understand the why behind the problems we have, and it really goes back to slavery and this historical distrust that’s been here from the beginning,” Dr. Mitchell said in an interview. “I hope this allows people to open their eyes and think about this situation from their patients’ shoes, to really put their guard down and explore, ‘how can I contribute to fixing this system that has been here from the beginning?’ I think a lot of people get defensive and think: ‘Oh, I’m not a racist. I just don’t want to talk about this,’ but it’s about a system being racist.” The question then, Dr. Mitchell said, is: “So how do I contribute to that system?”

Dr. Brown frequently returned to the theme of high stress levels in Black mothers contributing to poorer outcomes, such as preterm birth. That stress arises originally from the generational stress brought on by racism and oppression over the centuries but has been compounded by poverty, racial injustice, lack of access to adequate nutrition, lower education levels, environmental factors, and other determinants of health.

“The bottom line, as Dr. Brown said, is that we need to decrease the stress level of Black mothers giving birth,” Dr. Mitchell said. “How can I, as a provider, decrease the stress level of my patients? Well, No. 1, I can identify and eliminate implicit bias that I may harbor.”
 

Slavery husbandry laid the groundwork for today

The most surprising aspect of Dr. Brown’s lecture for Dr. Mitchell was the fact that enslaved women received a measure of protection that other enslaved people did not to “ensure that they were healthy and that they were able to reproduce in the future,” Dr. Mitchell said. “It was for the wrong reasons – to keep slavery going – but in a sense they were prioritizing Black women to take advantage of their reproductive capacity, compared to nowadays where Black women are facing severe disparities.”

To safeguard enslaved women’s fecundity, plantation owners attempted to reduce stressors in the women’s lives, such as allowing them to cohabitate with a husband and nuclear family, though sexual assault and abuse still occurred. The owners also tracked the enslaved girls’ menstrual cycles after menarche to maximize their “breeding” potential, especially between the ages of 15 and 24. Slave owners delegated older enslaved women as maternity caregivers and midwives, leading to the passing down of midwifery skills through generations of Black American women.

“Pregnant women received the best medical care on the plantation because of the premium placed on reproduction,” Dr. Brown said. Wealthier planters called in doctors for complicated deliveries, which provided J. Marian Sims the ability conduct surgical experiments on Betsey, Lucy, and Anarcha to treat vesicovaginal fistula since fistula “limited her ability to do the maximum work she could in the house or on the plantation,” Dr. Brown said.

After slavery ended, health care access did not improve for Black people. In 1920, there was approximately 1 Black physician for every 3,000 Black people, compared with 1 in 500 for the White population, and grannie midwives continued to be the primary birthing attendants for Black women. Over the next several decades, however, both maternal and infant mortality across all races began steeply dropping. Reasons for the drop included the incorporation of the American Board of Obstetrics and Gynecology in 1930, a shift from home births to hospital births, and the legalization of abortion, which led to an 89% decline in deaths from septic illegal abortions from 1950 to 1973.

Still, Black maternal and infant mortality remained higher than White, and the poverty gap further exacerbated outcomes.

“Substandard maternity care really is the origin of many of the Black maternal and infant morbidity and mortality” complications, such as low birth weight, small for gestational age, growth restriction, and intrauterine starvation, “which we now believe are the origin of things like hypertension, diabetes, and obesity,” Dr. Brown said.

Today, inequities persist because of the systemic racism throughout this history.

“As we talk about health disparities, prematurity, growth restriction, and maternal morbidity, the fetal origins for adult disease in diabetes and hypertension and obesity have generational implications over the last 400 years,” Dr. Brown said. “Generational stress and stresses in lack women from slavery to present times are some of the origins of the things that we see today, including segregation, economic inequities, eugenic sterilizations, the quality of education, and of course, systemic racism on health care access and quality.”

It is this long arc of history that Dr. Mitchell hopes attendees will begin to grasp.

“If you don’t understand all that and have that depth, there’s no way for you to truly understand the problems that are going on and how to solve them,” Dr. Mitchell said. She hopes that especially those who have been more “resistant to accepting these truths” can start to see the big picture. “Hopefully, they can look at it as a systemic problem and then focus on how they can change the system.”

Dr Brown is a contributor to UpToDate and the Merck Manual and serves on the advisory boards of Merck for Mothers Global Women’s Health and BabyScripts. Dr. Mitchell has no disclosures.

The health disparities seen in today’s high rates of Black infant and maternal morbidity and mortality are rooted in health inequities and generational stress dating back centuries in the United States, but today’s obstetricians can make changes in their own practices to address this inequity, according to Haywood L. Brown, MD, professor of ob.gyn. and associate dean of diversity at the Morsani College of Medicine and vice president of institutional equity at the University of South Florida, Tampa.

Dr. Brown delivered his remarks during the Benson and Pamela Harer Seminar on History at the annual meeting of the American College of Obstetricians and Gynecologists on May 2. His talk focused on the origins of perinatal and maternal health inequities and how those original factors play out today in increased maternal and neonatal morbidity and mortality among Black women and their babies.

“Racial and ethnic disparities and inequity in maternal and child health are prevalent and persistent. We have to move beyond the documentation,” Dr. Brown told attendees. “We have to adopt uniform care standards, recognizing our own biases and understanding that the contribution of social determinants of health are important in the care and outcome of women. And we have to work on decreasing the stress of women who give birth.”

Evelyn Nicole Mitchell, MD, faculty chair of the ob.gyn. diversity and inclusion committee at the University of Southern California, found Dr. Brown’s talk compelling and hopes it opens the eyes of others who attended.

“You really have to understand the why behind the problems we have, and it really goes back to slavery and this historical distrust that’s been here from the beginning,” Dr. Mitchell said in an interview. “I hope this allows people to open their eyes and think about this situation from their patients’ shoes, to really put their guard down and explore, ‘how can I contribute to fixing this system that has been here from the beginning?’ I think a lot of people get defensive and think: ‘Oh, I’m not a racist. I just don’t want to talk about this,’ but it’s about a system being racist.” The question then, Dr. Mitchell said, is: “So how do I contribute to that system?”

Dr. Brown frequently returned to the theme of high stress levels in Black mothers contributing to poorer outcomes, such as preterm birth. That stress arises originally from the generational stress brought on by racism and oppression over the centuries but has been compounded by poverty, racial injustice, lack of access to adequate nutrition, lower education levels, environmental factors, and other determinants of health.

“The bottom line, as Dr. Brown said, is that we need to decrease the stress level of Black mothers giving birth,” Dr. Mitchell said. “How can I, as a provider, decrease the stress level of my patients? Well, No. 1, I can identify and eliminate implicit bias that I may harbor.”
 

Slavery husbandry laid the groundwork for today

The most surprising aspect of Dr. Brown’s lecture for Dr. Mitchell was the fact that enslaved women received a measure of protection that other enslaved people did not to “ensure that they were healthy and that they were able to reproduce in the future,” Dr. Mitchell said. “It was for the wrong reasons – to keep slavery going – but in a sense they were prioritizing Black women to take advantage of their reproductive capacity, compared to nowadays where Black women are facing severe disparities.”

To safeguard enslaved women’s fecundity, plantation owners attempted to reduce stressors in the women’s lives, such as allowing them to cohabitate with a husband and nuclear family, though sexual assault and abuse still occurred. The owners also tracked the enslaved girls’ menstrual cycles after menarche to maximize their “breeding” potential, especially between the ages of 15 and 24. Slave owners delegated older enslaved women as maternity caregivers and midwives, leading to the passing down of midwifery skills through generations of Black American women.

“Pregnant women received the best medical care on the plantation because of the premium placed on reproduction,” Dr. Brown said. Wealthier planters called in doctors for complicated deliveries, which provided J. Marian Sims the ability conduct surgical experiments on Betsey, Lucy, and Anarcha to treat vesicovaginal fistula since fistula “limited her ability to do the maximum work she could in the house or on the plantation,” Dr. Brown said.

After slavery ended, health care access did not improve for Black people. In 1920, there was approximately 1 Black physician for every 3,000 Black people, compared with 1 in 500 for the White population, and grannie midwives continued to be the primary birthing attendants for Black women. Over the next several decades, however, both maternal and infant mortality across all races began steeply dropping. Reasons for the drop included the incorporation of the American Board of Obstetrics and Gynecology in 1930, a shift from home births to hospital births, and the legalization of abortion, which led to an 89% decline in deaths from septic illegal abortions from 1950 to 1973.

Still, Black maternal and infant mortality remained higher than White, and the poverty gap further exacerbated outcomes.

“Substandard maternity care really is the origin of many of the Black maternal and infant morbidity and mortality” complications, such as low birth weight, small for gestational age, growth restriction, and intrauterine starvation, “which we now believe are the origin of things like hypertension, diabetes, and obesity,” Dr. Brown said.

