March 24, 2023
Dear Interested Readers,
“Woke” Healthcare: Implicit Racism, DEI, ESG, Biases, Intersectionality, and Duality in Healthcare
I don’t know if you noticed it or not, but some politicians who seek to gain political advantage on the right tried to blame the collapse of Silicon Valley Bank and its impact on our banking system and financial markets on SVB’s “woke” policies. I am not a banker or an economist, so what do I know? Could a bank fail because it had progressive policies on diversity, equity, and inclusion in reference to its employees, or because it considered environmental and social issues when it loaned money? I doubted it, and was relieved to have my skepticism confirmed by an article in the New York Times entitled “No, ‘Wokeness’ Did Not Cause Silicon Valley Bank’s Collapse.” In the article which was written by Linda Qiu, we read:
A growing chorus of conservative pundits and politicians have said the failure of Silicon Valley Bank was the result of the bank’s “woke” policies, blaming the California lender’s commitments to workplace diversity and environmentally and socially conscious investments.
These claims are without merit. The bank’s collapse was due to financial missteps and a bank run.
Moreover, the firm’s policy on diversity, equity and inclusion — also known as D.E.I. — is similar to ones that have been broadly adopted in the banking sector. So is its approach to taking environmental and social considerations into account when investing — referred to as E.S.G. — although that has become a target of conservatives.
The article includes some comments from prominent Republican politicians that were made on Fox News where conservatives have their opinions validated.
“They were one of the most woke banks in their quest for the E.S.G.-type policy in investing.”— Representative James R. Comer, Republican of Kentucky [Chairman of the House Committee on Oversight and Accountability] in an appearance on Fox News on Sunday.
“This bank, they’re so concerned with D.E.I. and politics and all kinds of stuff. I think that really diverted from them focusing on their core mission.” — Gov. Ron DeSantis of Florida on Fox News on Sunday.
The current debates over who is “woke,” what woke really means, and the impact of “wokeness” in our daily lives seem to me to be low points in our ever more absurd discussions that characterize our increasingly riven society. Is being “woke” a “dis” or a desired state? I wish the term did not exist. It seems to have added more confusion than clarity to any subject to which it is applied, but I am not in charge and I think the term will persist for a while, albeit, mired in ambiguity. The practical answers about what is “woke” seem to depend on your political point of view. Even more confusing to me is the application of “wokeness” to healthcare. Despite the confusion, “woke” is being applied frequently and derisively to describe those who are concerned about the social determinants of health.
I don’t think that in one Friday letter to you, I can adequately discuss wokeness and the associated vocabulary that includes racism, DEI-diversity, equity, inclusion, ESG, intersectionality, various forms of bias, and dualism, a term I use to describe the tension between members of an “in” group versus those who are outside their circle. There is substantial evidence that all of these issues impact medical outcomes, the patient experience, and even the cost of care. In my opinion, the most important point of entry into this conversation about being “woke” in healthcare is the subject of implicit racism in healthcare which leads to substantial differences in outcomes that can’t be explained entirely on the basis of socioeconomic factors, access to care, or education.
This discussion can’t and shouldn’t be finished quickly. My objective is to just start it. I have tangentially approached many of the issues in previous letters. This is the beginning of another attempt at a deeper understanding of the implicit attitudes and issues that lead to variable outcomes in “out-groups.” I am convinced that a gradual increase in understanding can be accomplished by returning to the complexity of the issues again and again. It is not a “one-and-done” conversation. I confess that I gain new insights each time I return to this collection of concerns. One insight this time around is that in healthcare much of the current progress in this complex of issues is being led by medical students.
Last September the Boston Globe published an article entitled “Woke medicine doesn’t mean worse medicine: Antiracism training isn’t a substitute for what doctors typically learn in medical school. It’s an enhancement — and it’s exactly what the health care system needs.” The article was written by LaShyra Nolen. After being a Fulbright Scholar in Spain, Ms. Nolen entered Harvard Medical School in 2019. She is the first African American woman to become class president at Harvard Medical School. She has studied healthcare inequities associated with COVID-19 and racism in academic medicine and medical education. Her article begins:
Since my very first patient encounters at Harvard Medical School, I’ve seen how social inequity can limit the extent of medicine’s healing.
