Trickle-down racism is a phenomenon impeding the health industry from improving outcomes. As proven through history, racism is not a concept that can be remedied with time. It requires proactive action. For health systems to build appropriate programs that combat racism, they must first recognize the whole picture, and not just pieces of it. That process starts with diving into the four forms of racism. They are as follows:
-Structural
-Institutional
-Interpersonal
-Internalized
Tekisha Dwan Everette, during the “Road to Equity: Structural Forum,” hosted by CMS and the Office of Minority Health came to talk about how each of these categories of racism trickles down into the next, widening health disparities at each level.
The Overarching Problem: Structural and Institutional Racism
As noted in the webinar, structural racism is the invisible hand. This is the highest level, and the level in which injustice operates at its most integrated level.
Institutional racism is the hand that makes structural racism seen. Speakers in the webinar defined it as: “policies and practices within and across institutions that foster and further racial inequity.”
“Race is something designed and it is something that can be dismantled,” said Everette during the webinar. This means action is not just a hope, but a requirement.
Some in the health industry may think their responsibilities begin at the interpersonal level, but it’s imperative for those individuals to realize they are working within an institution themselves, one in which the institution has the power over patients living or dying. Patient policies within health organizations can be a continuous perpetuator of institutional racism.
“One example is seeing medicaid patients on one specific day of the week, rather than allowing to see them every day,” Everette said during the forum. “Or that you don’t see them at all. These everyday decisions may seem to have a business case to them, but ultimately are rooted in inequity and creating and fostering different opportunities for people of color.”
A lot of health care leaders have the power to proactively reverse health disparities through policy changes, rather than just through program implementation.
Telehealth can be a great tool to spearhead policy changes and create change from top to bottom. At the institutional level, telehealth modalities can be used to categorizes patients most at risk for certain diseases or most vulnerable based on community history. Take for example this initiative at Brigham Health (link to previous blog), which flags cardiac patients of color to encourage providers to admit them to the cardiology department, rather than just to general medicine. The approach seeks to meet patients where they are, and at the same time, recognizes that structural racism has created imbalanced power dynamics between providers and patients of color. Innovative approaches like these, while they can seem uncomfortable, are needed for true change. Ultimately those who drive change are not those who sit by idly and wait for government action, but rather they create that action to the best of their capabilities.
Interpersonal
Interpersonal racism is defined as the racism, bigotry and bias that is expressed and experienced by individuals. This is the level in which we most often see initiatives like bias training. Telehealth platforms can incorporate equity into clinical decision support making tools. On the end of the provider, while reviewing a patient’s EMR, they can be supplied with surveys which ask equity-focused questions. Examples of questions could include the following:
- Do I have any preexisting beliefs about health and this patient’s race? Example: Have I heard that black people experience pain less than white people?
- Have I thoroughly listened to the patient’s concerns, or may I have been a little dismissive? Investigate further and ask supplementary questions.
- Are there any concerns the patient may have about trust in our relationship? Have I made it clear to the patient that I am willing to make them an equal member of their care team?
As hinted above, this level presents an opportunity to rebuild years of historical mistrust and misconceptions through cognitive awareness. The point is not to question a provider’s knowledge, but to prompt critical thinking that will ultimately save lives. There have been many instances where patients-of-colors’ concerns were belittled, resulting in serious consequence or death. Take for example Serena William’s pregnancy. She told her doctors she could not breathe, but ultimately, they did not listen and belittled her concerns. After Williams’ pleading, the doctors performed a CT scan and found multiple small blood clots in her lungs, which would’ve killed her if she had not continued to advocate for herself. There are many instances of this disregard for minority patient concerns, both in maternal health and general medicine.
Throughout the pandemic, studies showed black patients were more likely to use telehealth than their white counterparts. This demonstrates that fear and confusion make patients want to connect with their providers. If providers are willing to make the effort to rebuild trust with patient, they can launch telehealth programs designed around connection and relationship-building. Either providers or virtual health coaches can reserve dedicated time to help patients work through any health misunderstandings. For example, a health organization could launch a series of Q&A sessions on living with chronic diseases during the COVID-19 pandemic. This gives patients the time to feel connected outside the 15-minute office visit. Through the use of telehealth we can start to reverse years of health inequities which requires care teams to give patients of color back their power and confidence in their health.
“A one size fits all approach to health care deepens inequities,” Everette elaborated. “We cannot use the same tools that got us to this place to undo the inequalities.”
Internalized
Internalized racism is how all of these previous levels combined give a person a sense of inferiority or superiority. During the webinar, Everette gave an example of how a sense of inferiority in minority patients might influence their interactions with venues of care. For example, if a patient doesn’t see a representation of themselves at the hospital, they may internalize the belief that it’s not for them. This can lead to fear which causes them to seek care less frequently. Or even if they do make it into the venue of care, they could decide not to question a doctor’s opinion on their body they know inherently does not feel right. This is because some patients may have internalized the belief that the doctor knows more than them. No one knows more about a body than the person that lives in it. Power dynamics in patient-provider relationships need to reflect this level of respect.
The approaches explained in the interpersonal racism section can also be applicable here. Eradicating health inequity starts with meeting marginalized individuals where they are, in the places they are most comfortable, rather than waiting for them to muster up the courage to come to us.
Everette closed out her session by saying that the process of dismantling racism always starts with an openness to learn and a passion to see it through.
“Deepen your learning consistently, and put it into action,” Everette said. “You have to be committed to equity from top to bottom. Everyone from the CEO to the custodian must be engaged in promoting equity. We have to start today. You have to be prepared to fail, but also exceed beyond your imagination.”
Take Action:
If your institution will benefit from this overview on overarching racism affecting day-to-day operations, please print or share with your colleague. Drop us a line if you would like to collaborate on reviewing internal policies and taking action to reverse operational inequities.