Today, inequities persist because of the systemic racism throughout this history.

“As we talk about health disparities, prematurity, growth restriction, and maternal morbidity, the fetal origins for adult disease in diabetes and hypertension and obesity have generational implications over the last 400 years,” Dr. Brown said. “Generational stress and stresses in lack women from slavery to present times are some of the origins of the things that we see today, including segregation, economic inequities, eugenic sterilizations, the quality of education, and of course, systemic racism on health care access and quality.”

It is this long arc of history that Dr. Mitchell hopes attendees will begin to grasp.

“If you don’t understand all that and have that depth, there’s no way for you to truly understand the problems that are going on and how to solve them,” Dr. Mitchell said. She hopes that especially those who have been more “resistant to accepting these truths” can start to see the big picture. “Hopefully, they can look at it as a systemic problem and then focus on how they can change the system.”

Dr Brown is a contributor to UpToDate and the Merck Manual and serves on the advisory boards of Merck for Mothers Global Women’s Health and BabyScripts. Dr. Mitchell has no disclosures.

The health disparities seen in today’s high rates of Black infant and maternal morbidity and mortality are rooted in health inequities and generational stress dating back centuries in the United States, but today’s obstetricians can make changes in their own practices to address this inequity, according to Haywood L. Brown, MD, professor of ob.gyn. and associate dean of diversity at the Morsani College of Medicine and vice president of institutional equity at the University of South Florida, Tampa.

Dr. Brown delivered his remarks during the Benson and Pamela Harer Seminar on History at the annual meeting of the American College of Obstetricians and Gynecologists on May 2. His talk focused on the origins of perinatal and maternal health inequities and how those original factors play out today in increased maternal and neonatal morbidity and mortality among Black women and their babies.

“Racial and ethnic disparities and inequity in maternal and child health are prevalent and persistent. We have to move beyond the documentation,” Dr. Brown told attendees. “We have to adopt uniform care standards, recognizing our own biases and understanding that the contribution of social determinants of health are important in the care and outcome of women. And we have to work on decreasing the stress of women who give birth.”

Evelyn Nicole Mitchell, MD, faculty chair of the ob.gyn. diversity and inclusion committee at the University of Southern California, found Dr. Brown’s talk compelling and hopes it opens the eyes of others who attended.

“You really have to understand the why behind the problems we have, and it really goes back to slavery and this historical distrust that’s been here from the beginning,” Dr. Mitchell said in an interview. “I hope this allows people to open their eyes and think about this situation from their patients’ shoes, to really put their guard down and explore, ‘how can I contribute to fixing this system that has been here from the beginning?’ I think a lot of people get defensive and think: ‘Oh, I’m not a racist. I just don’t want to talk about this,’ but it’s about a system being racist.” The question then, Dr. Mitchell said, is: “So how do I contribute to that system?”

Dr. Brown frequently returned to the theme of high stress levels in Black mothers contributing to poorer outcomes, such as preterm birth. That stress arises originally from the generational stress brought on by racism and oppression over the centuries but has been compounded by poverty, racial injustice, lack of access to adequate nutrition, lower education levels, environmental factors, and other determinants of health.

“The bottom line, as Dr. Brown said, is that we need to decrease the stress level of Black mothers giving birth,” Dr. Mitchell said. “How can I, as a provider, decrease the stress level of my patients? Well, No. 1, I can identify and eliminate implicit bias that I may harbor.”
 

Slavery husbandry laid the groundwork for today

The most surprising aspect of Dr. Brown’s lecture for Dr. Mitchell was the fact that enslaved women received a measure of protection that other enslaved people did not to “ensure that they were healthy and that they were able to reproduce in the future,” Dr. Mitchell said. “It was for the wrong reasons – to keep slavery going – but in a sense they were prioritizing Black women to take advantage of their reproductive capacity, compared to nowadays where Black women are facing severe disparities.”

To safeguard enslaved women’s fecundity, plantation owners attempted to reduce stressors in the women’s lives, such as allowing them to cohabitate with a husband and nuclear family, though sexual assault and abuse still occurred. The owners also tracked the enslaved girls’ menstrual cycles after menarche to maximize their “breeding” potential, especially between the ages of 15 and 24. Slave owners delegated older enslaved women as maternity caregivers and midwives, leading to the passing down of midwifery skills through generations of Black American women.

“Pregnant women received the best medical care on the plantation because of the premium placed on reproduction,” Dr. Brown said. Wealthier planters called in doctors for complicated deliveries, which provided J. Marian Sims the ability conduct surgical experiments on Betsey, Lucy, and Anarcha to treat vesicovaginal fistula since fistula “limited her ability to do the maximum work she could in the house or on the plantation,” Dr. Brown said.

After slavery ended, health care access did not improve for Black people. In 1920, there was approximately 1 Black physician for every 3,000 Black people, compared with 1 in 500 for the White population, and grannie midwives continued to be the primary birthing attendants for Black women. Over the next several decades, however, both maternal and infant mortality across all races began steeply dropping. Reasons for the drop included the incorporation of the American Board of Obstetrics and Gynecology in 1930, a shift from home births to hospital births, and the legalization of abortion, which led to an 89% decline in deaths from septic illegal abortions from 1950 to 1973.

Still, Black maternal and infant mortality remained higher than White, and the poverty gap further exacerbated outcomes.

“Substandard maternity care really is the origin of many of the Black maternal and infant morbidity and mortality” complications, such as low birth weight, small for gestational age, growth restriction, and intrauterine starvation, “which we now believe are the origin of things like hypertension, diabetes, and obesity,” Dr. Brown said.

Today, inequities persist because of the systemic racism throughout this history.

“As we talk about health disparities, prematurity, growth restriction, and maternal morbidity, the fetal origins for adult disease in diabetes and hypertension and obesity have generational implications over the last 400 years,” Dr. Brown said. “Generational stress and stresses in lack women from slavery to present times are some of the origins of the things that we see today, including segregation, economic inequities, eugenic sterilizations, the quality of education, and of course, systemic racism on health care access and quality.”

It is this long arc of history that Dr. Mitchell hopes attendees will begin to grasp.

“If you don’t understand all that and have that depth, there’s no way for you to truly understand the problems that are going on and how to solve them,” Dr. Mitchell said. She hopes that especially those who have been more “resistant to accepting these truths” can start to see the big picture. “Hopefully, they can look at it as a systemic problem and then focus on how they can change the system.”

Dr Brown is a contributor to UpToDate and the Merck Manual and serves on the advisory boards of Merck for Mothers Global Women’s Health and BabyScripts. Dr. Mitchell has no disclosures.

The American Medical Association has released a 3-year strategic plan to counter longstanding health inequities that hurt marginalized communities and to improve the AMA’s own performance in this regard.

The 82-page report, which was created by the association’s Center for Health Equity, argues for both internal changes at the AMA and changes in how the association addresses race-based inequities in general.

The report was released just 2 months after this news organization reported that a podcast hosted by AMA’s top journal was lambasted as racist and out of touch. In the podcast – entitled “Stuctural Racism for Doctors – What Is It?” – one JAMA editor argued that structural racism doesn’t exist. He eventually resigned and the journal’s top editor was placed on administration leave.

The new AMA report’s strategic framework “is driven by the immense need for equity-centered solutions to confront harms produced by systemic racism and other forms of oppression for Black, Latinx, Indigenous, Asian, and other people of color, as well as people who identify as LGBTQ+ and people with disabilities,” the AMA said in a news release. “Its urgency is underscored by ongoing circumstances including inequities exacerbated by the COVID-19 pandemic, ongoing police brutality, and hate crimes targeting Asian, Black, and Brown communities.”

The plan includes five main approaches to addressing inequities in health care and the AMA:

• Implement antiracist equity strategies through AMA practices, programming, policies, and culture.
• Build alliances with marginalized doctors and other stakeholders to elevate the experiences and ideas of historically marginalized and minority health care leaders.
• Strengthen, empower, and equip doctors with the knowledge and tools to dismantle structural and social health inequities.
• Ensure equitable opportunities in innovation.
• Foster truth, racial healing, reconciliation, and transformation for AMA’s past by accounting for how policies and processes excluded, discriminated, and harmed communities.

As the report acknowledges, the AMA has a long history of exclusion of and discrimination against Black physicians, for which the association publicly apologized in 2008. Within the past year, the AMA has reaffirmed its commitment to addressing this legacy and to be proactive on health equity.

Among other things, the association has described racism as a public health crisis, stated that race has nothing to do with biology, said police brutality is a product of structural racism, and called on the federal government to collect and release COVID-19 race/ethnicity data. It also removed the name of AMA founder Nathan Davis, MD, from an annual award and display because of his contribution to explicit racist practices.
 