I’ve seen patients forgo brain imaging due to financial challenges and defer a colonoscopy because of lack of transportation. I’ve seen patients’ health–and my ability to support these patients–deteriorate under the pressure of towering structural barriers.
Overwhelmingly, these patients have been racial and ethnic minorities (I believe minoritized might be a more accurate term), LGBTQ, undocumented, disabled, and/or low-income. The United States’ history of oppression follows patients through the doors of every hospital across the country–and the hard blow of its impact is felt at every level, from the systemic to the interpersonal.
After decades of advocacy, major medical associations are finally starting to recognize how these interlocking systems of oppression limit what doctors and trainees can do for their patients.
For example, recently the American Association of Medical Colleges (AAMC) released guidelines outlining ways that doctors and trainees can promote diversity, equity, and inclusion in medical school and continuing education…It seems the medical institution is finally waking up. But a growing number of fearmongering “anti-woke” detractors are pushing back.
Ms. Nolen’s article continues by identifying pushback from the Wall Street Journal and reactionary organizations like Do No Harm, a group that is actively trying to undermine antiracist training in medical schools. I recommend that you click on both of these links because it is startling to read “anti-woke” comments about medical education from the editorial board of one of the nation’s most influential newspapers. The sarcastic comments made in the WSJ editorial and by the group that calls itself Do No Harm are perhaps more focused and more deceptive than the divisive rhetoric that Governor DeSantis applies to education and the teaching of Critical Race Theory or the LGBTQ community. The WSJ editorial ends with unabated negativity that intends to induce fear and concern and sounds like the words were written by Tucker Carlson:
America faces a looming and severe doctor shortage as baby boomers retire. It won’t help attract prospective doctors to tell top students they must attend to their guilt as racial and political oppressors before they can diagnose your cancer.
The Wall Street Journal editorial was written by journalists, not doctors, last summer, but I think they were channeling an opinion piece that also appeared in the Journal in 2019 that was written by Stanley Goldfarb, MD, a former associate dean for curriculum at the University of Pennsylvania’s medical school. Dr. Goldfarb’s piece was creatively titled “Take Two Aspirin and Call Me by My Pronouns: At ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness.” Dr. Goldfarb does not see the benefit of a curriculum that seeks to add a social dimension to the education of future physicians. He writes:
The zeitgeist of sociology and social work have become the driving force in medical education. The goal of today’s educators is to produce legions of primary care physicians who engage in what is termed “population health.”
This fits perfectly with the current administrator-rich, policy-heavy, form-over-function approach at every level of American education. Theories of learning with virtually no experimental basis for their impact on society and professions now prevail. Students are taught in the tradition of educational theorist Étienne Wenger, who emphasized “communal learning” rather than individual mastery of crucial information.
Where will all this lead? Medical school bureaucracies have become bloated, as they have in every other sphere of education. Curricula will increasingly focus on climate change, social inequities, gun violence, bias and other progressive causes only tangentially related to treating illness. And so will many of your doctors in coming years.
Dr. Goldfarb goes on to speculate that attention to what you and I would call the social determinants of health will in some way reduce our production of effective cardiologists, oncologists, surgeons, and “other medical specialists” that “are in short supply.”
I would recommend that you read the rest of Ms. Nolen’s article because she goes beyond the experience of Black Americans to discuss healthcare biases that diminish the care experience of other “out” groups whose care is impacted by biases. She also touches on how the “Great Resignation” will impact care as 20% of physicians report that they plan to leave medicine in the next two years because they are “burned out.”
The problems within our systems of care cut both ways. She reports that a study by the PEW Research Center recently found that 56% of Black Americans report a negative experience with their caregivers. They feel they must “speak up to get the proper care” and are “treated with less respect than other patients.” This is a recurrent theme in Linda Villarosa’s excellent book, Under The Skin: The Hidden Toll of Racism on American Lives and on the Health of the Nation, published last year
I would expect that Dr. Goldfarb was distressed by Janice Sabin’s excellent article in The New England Journal last July entitled “Tackling Implicit Bias in Health Care.” Dr. Sabin begins her article by helpfully describing the difference between implicit and explicit biases. [I added the bolding.]
