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It's well-documented that a person's skin color impacts the quality of medical care they receive.
As director of the Office of Diversity, Equity, and Inclusion (DEI) in the University of Iowa Carver College of Medicine, Nicole Del Castillo, MD, MPH (14R), is invested in making health care more equitable and inclusive.
Early in her training, Del Castillo was introduced to the health disparities that impact the Black community, especially in her field of psychiatry. As a physician-in-training, she wanted to address these problems directly through patient encounters. But pursuing a public health degree transformed her thinking and shifted her focus to the systemic changes needed to address this public health crisis.
Her focus now is to provide resources and support for students, trainees, faculty, and staff to help them recognize implicit biases and microaggressions, respond to mistreatment, and improve the recruitment and hiring of individuals from underrepresented backgrounds.
Systematically, we talk about health disparities and how certain groups have worse health outcomes due to cultural or environment factors. But one of those determinants can often be racism.
Some of this has been highlighted over the last couple of years and seen in maternal health. With Black women, no matter their income or location, there's data that shows they are having worse outcomes than their white counterparts due to implicit bias or racism. Even celebrities have shed light onto this. Tennis player Serena Williams was having shortness of breath after delivering her daughter and felt her health care team wasn't very responsive to her symptoms. In Iowa, pregnancy-related maternal mortality is six times higher for Black women compared to their white counterparts [according to the Iowa Department of Public Health].
People of color are often perceived as not experiencing pain the same way as white people, and some individuals think they don't need as much pain medication, which can impact recovery.
Within psychiatry, there's data that shows Black populations are more often misdiagnosed with schizophrenia compared to the white population, which can lead to poor treatment responses and excessive use of antipsychotics. There may be many factors as to why this misdiagnosis occurs which include implicit bias and racial stereotyping.
I think what we see tends to be more covert. There are definitely instances that people are consciously aware of their racism, but for the most part, it tends to be unconscious. Health care providers don't go into this profession with the intent to harm people. Implicit biases develop over the course of a lifetime and typically at a very early age. Therefore, people bring these biases with them into their medical training because the systems in our country have such a strong history of racism. Students, trainees, and health professionals are unaware of the associations they may have and how it's impacting their clinical encounters with patients. That's why it's so important to recognize where your implicit biases lie and work to mitigate them.
You can provide equal care, or making sure everyone is getting the same care, but equitable care goes beyond that. You have to look at barriers that people might have to access care and find ways to break them down. If it's a language barrier, we provide interpreters, and the information we send out to patients is in languages that anyone can access.
Building relationships and communities is also important. Black, Indigenous, and people of color sometimes harbor medical stigma, or fear of going to a hospital or seeing a provider. So, it involves building those relationships, seeing where people are, assessing their health care needs, and building clinics in different areas so that it's accessible.
At UI Health Care we have CultureVision, an online tool that providers can use to become more aware of cultural aspects that might influence a clinical encounter. It's not intended to reinforce stereotypes but to increase awareness and understanding about a patient's health care beliefs or practices, reduce disparities, and improve quality of care and patient satisfaction.
Building trust also requires being more patient-centered through empathy, finding commonality with your patient, and increasing communication. When you first meet a patient, asking them about their background might build trust and communication. You can preface that with "I want to provide the best care for you. Is there anything I should know about you that would be helpful?"
Listening is really important. Listening to stories that people are willing to share while trying to resist the tendency to be defensive or come up with answers or suggestions. It's also really important to try to learn about your own implicit biases so that you can mitigate them and work to build new associations.
Attend an upstander training, where you can learn how to respond when someone is being discriminated against or treated unfairly.
If you're in a position of power, it's important to look at your office, department, or institution and ask: Where are there areas for improvement? Look at your hiring practices. How can we diversify our community? What can we do day-to-day to provide a welcoming, inclusive, and equitable place to our employees and patients?
As an institution, the work we've done already to address health disparities is seen in some of our clinics, including the Ethnic Skin Care Clinic, the Mobile Clinic, our LGBTQ Clinic, and school clinics. Offering these spaces for us to provide care for patients is really important.
Across the country, people are recognizing the work they've done, but there's definitely work left to do. That's the stage we're at as an institution, as well. UI Health Care senior leaders have held listening sessions with Black students, trainees, staff, and faculty to better understand their experience and develop recommendations on how we can create a more inclusive culture. We have established a DEI task force, co-chaired by Brooks Jackson, MD, and Denise Martinez, MD, with the following work groups: patient-initiated identity harassment and health disparities, recruitment and retention, and culture and environment. The charge to these groups is to implement meaningful strategies that will make a measurable difference for Black, Indigenous, and people of color at UI Health Care.
Office of Diversity, Equity, and Inclusion
Mindful of all aspects of human difference, the Office of Diversity, Equity, and Inclusion strives to create a welcoming and inclusive culture across the enterprise.