Equity-centered solutions

The AMA launched its Center for Health Equity in 2019 with a mandate “to embed health equity across the organization.” Aletha Maybank, MD, was named the AMA’s chief health equity officer to lead the center.

In the report that Dr. Maybank helped write, the AMA discusses the consequences of individual and systemic injustice toward minorities. Among these consequences, the report said, is “segregated and inequitable health care systems.”

The “equity-centered solutions” listed in the report include:

• End segregated health care.
• Establish national health care equity and racial justice standards.
• End the use of race-based clinical decision models.
• Eliminate all forms of discrimination, exclusion and oppression in medical and physician education, training, hiring, and promotion.
• Prevent exclusion of and ensure equal representation of Black, Indigenous and Latinx people in medical school admissions as well as medical school and hospital leadership ranks.
• Ensure equity in innovation, including design, development, implementation along with support for equitable innovation opportunities and entrepreneurship.
• Solidify connections and coordination between health care and public health.
• Acknowledge and repair past harms committed by institutions.
•  

Changing medical education

In an exclusive interview, Gerald E. Harmon, MD, president-elect of the AMA, singled out medical education as an area that is ripe for change. “One of the most threatened phenotypes on the planet is the Black male physician,” he said. “Their numbers among medical school applicants continue to drop. We have increasing numbers of women in medical schools – over 50% of trainees are women – and more Black women are entering medical school, but Black men in medical school are an endangered species.

“We’re trying to get the physician workforce to look like the patient workforce.”

Dr. Harmon cited the “pipeline program” at the Morehouse School of Medicine in Atlanta and the AMA’s “doctors back to school” program as examples of efforts to attract minority high school students to health care careers. Much more needs to be done, he added. “We have to put equity and representation into our medical workforce so we can provide better high quality, more reliable care for underrepresented patients.”
 

Putting the AMA’s house in order

In its report, the AMA also makes recommendations about how it can improve equity within its own organization. Over the next 3 years, among other things, the association plans to improve the diversity of leadership at the AMA and its journal, JAMA; train all staff on equity requirements; and develop a plan to recruit more racial and ethnic minorities, LGBTQ+ people, and disabled people.

Dr. Maybank, the AMA’s chief health equity officer, said in an interview that she wouldn’t describe these efforts as affirmative action. “This is beyond affirmative action. It’s about intentional activity and action to ensure equity and justice within the AMA.”

The AMA has to thoroughly examine its own processes and determine “how inequity shows up on a day-to-day basis,” she said. “Whether it’s through hiring, innovation, publishing or communications, everybody needs to know how inequity shows up and how their own mental models can exacerbate inequities. People need tools to challenge themselves and ask themselves critical questions about racism in their processes and what they can do to mitigate those.”

A version of this article first appeared on WebMD.com.

The American Medical Association has released a 3-year strategic plan to counter longstanding health inequities that hurt marginalized communities and to improve the AMA’s own performance in this regard.

The 82-page report, which was created by the association’s Center for Health Equity, argues for both internal changes at the AMA and changes in how the association addresses race-based inequities in general.

The report was released just 2 months after this news organization reported that a podcast hosted by AMA’s top journal was lambasted as racist and out of touch. In the podcast – entitled “Stuctural Racism for Doctors – What Is It?” – one JAMA editor argued that structural racism doesn’t exist. He eventually resigned and the journal’s top editor was placed on administration leave.

The new AMA report’s strategic framework “is driven by the immense need for equity-centered solutions to confront harms produced by systemic racism and other forms of oppression for Black, Latinx, Indigenous, Asian, and other people of color, as well as people who identify as LGBTQ+ and people with disabilities,” the AMA said in a news release. “Its urgency is underscored by ongoing circumstances including inequities exacerbated by the COVID-19 pandemic, ongoing police brutality, and hate crimes targeting Asian, Black, and Brown communities.”

The plan includes five main approaches to addressing inequities in health care and the AMA:

• Implement antiracist equity strategies through AMA practices, programming, policies, and culture.
• Build alliances with marginalized doctors and other stakeholders to elevate the experiences and ideas of historically marginalized and minority health care leaders.
• Strengthen, empower, and equip doctors with the knowledge and tools to dismantle structural and social health inequities.
• Ensure equitable opportunities in innovation.
• Foster truth, racial healing, reconciliation, and transformation for AMA’s past by accounting for how policies and processes excluded, discriminated, and harmed communities.

As the report acknowledges, the AMA has a long history of exclusion of and discrimination against Black physicians, for which the association publicly apologized in 2008. Within the past year, the AMA has reaffirmed its commitment to addressing this legacy and to be proactive on health equity.

Among other things, the association has described racism as a public health crisis, stated that race has nothing to do with biology, said police brutality is a product of structural racism, and called on the federal government to collect and release COVID-19 race/ethnicity data. It also removed the name of AMA founder Nathan Davis, MD, from an annual award and display because of his contribution to explicit racist practices.
 

Equity-centered solutions

The AMA launched its Center for Health Equity in 2019 with a mandate “to embed health equity across the organization.” Aletha Maybank, MD, was named the AMA’s chief health equity officer to lead the center.

In the report that Dr. Maybank helped write, the AMA discusses the consequences of individual and systemic injustice toward minorities. Among these consequences, the report said, is “segregated and inequitable health care systems.”

The “equity-centered solutions” listed in the report include:

• End segregated health care.
• Establish national health care equity and racial justice standards.
• End the use of race-based clinical decision models.
• Eliminate all forms of discrimination, exclusion and oppression in medical and physician education, training, hiring, and promotion.
• Prevent exclusion of and ensure equal representation of Black, Indigenous and Latinx people in medical school admissions as well as medical school and hospital leadership ranks.
• Ensure equity in innovation, including design, development, implementation along with support for equitable innovation opportunities and entrepreneurship.
• Solidify connections and coordination between health care and public health.
• Acknowledge and repair past harms committed by institutions.
•  

Changing medical education

In an exclusive interview, Gerald E. Harmon, MD, president-elect of the AMA, singled out medical education as an area that is ripe for change. “One of the most threatened phenotypes on the planet is the Black male physician,” he said. “Their numbers among medical school applicants continue to drop. We have increasing numbers of women in medical schools – over 50% of trainees are women – and more Black women are entering medical school, but Black men in medical school are an endangered species.

“We’re trying to get the physician workforce to look like the patient workforce.”

Dr. Harmon cited the “pipeline program” at the Morehouse School of Medicine in Atlanta and the AMA’s “doctors back to school” program as examples of efforts to attract minority high school students to health care careers. Much more needs to be done, he added. “We have to put equity and representation into our medical workforce so we can provide better high quality, more reliable care for underrepresented patients.”
 

Putting the AMA’s house in order

In its report, the AMA also makes recommendations about how it can improve equity within its own organization. Over the next 3 years, among other things, the association plans to improve the diversity of leadership at the AMA and its journal, JAMA; train all staff on equity requirements; and develop a plan to recruit more racial and ethnic minorities, LGBTQ+ people, and disabled people.

Dr. Maybank, the AMA’s chief health equity officer, said in an interview that she wouldn’t describe these efforts as affirmative action. “This is beyond affirmative action. It’s about intentional activity and action to ensure equity and justice within the AMA.”

The AMA has to thoroughly examine its own processes and determine “how inequity shows up on a day-to-day basis,” she said. “Whether it’s through hiring, innovation, publishing or communications, everybody needs to know how inequity shows up and how their own mental models can exacerbate inequities. People need tools to challenge themselves and ask themselves critical questions about racism in their processes and what they can do to mitigate those.”

A version of this article first appeared on WebMD.com.

The American Medical Association has released a 3-year strategic plan to counter longstanding health inequities that hurt marginalized communities and to improve the AMA’s own performance in this regard.

The 82-page report, which was created by the association’s Center for Health Equity, argues for both internal changes at the AMA and changes in how the association addresses race-based inequities in general.

The report was released just 2 months after this news organization reported that a podcast hosted by AMA’s top journal was lambasted as racist and out of touch. In the podcast – entitled “Stuctural Racism for Doctors – What Is It?” – one JAMA editor argued that structural racism doesn’t exist. He eventually resigned and the journal’s top editor was placed on administration leave.

The new AMA report’s strategic framework “is driven by the immense need for equity-centered solutions to confront harms produced by systemic racism and other forms of oppression for Black, Latinx, Indigenous, Asian, and other people of color, as well as people who identify as LGBTQ+ and people with disabilities,” the AMA said in a news release. “Its urgency is underscored by ongoing circumstances including inequities exacerbated by the COVID-19 pandemic, ongoing police brutality, and hate crimes targeting Asian, Black, and Brown communities.”