Implicit and explicit biases are among many factors that contribute to disparities in health and health care. Explicit biases, the attitudes and assumptions that we acknowledge as part of our personal belief systems, can be assessed directly by means of self-report. Explicit, overtly racist, sexist, and homophobic attitudes often underpin discriminatory actions. Implicit biases, by contrast, are attitudes and beliefs about race, ethnicity, age, ability, gender, or other characteristics that operate outside our conscious awareness and can be measured only indirectly. Implicit biases surreptitiously influence judgment and can, without intent, contribute to discriminatory behavior. A person can hold explicit egalitarian beliefs while harboring implicit attitudes and stereotypes that contradict their conscious beliefs.
I had little knowledge of how biases operated in my own life until I read Daniel Kahneman’s THINKING, FAST AND SLOW (2011) about ten years ago. In the book, Kahneman explains the concepts of biases that he developed with his friend and collaborator, Aaron Tversky. Kahneman won the Nobel prize in 2002 for the work that he and Tversky had done in behavioral economics. Sadly, Tversky died of cancer in 1996 at the age of 59 and did not get to share the prize with Kahneman. The Nobel prize is not given posthumously. Since their work, the influence of biases has become recognized in almost every discussion of how our brains work and how biases then impact human behavior.
There are very long lists of biases. I find that individual biases are hard to remember as a list but easy to recognize once you are aware of their existence. Recently, while reading Brian McLaren’s new book, Do I Stay Christain: A GUIDE FOR THE DOUBTERS, THE DISAPPOINTED, AND THE DISILLUSIONED (2022), I discovered one of the most useful lists of some of the most important biases that I have seen. McLaren begins with “confirmation bias” as the cornerstone that is related to a cascade of other biases. My challenge to you is to contemplate how each bias operates in your own life and in healthcare. You can do the same exercise with politics. There are many other biases. If you are interested just scan the very long list in the GLOSSARY OF BIASES, FALLACIES, AND METAPHYSICAL BELIEFS.
McLaren’s list is:
Confirmation bias: names our brain’s tendencies to reject anything that doesn’t fit in with our current understanding, paradigm, belief system, or worldview. It’s closely related to about a dozen other biases, including:
Complexity bias: our brain’s tendency to prefer a simple lie to a complex truth.
Community bias: our brain’s tendency to reject any idea that will endanger our status in communities we belong to – to choose tribe, over truth.
Comfort/complacency bias: our brain’s tendency to reject information that makes us uncomfortable, is inconvenient or disrupts our complacency.
Confidence bias: our brain’s tendency to believe people who display confidence, rendering us susceptible to those who come on strong even when they’re wrong, including authoritarians and con artists.
Conspiracy bias: our brain’s tendency to believe stories that exonerate us or portray us as innocent victims or unsung heroes while vilifying an out-group or individual, real or concocted.
Catastrophe/normalcy bias: our brain’s tendency to respond to dramatic catastrophes but easily miss compounding slow erosions of normalcy.
Cash bias: our brain’s tendency to accept information that might interfere with our way of making a living.
From: Do I Stay Christain: A GUIDE FOR THE DOUBTERS, THE DISAPPOINTED, AND THE DISSILLUSIONED, by Brian d. McLaren, 2022. pages 67-68.
Near the end of her book, Linda Villarosa describes efforts to reduce implicit bias in healthcare through sessions of staff training. As you may imagine, change, at either a personal or institutional level, like the process Dr. Sabin advocates, is not easy and the results of efforts have been somewhat disappointing. Villarosa writes:
In general, this kind of training to root out and erase health-care bias in the United States remains patchy, unregulated, ad uncoordinated; even the names—implicit bias training, antiracism training, unconscious bias training, diversity training, antibias training, racial-bias training, undoing racism training, equal-opportunity training—lack consistency. It’s also unclear, depending on the structure and format, how well it works. Whatever the form, the goal is to fight against the sometimes centuries-old attitudes or images that unconsciously shape understanding, actions, and decisions. Implicit bias, based on views developed throughout life and shaped by social messages internalized as truths from family, peers, media, and authority figures, results in stereotypes that are lodged in the mind…
…Most acts of racism and bias arise in people with blind spots, not Proud Boys memberships.