The plan includes five main approaches to addressing inequities in health care and the AMA:

• Implement antiracist equity strategies through AMA practices, programming, policies, and culture.
• Build alliances with marginalized doctors and other stakeholders to elevate the experiences and ideas of historically marginalized and minority health care leaders.
• Strengthen, empower, and equip doctors with the knowledge and tools to dismantle structural and social health inequities.
• Ensure equitable opportunities in innovation.
• Foster truth, racial healing, reconciliation, and transformation for AMA’s past by accounting for how policies and processes excluded, discriminated, and harmed communities.

As the report acknowledges, the AMA has a long history of exclusion of and discrimination against Black physicians, for which the association publicly apologized in 2008. Within the past year, the AMA has reaffirmed its commitment to addressing this legacy and to be proactive on health equity.

Among other things, the association has described racism as a public health crisis, stated that race has nothing to do with biology, said police brutality is a product of structural racism, and called on the federal government to collect and release COVID-19 race/ethnicity data. It also removed the name of AMA founder Nathan Davis, MD, from an annual award and display because of his contribution to explicit racist practices.
 

Equity-centered solutions

The AMA launched its Center for Health Equity in 2019 with a mandate “to embed health equity across the organization.” Aletha Maybank, MD, was named the AMA’s chief health equity officer to lead the center.

In the report that Dr. Maybank helped write, the AMA discusses the consequences of individual and systemic injustice toward minorities. Among these consequences, the report said, is “segregated and inequitable health care systems.”

The “equity-centered solutions” listed in the report include:

• End segregated health care.
• Establish national health care equity and racial justice standards.
• End the use of race-based clinical decision models.
• Eliminate all forms of discrimination, exclusion and oppression in medical and physician education, training, hiring, and promotion.
• Prevent exclusion of and ensure equal representation of Black, Indigenous and Latinx people in medical school admissions as well as medical school and hospital leadership ranks.
• Ensure equity in innovation, including design, development, implementation along with support for equitable innovation opportunities and entrepreneurship.
• Solidify connections and coordination between health care and public health.
• Acknowledge and repair past harms committed by institutions.
•  

Changing medical education

In an exclusive interview, Gerald E. Harmon, MD, president-elect of the AMA, singled out medical education as an area that is ripe for change. “One of the most threatened phenotypes on the planet is the Black male physician,” he said. “Their numbers among medical school applicants continue to drop. We have increasing numbers of women in medical schools – over 50% of trainees are women – and more Black women are entering medical school, but Black men in medical school are an endangered species.

“We’re trying to get the physician workforce to look like the patient workforce.”

Dr. Harmon cited the “pipeline program” at the Morehouse School of Medicine in Atlanta and the AMA’s “doctors back to school” program as examples of efforts to attract minority high school students to health care careers. Much more needs to be done, he added. “We have to put equity and representation into our medical workforce so we can provide better high quality, more reliable care for underrepresented patients.”
 

Putting the AMA’s house in order

In its report, the AMA also makes recommendations about how it can improve equity within its own organization. Over the next 3 years, among other things, the association plans to improve the diversity of leadership at the AMA and its journal, JAMA; train all staff on equity requirements; and develop a plan to recruit more racial and ethnic minorities, LGBTQ+ people, and disabled people.

Dr. Maybank, the AMA’s chief health equity officer, said in an interview that she wouldn’t describe these efforts as affirmative action. “This is beyond affirmative action. It’s about intentional activity and action to ensure equity and justice within the AMA.”

The AMA has to thoroughly examine its own processes and determine “how inequity shows up on a day-to-day basis,” she said. “Whether it’s through hiring, innovation, publishing or communications, everybody needs to know how inequity shows up and how their own mental models can exacerbate inequities. People need tools to challenge themselves and ask themselves critical questions about racism in their processes and what they can do to mitigate those.”

A version of this article first appeared on WebMD.com.

Dermatologists and other clinicians should advise their patients with skin of color to practice sensible sun protection, including wearing protective clothing, staying in the shade when outdoors, and applying a tinted sunscreen with an SPF of 30 or greater to exposed areas, according to Henry W. Lim, MD.

In addition, “with rigorous photoprotection, vitamin D supplementation should be advised to patients,” Dr. Lim, a former chair of the department of dermatology at Henry Ford Health System, Detroit, said during the Society for Pediatric Dermatology pre-AAD meeting. “One multivitamin a day should be sufficient for most patients. This is especially relevant because we do know that skin of color patients tend to have lower vitamin D levels to start with.”

Photoprotection for people of color helps minimize the development of photodermatoses, postinflammatory hyperpigmentation, polymorphous light eruption, and chronic actinic dermatitis, he said. In a retrospective chart review of 1,080 people conducted at four academic medical centers in the United States, Dr. Lim and colleagues found a higher proportion of polymorphous light eruption and chronic actinic dermatitis in Black individuals, and a higher proportion of photoallergic contact dermatitis, phototoxic drug eruptions, phytophotodermatitis, porphyria, and solar urticaria in White individuals.

“Another pediatric photodermatosis, actinic prurigo, tends to occur most often in Mestizo individuals, patients of American Indian heritage,” he added. “This is a significant issue, especially in Latin America.”

In a systematic review of 20 studies in the medical literature, researchers assessed the quality of life and psychological impact of photodermatoses in affected patients. Studies included in the review drew from 2,487 adults and 119 children. Among adults, the self-administered Dermatology Life Quality Index (DLQI) revealed that photodermatoses adversely affected employment, education, and leisure activities in adults. Among children, the condition adversely affected outdoor activities and exacerbated symptoms in those with erythropoietic protoporphyria (EPP).

As for skin cancer risk, the association between UV light exposure and the development of melanoma is not as strong in people with skin of color, compared with light-skinned individuals. In a recent systematic review of 13 studies on the topic, 11 showed no association, one showed a small positive relationship in Black males and 1 showed a weak association in Hispanic males.

“The conclusion from this review is that UV protection for melanoma prevention in people of color is not supported by most studies,” said Dr. Lim, who was not affiliated with the review. “The authors also noted, however, that the evidence is of moderate to low quality. Larger studies should be done.”

The association between UV exposure and the development to squamous cell cancer in skin of color is also not strong. “However, we do know that sun exposure is associated with the development of basal cell carcinoma in this population,” he said.

Sunscreen ingredient studies

Dr. Lim also highlighted findings from two studies related to the effect of sunscreen application on plasma concentration of sunscreen active ingredients, both in adults. In the most recent analysis, scientists at the Food and Drug Administration and colleagues conducted a randomized clinical trial in 48 individuals with skin types II-IV.

Participants applied sunscreen at 2 mg/cm² to 75% of body surface area at 0 hours on day 1 and 4 times on day 2 through day 4 at 2-hour intervals. Over the course of 21 days, the researchers collected 34 blood samples from each participant, and evaluated six active ingredients in four sunscreen products: avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate.

For all active ingredients, levels of greater than 0.5 ng/mL were detected after a single application on day 1. Levels of greater than 0.5 ng/mL were detected up to day 7, and up to day 21 for oxybenzone. All were detected in skin on days 7 and 14 via tape stripping. The authors called for further studies to determine the clinical significance of these findings and emphasized that the results “do not indicate that individuals should refrain from the use of sunscreen.”

The FDA is asking for additional studies on the safety of these 12 filters, noted Dr. Lim, who is a past president of the American Academy of Dermatology. On Feb. 26, 2019, the FDA issued a proposed rule regarding sunscreen drug products for over-the-counter human use. It proposes that the 16 UV filters be classified into one of 3 categories. Category I would include zinc oxide and titanium dioxide, which are generally recognized as safe and effective (GRASE). Category II would include PABA and trolamine salicylate, which are not used in the United States and are not GRASE. Category III would include 12 filters that lack insufficient safety data to make a determination regarding GRASE.

The final FDA rule was scheduled to be released in September of 2020, but a result of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the FDA “will be moving from a laborious rulemaking process to an administrative order process, which means it should not take as long to implement a monograph,” Dr. Lim said. “The FDA has decided that there will not be a final rule regarding sunscreen drug products,” but is required to issue a proposed administrative order by Sept. 27, 2021, he said.

When the final administrative order has been issued, manufacturers would have at least 1 year to comply with sunscreen products offered in the United States. “The approximate timeline is probably going to be 2023,” he said.

Dr. Lim disclosed that he is an investigator for Incyte, L’Oreal, Pfizer, and the Patient-centered Outcomes Research Institute, and a consultant for Pierre Fabre, ISDIN, Ferndale, La Roche–Posay, and Beiersdorf. He has been a speaker at general educational sessions sponsored by La Roche–Posay and Cantabria Labs.

[email protected]

Dermatologists and other clinicians should advise their patients with skin of color to practice sensible sun protection, including wearing protective clothing, staying in the shade when outdoors, and applying a tinted sunscreen with an SPF of 30 or greater to exposed areas, according to Henry W. Lim, MD.

In addition, “with rigorous photoprotection, vitamin D supplementation should be advised to patients,” Dr. Lim, a former chair of the department of dermatology at Henry Ford Health System, Detroit, said during the Society for Pediatric Dermatology pre-AAD meeting. “One multivitamin a day should be sufficient for most patients. This is especially relevant because we do know that skin of color patients tend to have lower vitamin D levels to start with.”

Photoprotection for people of color helps minimize the development of photodermatoses, postinflammatory hyperpigmentation, polymorphous light eruption, and chronic actinic dermatitis, he said. In a retrospective chart review of 1,080 people conducted at four academic medical centers in the United States, Dr. Lim and colleagues found a higher proportion of polymorphous light eruption and chronic actinic dermatitis in Black individuals, and a higher proportion of photoallergic contact dermatitis, phototoxic drug eruptions, phytophotodermatitis, porphyria, and solar urticaria in White individuals.

“Another pediatric photodermatosis, actinic prurigo, tends to occur most often in Mestizo individuals, patients of American Indian heritage,” he added. “This is a significant issue, especially in Latin America.”

In a systematic review of 20 studies in the medical literature, researchers assessed the quality of life and psychological impact of photodermatoses in affected patients. Studies included in the review drew from 2,487 adults and 119 children. Among adults, the self-administered Dermatology Life Quality Index (DLQI) revealed that photodermatoses adversely affected employment, education, and leisure activities in adults. Among children, the condition adversely affected outdoor activities and exacerbated symptoms in those with erythropoietic protoporphyria (EPP).

As for skin cancer risk, the association between UV light exposure and the development of melanoma is not as strong in people with skin of color, compared with light-skinned individuals. In a recent systematic review of 13 studies on the topic, 11 showed no association, one showed a small positive relationship in Black males and 1 showed a weak association in Hispanic males.

“The conclusion from this review is that UV protection for melanoma prevention in people of color is not supported by most studies,” said Dr. Lim, who was not affiliated with the review. “The authors also noted, however, that the evidence is of moderate to low quality. Larger studies should be done.”

The association between UV exposure and the development to squamous cell cancer in skin of color is also not strong. “However, we do know that sun exposure is associated with the development of basal cell carcinoma in this population,” he said.

Sunscreen ingredient studies

Dr. Lim also highlighted findings from two studies related to the effect of sunscreen application on plasma concentration of sunscreen active ingredients, both in adults. In the most recent analysis, scientists at the Food and Drug Administration and colleagues conducted a randomized clinical trial in 48 individuals with skin types II-IV.

Participants applied sunscreen at 2 mg/cm² to 75% of body surface area at 0 hours on day 1 and 4 times on day 2 through day 4 at 2-hour intervals. Over the course of 21 days, the researchers collected 34 blood samples from each participant, and evaluated six active ingredients in four sunscreen products: avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate.

For all active ingredients, levels of greater than 0.5 ng/mL were detected after a single application on day 1. Levels of greater than 0.5 ng/mL were detected up to day 7, and up to day 21 for oxybenzone. All were detected in skin on days 7 and 14 via tape stripping. The authors called for further studies to determine the clinical significance of these findings and emphasized that the results “do not indicate that individuals should refrain from the use of sunscreen.”

The FDA is asking for additional studies on the safety of these 12 filters, noted Dr. Lim, who is a past president of the American Academy of Dermatology. On Feb. 26, 2019, the FDA issued a proposed rule regarding sunscreen drug products for over-the-counter human use. It proposes that the 16 UV filters be classified into one of 3 categories. Category I would include zinc oxide and titanium dioxide, which are generally recognized as safe and effective (GRASE). Category II would include PABA and trolamine salicylate, which are not used in the United States and are not GRASE. Category III would include 12 filters that lack insufficient safety data to make a determination regarding GRASE.

The final FDA rule was scheduled to be released in September of 2020, but a result of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the FDA “will be moving from a laborious rulemaking process to an administrative order process, which means it should not take as long to implement a monograph,” Dr. Lim said. “The FDA has decided that there will not be a final rule regarding sunscreen drug products,” but is required to issue a proposed administrative order by Sept. 27, 2021, he said.

When the final administrative order has been issued, manufacturers would have at least 1 year to comply with sunscreen products offered in the United States. “The approximate timeline is probably going to be 2023,” he said.

Dr. Lim disclosed that he is an investigator for Incyte, L’Oreal, Pfizer, and the Patient-centered Outcomes Research Institute, and a consultant for Pierre Fabre, ISDIN, Ferndale, La Roche–Posay, and Beiersdorf. He has been a speaker at general educational sessions sponsored by La Roche–Posay and Cantabria Labs.

[email protected]

Dermatologists and other clinicians should advise their patients with skin of color to practice sensible sun protection, including wearing protective clothing, staying in the shade when outdoors, and applying a tinted sunscreen with an SPF of 30 or greater to exposed areas, according to Henry W. Lim, MD.

In addition, “with rigorous photoprotection, vitamin D supplementation should be advised to patients,” Dr. Lim, a former chair of the department of dermatology at Henry Ford Health System, Detroit, said during the Society for Pediatric Dermatology pre-AAD meeting. “One multivitamin a day should be sufficient for most patients. This is especially relevant because we do know that skin of color patients tend to have lower vitamin D levels to start with.”

Photoprotection for people of color helps minimize the development of photodermatoses, postinflammatory hyperpigmentation, polymorphous light eruption, and chronic actinic dermatitis, he said. In a retrospective chart review of 1,080 people conducted at four academic medical centers in the United States, Dr. Lim and colleagues found a higher proportion of polymorphous light eruption and chronic actinic dermatitis in Black individuals, and a higher proportion of photoallergic contact dermatitis, phototoxic drug eruptions, phytophotodermatitis, porphyria, and solar urticaria in White individuals.

“Another pediatric photodermatosis, actinic prurigo, tends to occur most often in Mestizo individuals, patients of American Indian heritage,” he added. “This is a significant issue, especially in Latin America.”

In a systematic review of 20 studies in the medical literature, researchers assessed the quality of life and psychological impact of photodermatoses in affected patients. Studies included in the review drew from 2,487 adults and 119 children. Among adults, the self-administered Dermatology Life Quality Index (DLQI) revealed that photodermatoses adversely affected employment, education, and leisure activities in adults. Among children, the condition adversely affected outdoor activities and exacerbated symptoms in those with erythropoietic protoporphyria (EPP).

As for skin cancer risk, the association between UV light exposure and the development of melanoma is not as strong in people with skin of color, compared with light-skinned individuals. In a recent systematic review of 13 studies on the topic, 11 showed no association, one showed a small positive relationship in Black males and 1 showed a weak association in Hispanic males.

“The conclusion from this review is that UV protection for melanoma prevention in people of color is not supported by most studies,” said Dr. Lim, who was not affiliated with the review. “The authors also noted, however, that the evidence is of moderate to low quality. Larger studies should be done.”

The association between UV exposure and the development to squamous cell cancer in skin of color is also not strong. “However, we do know that sun exposure is associated with the development of basal cell carcinoma in this population,” he said.

Sunscreen ingredient studies

Dr. Lim also highlighted findings from two studies related to the effect of sunscreen application on plasma concentration of sunscreen active ingredients, both in adults. In the most recent analysis, scientists at the Food and Drug Administration and colleagues conducted a randomized clinical trial in 48 individuals with skin types II-IV.

Participants applied sunscreen at 2 mg/cm² to 75% of body surface area at 0 hours on day 1 and 4 times on day 2 through day 4 at 2-hour intervals. Over the course of 21 days, the researchers collected 34 blood samples from each participant, and evaluated six active ingredients in four sunscreen products: avobenzone, oxybenzone, octocrylene, homosalate, octisalate, and octinoxate.

For all active ingredients, levels of greater than 0.5 ng/mL were detected after a single application on day 1. Levels of greater than 0.5 ng/mL were detected up to day 7, and up to day 21 for oxybenzone. All were detected in skin on days 7 and 14 via tape stripping. The authors called for further studies to determine the clinical significance of these findings and emphasized that the results “do not indicate that individuals should refrain from the use of sunscreen.”

The FDA is asking for additional studies on the safety of these 12 filters, noted Dr. Lim, who is a past president of the American Academy of Dermatology. On Feb. 26, 2019, the FDA issued a proposed rule regarding sunscreen drug products for over-the-counter human use. It proposes that the 16 UV filters be classified into one of 3 categories. Category I would include zinc oxide and titanium dioxide, which are generally recognized as safe and effective (GRASE). Category II would include PABA and trolamine salicylate, which are not used in the United States and are not GRASE. Category III would include 12 filters that lack insufficient safety data to make a determination regarding GRASE.