Under the Skin: The Hidden Toll of Racism on American Lives and on the Health of Our Nation. (2022), Linda Villarosa, pages 183-184.
My experience with attempts to improve inherent bias in medical practice through staff training matches what Villarosa describes. The first program of “diversity training” for the medical practice of Harvard Community Health Plan occurred in the very early 90s, and I was trained to be one of the leaders in the ongoing program. We were diligent. We invested heavily. I am not sure what we accomplished. As Villarosa says, it is very hard to measure the results of such efforts. Despite the opinion of Governor DeSantis, I think the efforts to address implicit bias in all aspects of life, not just healthcare, must begin very early—preferably at home and in elementary school.
I am delighted to learn that there are woke medical students like Ms. Nolen. She is not alone. I envy the fact that they begin their journey through careers in medicine with a vocabulary of diversity, equity, and inclusion that few people in my era had. Effectively addressing the implicit racial biases in medicine is long overdue. Efforts to address inherent racism will quickly carry us to other issues of “wokeness” in medicine. I refer you to the website of The Institute for Healing and Justice in Medicine as an example of the work and passion of the next generation of healers who are “woke” to the issues that must be addressed and the changes that must be promoted if we are ever to have equal justice in healthcare.
There is an urgency for healthcare to become more “woke.” Until we are “woke” to the impact of biases there will be avoidable suffering and death. I urge you to examine the website of The Institute for Healing and Justice in Medicine or read Linda Villarosa’s book. In either resource, you will discover that implicit bias is more than a problem with individuals. Implicit racism is even embedded in tests that evaluate pulmonary function and renal function. There are a whole host of diagnostic and management errors that are derivative of the systemic manifestations of implicit racism. It is quite possible that one of the reasons that African Americans died at greater rates from COVIID than white patients was that their illness was evaluated against standards that were skewed by biases in test interpretation. Ms.Villarosa extensively reviews the impact of racial bias on avoidable maternal/child morbidity and mortality. How can we continue to ignore effectively addressing these problems and be faithful to our oath to care?
Spring Is Here, Sort of
I did not notice much change between 5:23 and 5:24 PM EST on Monday, but that is when we passed the vernal equinox. The vernal equinox describes when the sun is in direct alignment with the equator, the beginning of spring. I must admit that the days are a few minutes longer and the air has felt warmer since Monday, but that should not be a surprise since the high temp in New London on Sunday, the day before the sun aligned with the equator, was 27 degrees, and the mid-forties to low fifties is warmer. We are expecting more snow this weekend.
New London sits on a ridge, and we get more snow than Hanover which is 30 miles to the north, or Concord which is 35 miles to the south. The snow is mostly gone in Concord and Hanover where perhaps the idea of spring does not seem like such a joke. I took the picture in today’s header while on my walk on Wednesday. The temperature was in the high forties, but unlike the situation north and south of us, we still have a covering of snow and there are many places where the snow is more than a foot deep.
Where I live spring is a complex concept. In most of America, spring evolves quickly this time of year. First, we see crocuses which are followed in rapid succession by forsythia, daffodils, and then the necessity of mowing the grass. Here spring is also about those things, but they are secondary to “ice out,” mud season, and lots of pesky flies for a few weeks before you have a “classical” spring experience. The realities of a New Hampshire spring don’t diminish my enthusiasm for spring in any form from a technical definition to the anticipation of the first cloudless day with budding trees, singing birds, and warm breezes completing the classical picture. I am sure we will have such a day by mid to late May.
Whatever the weather this weekend, I hope that you will be with friends and family and be out and about if the weather permits. We may not have full spring yet, but sundown is now after 7 PM and it won’t be long until we enjoy some warmer long lovely evenings with gorgeous sunsets.
Be well,
Gene