The final FDA rule was scheduled to be released in September of 2020, but a result of the Coronavirus Aid, Relief, and Economic Security (CARES) Act, the FDA “will be moving from a laborious rulemaking process to an administrative order process, which means it should not take as long to implement a monograph,” Dr. Lim said. “The FDA has decided that there will not be a final rule regarding sunscreen drug products,” but is required to issue a proposed administrative order by Sept. 27, 2021, he said.

When the final administrative order has been issued, manufacturers would have at least 1 year to comply with sunscreen products offered in the United States. “The approximate timeline is probably going to be 2023,” he said.

Dr. Lim disclosed that he is an investigator for Incyte, L’Oreal, Pfizer, and the Patient-centered Outcomes Research Institute, and a consultant for Pierre Fabre, ISDIN, Ferndale, La Roche–Posay, and Beiersdorf. He has been a speaker at general educational sessions sponsored by La Roche–Posay and Cantabria Labs.

[email protected]

I applaud the joint statement by the editors of the family medicine journals to commit to the eradication of systemic racism in medicine ( J Fam Pract . 2021;70:3 -4). These are crucial times in our history, where proactive change is necessary. The leadership they have shown is important.

Even in systems where insurance status is the same, there are documented differences in care.

No one wants health disparities. So, to eliminate them, we need to know what they are and where they came from. In my presentations on health disparities to students, residents, and health care providers, I use 3 definitions of health disparities. My definitions are slightly different from those proposed in the seminal report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, from the National Academy of Medicine (then Institute of Medicine).¹ I like to think that my definitions elicit the information needed to guide change.

The first definition focuses on health statistics. When there are different outcomes for different demographic groups for the same disease, that is a disparity. This could be Black vs white, male vs female, or 1 zip code vs another.² We owe ourselves an explanation for these differences if we are to be able to propose solutions.

Second, there are disparities in the provision of health care. If there are 2 individuals who present with the exact same symptoms, we need to ask ourselves why they would be treated differently. Even in systems where insurance status is the same, there are documented differences in care. A well-studied example of this is pain. In 1 such study, a ­meta-analysis showed that Blacks were less likely than whites to receive medication for acute pain in the emergency department (OR = 0.60 [95% CI, 0.43-0.83]).³ Other examples of differences by race include cardiac ­services,⁴ lung cancer screening,⁵ and stroke ­interventions.⁶ 

The third definition of health disparities involves differences in health-seeking behavior. This is not to blame the “victim,” but to understand the reason why the difference exists so that adequate interventions can be designed to improve outcomes. Traditionally, the concept of access referenced whether or not the patient had health insurance. But the provision of health insurance is insufficient to explain issues of access.⁷

Extrinsic and intrinsic factors at work. Factors related to insurance are an example of the extrinsic factors related to access. However, there are intrinsic factors related to access, most of which involve health literacy. We must ask ourselves: What are the best practices to educate patients to get the care they need? I will take this 1 step further; it is the duty of all health care professionals to improve health literacy 1 patient, 1 community at a time.

The next point that I make in my presentations on health disparities is that if you control for socioeconomic status, some of the health disparities go away. However, they rarely disappear. We measure socioeconomic status in a variety of ways: education, insurance status, income, and wealth. And as would be expected, these variables are usually correlated. We also know that these variables are not distributed equally by race. This is by design. This has been intentional. This has been, in many cases, our country’s policy. This is the result of systemic racism. 

Continue to: It is necessary...

It is necessary for us to be willing to accept the toxicity of racism. This we can assess in 2 major ways. First, if we apply the Koch postulates or the Bradford Hill criteria for causation to racism, we can assess the degree to which racism is an explanation for health disparities. These principles offer methods for determining the relationship between risk and outcome.

Second, when we analyze the historical antecedents of health disparities, we find that racism is directly responsible not only for the current toxicity that Black people face today, but for the socioeconomic disparities that continue to exist. Let me give just a few examples. 

1. The Farm Security Administration was created in 1937 to avoid the collapse of the farming industry. As a compromise to southern legislators, a model was approved to allow local administration of support to farmers that essentially condoned the discrimination that had been occurring and would continue to occur—especially in the South.
2. The National Housing Act of 1934 was created to provide stability to the banking industry at a time of national crisis. It subsidized a massive building program, and many of the units had restrictive covenants that prevented the sale to Blacks. It also codified redlining that prevented insured mortgages from being provided to Black communities.
3. The Social Security Act of 1935 was created to provide benefits for the elderly and disabled. All workers were included except domestic workers and farm workers—the majority of whom were Black. This was another compromise that was made with southern congressman to get this act passed.  
4. The Servicemen’s Readjustment Act of 1944 (also known as the GI Bill) was passed to support veterans returning from World War II. Two major functions of the bill were to support educational opportunities for veterans and their families and to support the purchase of homes. From 1945 to 1954, the US added 13 million new homes. In 1946 and 1947, the Veterans Administration financed 40% of all single-­family houses in the United States. Additionally, there were educational benefits for veterans to go to college or to learn a trade. These provisions, education, and housing were not equally available to Blacks. Columbia University professor Ira Katznelson called this act and others “affirmative action for whites.” ⁸

In 2019, the median income in white households was $76,057 and in Black households it was $46,073. ⁹ So, when we look at disparities of income, we must acknowledge this difference within the context of the current environment and the historical conditions that created these disparities. If we go 1 step further and look at disparities of wealth, we find that in 2019, the median wealth for white families was $188,200 and the median wealth for Black families was $24,100. ¹⁰

When one considers that a major contributor of wealth is home ownership, these differences seem logical—particularly related to points 1, 2, and 4 that I've just described. These economic disparities would not be as great today if the 4 examples given here (not to mention numerous other examples) had been administered equitably. The same applies to disparities in housing, employment, and education. Systemic racism is the causative agent. Systemic racism must be neutralized if we are to obtain anything close to health equity. ¹¹

The Centers for Disease Control and Prevention (CDC) has recently taken new steps to recognize the role of racism in health. ¹² The CDC plans to use “science to investigate and better understand the intersection of racism and health, and then to take action.” ¹³ 

It is time for the entire nation to recognize the links between racism and health outcomes and examine how we can design, implement, and evaluate interventions that will permanently correct these inequities.

I applaud the joint statement by the editors of the family medicine journals to commit to the eradication of systemic racism in medicine ( J Fam Pract . 2021;70:3 -4). These are crucial times in our history, where proactive change is necessary. The leadership they have shown is important.

Even in systems where insurance status is the same, there are documented differences in care.

No one wants health disparities. So, to eliminate them, we need to know what they are and where they came from. In my presentations on health disparities to students, residents, and health care providers, I use 3 definitions of health disparities. My definitions are slightly different from those proposed in the seminal report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, from the National Academy of Medicine (then Institute of Medicine).¹ I like to think that my definitions elicit the information needed to guide change.

The first definition focuses on health statistics. When there are different outcomes for different demographic groups for the same disease, that is a disparity. This could be Black vs white, male vs female, or 1 zip code vs another.² We owe ourselves an explanation for these differences if we are to be able to propose solutions.

Second, there are disparities in the provision of health care. If there are 2 individuals who present with the exact same symptoms, we need to ask ourselves why they would be treated differently. Even in systems where insurance status is the same, there are documented differences in care. A well-studied example of this is pain. In 1 such study, a ­meta-analysis showed that Blacks were less likely than whites to receive medication for acute pain in the emergency department (OR = 0.60 [95% CI, 0.43-0.83]).³ Other examples of differences by race include cardiac ­services,⁴ lung cancer screening,⁵ and stroke ­interventions.⁶ 

The third definition of health disparities involves differences in health-seeking behavior. This is not to blame the “victim,” but to understand the reason why the difference exists so that adequate interventions can be designed to improve outcomes. Traditionally, the concept of access referenced whether or not the patient had health insurance. But the provision of health insurance is insufficient to explain issues of access.⁷

Extrinsic and intrinsic factors at work. Factors related to insurance are an example of the extrinsic factors related to access. However, there are intrinsic factors related to access, most of which involve health literacy. We must ask ourselves: What are the best practices to educate patients to get the care they need? I will take this 1 step further; it is the duty of all health care professionals to improve health literacy 1 patient, 1 community at a time.

The next point that I make in my presentations on health disparities is that if you control for socioeconomic status, some of the health disparities go away. However, they rarely disappear. We measure socioeconomic status in a variety of ways: education, insurance status, income, and wealth. And as would be expected, these variables are usually correlated. We also know that these variables are not distributed equally by race. This is by design. This has been intentional. This has been, in many cases, our country’s policy. This is the result of systemic racism. 

Continue to: It is necessary...

It is necessary for us to be willing to accept the toxicity of racism. This we can assess in 2 major ways. First, if we apply the Koch postulates or the Bradford Hill criteria for causation to racism, we can assess the degree to which racism is an explanation for health disparities. These principles offer methods for determining the relationship between risk and outcome.

Second, when we analyze the historical antecedents of health disparities, we find that racism is directly responsible not only for the current toxicity that Black people face today, but for the socioeconomic disparities that continue to exist. Let me give just a few examples. 

1. The Farm Security Administration was created in 1937 to avoid the collapse of the farming industry. As a compromise to southern legislators, a model was approved to allow local administration of support to farmers that essentially condoned the discrimination that had been occurring and would continue to occur—especially in the South.
2. The National Housing Act of 1934 was created to provide stability to the banking industry at a time of national crisis. It subsidized a massive building program, and many of the units had restrictive covenants that prevented the sale to Blacks. It also codified redlining that prevented insured mortgages from being provided to Black communities.
3. The Social Security Act of 1935 was created to provide benefits for the elderly and disabled. All workers were included except domestic workers and farm workers—the majority of whom were Black. This was another compromise that was made with southern congressman to get this act passed.  
4. The Servicemen’s Readjustment Act of 1944 (also known as the GI Bill) was passed to support veterans returning from World War II. Two major functions of the bill were to support educational opportunities for veterans and their families and to support the purchase of homes. From 1945 to 1954, the US added 13 million new homes. In 1946 and 1947, the Veterans Administration financed 40% of all single-­family houses in the United States. Additionally, there were educational benefits for veterans to go to college or to learn a trade. These provisions, education, and housing were not equally available to Blacks. Columbia University professor Ira Katznelson called this act and others “affirmative action for whites.” ⁸

In 2019, the median income in white households was $76,057 and in Black households it was $46,073. ⁹ So, when we look at disparities of income, we must acknowledge this difference within the context of the current environment and the historical conditions that created these disparities. If we go 1 step further and look at disparities of wealth, we find that in 2019, the median wealth for white families was $188,200 and the median wealth for Black families was $24,100. ¹⁰

When one considers that a major contributor of wealth is home ownership, these differences seem logical—particularly related to points 1, 2, and 4 that I've just described. These economic disparities would not be as great today if the 4 examples given here (not to mention numerous other examples) had been administered equitably. The same applies to disparities in housing, employment, and education. Systemic racism is the causative agent. Systemic racism must be neutralized if we are to obtain anything close to health equity. ¹¹

The Centers for Disease Control and Prevention (CDC) has recently taken new steps to recognize the role of racism in health. ¹² The CDC plans to use “science to investigate and better understand the intersection of racism and health, and then to take action.” ¹³ 

It is time for the entire nation to recognize the links between racism and health outcomes and examine how we can design, implement, and evaluate interventions that will permanently correct these inequities.

I applaud the joint statement by the editors of the family medicine journals to commit to the eradication of systemic racism in medicine ( J Fam Pract . 2021;70:3 -4). These are crucial times in our history, where proactive change is necessary. The leadership they have shown is important.

Even in systems where insurance status is the same, there are documented differences in care.

No one wants health disparities. So, to eliminate them, we need to know what they are and where they came from. In my presentations on health disparities to students, residents, and health care providers, I use 3 definitions of health disparities. My definitions are slightly different from those proposed in the seminal report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care, from the National Academy of Medicine (then Institute of Medicine).¹ I like to think that my definitions elicit the information needed to guide change.

The first definition focuses on health statistics. When there are different outcomes for different demographic groups for the same disease, that is a disparity. This could be Black vs white, male vs female, or 1 zip code vs another.² We owe ourselves an explanation for these differences if we are to be able to propose solutions.

Second, there are disparities in the provision of health care. If there are 2 individuals who present with the exact same symptoms, we need to ask ourselves why they would be treated differently. Even in systems where insurance status is the same, there are documented differences in care. A well-studied example of this is pain. In 1 such study, a ­meta-analysis showed that Blacks were less likely than whites to receive medication for acute pain in the emergency department (OR = 0.60 [95% CI, 0.43-0.83]).³ Other examples of differences by race include cardiac ­services,⁴ lung cancer screening,⁵ and stroke ­interventions.⁶ 

The third definition of health disparities involves differences in health-seeking behavior. This is not to blame the “victim,” but to understand the reason why the difference exists so that adequate interventions can be designed to improve outcomes. Traditionally, the concept of access referenced whether or not the patient had health insurance. But the provision of health insurance is insufficient to explain issues of access.⁷

Extrinsic and intrinsic factors at work. Factors related to insurance are an example of the extrinsic factors related to access. However, there are intrinsic factors related to access, most of which involve health literacy. We must ask ourselves: What are the best practices to educate patients to get the care they need? I will take this 1 step further; it is the duty of all health care professionals to improve health literacy 1 patient, 1 community at a time.

The next point that I make in my presentations on health disparities is that if you control for socioeconomic status, some of the health disparities go away. However, they rarely disappear. We measure socioeconomic status in a variety of ways: education, insurance status, income, and wealth. And as would be expected, these variables are usually correlated. We also know that these variables are not distributed equally by race. This is by design. This has been intentional. This has been, in many cases, our country’s policy. This is the result of systemic racism. 

Continue to: It is necessary...

It is necessary for us to be willing to accept the toxicity of racism. This we can assess in 2 major ways. First, if we apply the Koch postulates or the Bradford Hill criteria for causation to racism, we can assess the degree to which racism is an explanation for health disparities. These principles offer methods for determining the relationship between risk and outcome.

Second, when we analyze the historical antecedents of health disparities, we find that racism is directly responsible not only for the current toxicity that Black people face today, but for the socioeconomic disparities that continue to exist. Let me give just a few examples. 

1. The Farm Security Administration was created in 1937 to avoid the collapse of the farming industry. As a compromise to southern legislators, a model was approved to allow local administration of support to farmers that essentially condoned the discrimination that had been occurring and would continue to occur—especially in the South.
2. The National Housing Act of 1934 was created to provide stability to the banking industry at a time of national crisis. It subsidized a massive building program, and many of the units had restrictive covenants that prevented the sale to Blacks. It also codified redlining that prevented insured mortgages from being provided to Black communities.
3. The Social Security Act of 1935 was created to provide benefits for the elderly and disabled. All workers were included except domestic workers and farm workers—the majority of whom were Black. This was another compromise that was made with southern congressman to get this act passed.  
4. The Servicemen’s Readjustment Act of 1944 (also known as the GI Bill) was passed to support veterans returning from World War II. Two major functions of the bill were to support educational opportunities for veterans and their families and to support the purchase of homes. From 1945 to 1954, the US added 13 million new homes. In 1946 and 1947, the Veterans Administration financed 40% of all single-­family houses in the United States. Additionally, there were educational benefits for veterans to go to college or to learn a trade. These provisions, education, and housing were not equally available to Blacks. Columbia University professor Ira Katznelson called this act and others “affirmative action for whites.” ⁸

In 2019, the median income in white households was $76,057 and in Black households it was $46,073. ⁹ So, when we look at disparities of income, we must acknowledge this difference within the context of the current environment and the historical conditions that created these disparities. If we go 1 step further and look at disparities of wealth, we find that in 2019, the median wealth for white families was $188,200 and the median wealth for Black families was $24,100. ¹⁰

When one considers that a major contributor of wealth is home ownership, these differences seem logical—particularly related to points 1, 2, and 4 that I've just described. These economic disparities would not be as great today if the 4 examples given here (not to mention numerous other examples) had been administered equitably. The same applies to disparities in housing, employment, and education. Systemic racism is the causative agent. Systemic racism must be neutralized if we are to obtain anything close to health equity. ¹¹

The Centers for Disease Control and Prevention (CDC) has recently taken new steps to recognize the role of racism in health. ¹² The CDC plans to use “science to investigate and better understand the intersection of racism and health, and then to take action.” ¹³ 

It is time for the entire nation to recognize the links between racism and health outcomes and examine how we can design, implement, and evaluate interventions that will permanently correct these inequities.

An online, culturally based peer support group that uses theater and other creative outlets is helping Asian Americans cope with the COVID-19 pandemic, new research shows.

The findings of the qualitative study suggest that the program could be a model to support the mental health of other minority community groups during the COVID pandemic and beyond, say investigators from the Yale University Child Study Center, New Haven, Conn.

The Yale Compassionate Home, Action Together (CHATogether) group was created to promote emotional wellness among Asian American youth, young adults, and their families.

Early in the pandemic, it expanded its purpose to serve as a COVID-19 support group. Through social media outreach, CHATogether encourages members to cope with COVID-19 by using productive and creative outlets.

“We are a community education program serving Asian American families,” said Eunice Yuen, MD, PhD, the program’s founder and director, who is with the Yale University Child Study Center.

“We started when the pandemic began, and we realized the unique emotional distress shared among Asian American families, such as family conflict and xenophobic attacks,” said Dr. Yuen.

She discussed the program at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
 

Skits, role playing

CHATogether groups consist of people with similar experiences and challenges who support each other through weekly online group meetings, she explained.

Group members work together to create family conflict scenarios and role-play dialogues on topics amplified during the COVID-19 pandemic, such as cross-cultural challenges among Asian Americans, academic expectations in home schooling, and Black Lives Matter and LGBTQ conflicts within Asian families.

Group members create skits that are based on their personal experiences and that allow them to work through their own internal conflicts and gain a sense of agency, said Dr. Yuen.

“CHATogether is really the interface of mental health, art, and theater, and we’re trying to create a vehicle that can be a lighthearted way for people to talk about mental health, especially for Asian American families,” said Dr. Yuen.

Preliminary results from a focus group with 10 CHATogether members who joined the program since the pandemic started identified four major ways in which the program has had a positive impact on the mental health and well-being of participants:

• It provides a safe and supportive environment, strengthens bonds between members, and increases the sense of belonging, thus encouraging engagement.
• It provides structural consistency/stability through regular meetings and consistent group functions. Weekly meetings provide a sense of control and hope in the midst of uncertainty during periods of sheltering in place.
• Through adapting the group to virtual platforms, group members experience the inherent strengths of a growth mindset and cognitive flexibility when facing challenges.
• It supports healthy coping skills through sublimation and altruism.

Looking ahead, Dr. Yuen said, the team plans to investigate the validity and effectiveness of this model and to expand the group to include other minorities, school educators, and medical education for trainees and medical students.

Commenting on the program, briefing moderator Jeffrey Borenstein, MD, president and CEO of the Brain and Behavior Research Foundation and editor-in-chief of Psychiatric News, described the initiative as a “great project that serves as a model that can be used not only for Asian Americans but for other groups.

“I think the key to it is that cultural sensitivity that we need to really take into account and cultural differences among people in order to best engage them and help support them. I think this program does that beautifully,” said Dr. Borenstein.

The work was supported by the APA’s Substance Abuse and Mental Health Services Administration Minority Fellowship, which provides a 1-year fellowship to psychiatry residents committed to addressing minority psychiatric mental health issues. Dr. Yuen and Dr. Borenstein disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

An online, culturally based peer support group that uses theater and other creative outlets is helping Asian Americans cope with the COVID-19 pandemic, new research shows.

The findings of the qualitative study suggest that the program could be a model to support the mental health of other minority community groups during the COVID pandemic and beyond, say investigators from the Yale University Child Study Center, New Haven, Conn.

The Yale Compassionate Home, Action Together (CHATogether) group was created to promote emotional wellness among Asian American youth, young adults, and their families.

Early in the pandemic, it expanded its purpose to serve as a COVID-19 support group. Through social media outreach, CHATogether encourages members to cope with COVID-19 by using productive and creative outlets.

“We are a community education program serving Asian American families,” said Eunice Yuen, MD, PhD, the program’s founder and director, who is with the Yale University Child Study Center.

“We started when the pandemic began, and we realized the unique emotional distress shared among Asian American families, such as family conflict and xenophobic attacks,” said Dr. Yuen.

She discussed the program at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
 

Skits, role playing

CHATogether groups consist of people with similar experiences and challenges who support each other through weekly online group meetings, she explained.

Group members work together to create family conflict scenarios and role-play dialogues on topics amplified during the COVID-19 pandemic, such as cross-cultural challenges among Asian Americans, academic expectations in home schooling, and Black Lives Matter and LGBTQ conflicts within Asian families.

Group members create skits that are based on their personal experiences and that allow them to work through their own internal conflicts and gain a sense of agency, said Dr. Yuen.

“CHATogether is really the interface of mental health, art, and theater, and we’re trying to create a vehicle that can be a lighthearted way for people to talk about mental health, especially for Asian American families,” said Dr. Yuen.

Preliminary results from a focus group with 10 CHATogether members who joined the program since the pandemic started identified four major ways in which the program has had a positive impact on the mental health and well-being of participants:

• It provides a safe and supportive environment, strengthens bonds between members, and increases the sense of belonging, thus encouraging engagement.
• It provides structural consistency/stability through regular meetings and consistent group functions. Weekly meetings provide a sense of control and hope in the midst of uncertainty during periods of sheltering in place.
• Through adapting the group to virtual platforms, group members experience the inherent strengths of a growth mindset and cognitive flexibility when facing challenges.
• It supports healthy coping skills through sublimation and altruism.

Looking ahead, Dr. Yuen said, the team plans to investigate the validity and effectiveness of this model and to expand the group to include other minorities, school educators, and medical education for trainees and medical students.

Commenting on the program, briefing moderator Jeffrey Borenstein, MD, president and CEO of the Brain and Behavior Research Foundation and editor-in-chief of Psychiatric News, described the initiative as a “great project that serves as a model that can be used not only for Asian Americans but for other groups.

“I think the key to it is that cultural sensitivity that we need to really take into account and cultural differences among people in order to best engage them and help support them. I think this program does that beautifully,” said Dr. Borenstein.

The work was supported by the APA’s Substance Abuse and Mental Health Services Administration Minority Fellowship, which provides a 1-year fellowship to psychiatry residents committed to addressing minority psychiatric mental health issues. Dr. Yuen and Dr. Borenstein disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.

An online, culturally based peer support group that uses theater and other creative outlets is helping Asian Americans cope with the COVID-19 pandemic, new research shows.

The findings of the qualitative study suggest that the program could be a model to support the mental health of other minority community groups during the COVID pandemic and beyond, say investigators from the Yale University Child Study Center, New Haven, Conn.

The Yale Compassionate Home, Action Together (CHATogether) group was created to promote emotional wellness among Asian American youth, young adults, and their families.

Early in the pandemic, it expanded its purpose to serve as a COVID-19 support group. Through social media outreach, CHATogether encourages members to cope with COVID-19 by using productive and creative outlets.

“We are a community education program serving Asian American families,” said Eunice Yuen, MD, PhD, the program’s founder and director, who is with the Yale University Child Study Center.

“We started when the pandemic began, and we realized the unique emotional distress shared among Asian American families, such as family conflict and xenophobic attacks,” said Dr. Yuen.

She discussed the program at the annual meeting of the American Psychiatric Association, which was held as a virtual live event.
 

Skits, role playing

CHATogether groups consist of people with similar experiences and challenges who support each other through weekly online group meetings, she explained.

Group members work together to create family conflict scenarios and role-play dialogues on topics amplified during the COVID-19 pandemic, such as cross-cultural challenges among Asian Americans, academic expectations in home schooling, and Black Lives Matter and LGBTQ conflicts within Asian families.

Group members create skits that are based on their personal experiences and that allow them to work through their own internal conflicts and gain a sense of agency, said Dr. Yuen.

“CHATogether is really the interface of mental health, art, and theater, and we’re trying to create a vehicle that can be a lighthearted way for people to talk about mental health, especially for Asian American families,” said Dr. Yuen.

Preliminary results from a focus group with 10 CHATogether members who joined the program since the pandemic started identified four major ways in which the program has had a positive impact on the mental health and well-being of participants:

• It provides a safe and supportive environment, strengthens bonds between members, and increases the sense of belonging, thus encouraging engagement.
• It provides structural consistency/stability through regular meetings and consistent group functions. Weekly meetings provide a sense of control and hope in the midst of uncertainty during periods of sheltering in place.
• Through adapting the group to virtual platforms, group members experience the inherent strengths of a growth mindset and cognitive flexibility when facing challenges.
• It supports healthy coping skills through sublimation and altruism.

Looking ahead, Dr. Yuen said, the team plans to investigate the validity and effectiveness of this model and to expand the group to include other minorities, school educators, and medical education for trainees and medical students.

Commenting on the program, briefing moderator Jeffrey Borenstein, MD, president and CEO of the Brain and Behavior Research Foundation and editor-in-chief of Psychiatric News, described the initiative as a “great project that serves as a model that can be used not only for Asian Americans but for other groups.

“I think the key to it is that cultural sensitivity that we need to really take into account and cultural differences among people in order to best engage them and help support them. I think this program does that beautifully,” said Dr. Borenstein.

The work was supported by the APA’s Substance Abuse and Mental Health Services Administration Minority Fellowship, which provides a 1-year fellowship to psychiatry residents committed to addressing minority psychiatric mental health issues. Dr. Yuen and Dr. Borenstein disclosed no relevant financial relationships.

A version of this article first appeared on Medscape.com.