Read on Twitter
So excited to FINALLY be able to share my new @greenjrnl article w/ @heidiwbrown @DrJasmineZapata and Nao Hagiwara. We issue a challenge to policymakers, health care orgs and med schools: change the way you operate or Black maternal health won't. https://journals.lww.com/greenjournal/Fulltext/9900/Rethinking_Bias_to_Achieve_Maternal_Health_Equity_.177.aspx
A cornerstone of recent policy solutions has been to mandate implicit bias training. The assumption is that Black women's disparate outcomes are due to clinicians' implicit bias and that training will fix it. While well-intentioned, this will likely have no impact on disparities.
We list the reasons in the article, but in summary: 1) Current trainings (mostly) focus on implicit prejudice and not stereotyping. Implicit prejudice impacts communication but no evidence it impacts treatment. 2) A few pilot trainings have been shown to impact implicit
negative stereotyping but no evidence yet that effects are sustainable or universally effective 3) Trainings put the onus on individuals when we know that individuals operate in social structures that allow bias to thrive.
In obstetrics, patient-level stereotyping runs rampant. This of course, is rooted in history. Black women are the mothers of gynecology. The discipline literally gained legitimacy on our backs and through tortuous experimentation.
You can draw an almost direct line from the stereotyping of Black women's tolerance to pain to our treatment today. Not being believed when it comes to pain, undermedicated during and after labor (see my recent collaborative work w/ Dr. John Poehlman): https://www.ajog.org/article/S0002-9378(20)31415-0/abstract
Race is even embedded in clinical algorithms, most notably with the current VBAC calculator. In other words: we are worried about the WRONG things y'all! https://www.whijournal.com/article/S1049-3867(19)30098-2/abstract
Then there's the treatment of Black doctors, who have been consistently marginalized in the profession even though we have empirical evidence that they are more likely to treat underserved patients, know more about health disparities and are linked to better outcomes.
But we didn't want to write another commentary raising these issues without also providing a path forward (and highlighting the work that so many people are doing to create a better world). Changing racial stereotyping in care is a big one.
And, unsurprisingly, Black medical students have been at the vanguard of efforts to eliminate stereotyping from clinical algorithms. See, for example, @UWMedicine the 1st to eliminate race from the calculation of the glomerular filtration rate (GFR).
https://medicine.uw.edu/news/uw-medicine-exclude-race-calculation-egfr-measure-kidney-function
https://medicine.uw.edu/news/uw-medicine-exclude-race-calculation-egfr-measure-kidney-function
See this thread that provides a history of these collaborative efforts between students and faculty: https://twitter.com/NNkinsi/status/1265340643859038210
Similarly, we see several examples of the ways in which standardized clinical protocols have improved maternal health disparities, such as the CA hemorrhage quality improvement initiative: https://www.sciencedirect.com/science/article/pii/S0002937817301242?casa_token=zswtWE0CM4QAAAAA:jckvy-ABP9e5GloiMsPALYsz7WToDOFgVJCOfzzdcEZhaVaU50lw06fqjiC6hycja1luHKWeEw
We must, of course, tread carefully as standardized protocols could worsen disparities, especially if underresourced facilities that disproportionately aren't given what they need for proper implementation. It's also critical to center communities because..guess what?
They often know more than we do about what they need! https://apha.confex.com/apha/2020/meetingapp.cgi/Paper/480077
One thing that's surprising is policymakers' lack of attention to reforming laws to address discrimination. The work of @ruqaiijah and @daynamatthew3 has been foundational for me in understanding how civil rights laws can be used to address MCH disparities.
See work on how structural racism is embedded into the law, for example from @ruqaiijah: https://onlinelibrary.wiley.com/doi/full/10.1111/ajes.12230?casa_token=GvL0FkARM8QAAAAA%3AtwEzvwj6eNp_rFD7bDjN6HM5MNrefykn3hBwG0jXKYQuYs82Mb3wRT0NZQjnvGVH51n3aFOuWD_MV1Y
Just Medicine from @daynamatthew3 was essential reading for this non-lawyer trying to parse the nuances of how the law limits individual's options for addressing the harm from disparate racial impacts of medical practices: https://www.google.com/books/edition/Just_Medicine/xq84DwAAQBAJ?hl=en&gbpv=1&dq=info:Pr5No0ALA7AJ:scholar.google.com&pg=PP11&printsec=frontcover
And then there's addressing the stoppages in the pipeline of physicians. First, @XavierU, an HBCU with FAR fewer resources than PWIs, has sent more Black students to med school than any other institution. See this great article by @nhannahjones for more: https://www.nytimes.com/2015/09/13/magazine/a-prescription-for-more-black-doctors.html
Med schools also need to change the way they teach and train physicians. Stop embedding stereotyping in teaching and training (e.g., race as biology rather than social construct). And implement better recruitment practices that will increase not just the number of Black students
But first generation students, and students who have lived experiences that will help them center the communities we serve. Here too, medical students are at the vanguard of thinking through these issues: https://journals.lww.com/academicmedicine/Fulltext/2020/12000/Changing_How_Race_Is_Portrayed_in_Medical.16.aspx?casa_token=4zAodus0Is4AAAAA:FTdM_2ZURcSpSF9wuGV0w7gpC-pZScOZWMEgaJfQ4ltB-lhqAIDzQVGdF7he8kLJC_3aOXWvP-dGcpY6nohADbPUyg
And finally, institutions can recruit Black physicians but they're leaving in droves. We've seen several recent examples of Black clinicians being disciplined for talking about race: https://www.nola.com/news/healthcare_hospitals/article_b6ccf066-8d73-11eb-85b0-6728a33075e1.html
In addition to creating institutional cultures that VALUE these necessary and evidence-based discussions and protect the academic freedom of Black physicians, institutions must be fearless about holding perpetrators of discrimination accountable. Racial bias is not just a moral
issue, it's one of clinical incompetence and should be treated accordingly. And, as studies have pointed out, Black scholars are systematically discriminated against when it comes to @NIH grants in part because of topic choice. In other words, the people who are doing
the necessary disparities research are less likely to be funded. In the meantime, institutions have to value both federal and non-federal grant souces and provide other measures of support, as @KemiDoll points out here: https://www.nejm.org/doi/full/10.1056/NEJMms2003544
Does all of this mean we're opposed to implicit bias training? Nope! Evidence-based training could help to improve doctor-patient communication and provide support for larger structural reforms.
But we need to have a REAL conversation about how institutions are using implicit bias training as a way to pretend they're doing something substantive, rather than to do the hard, difficult and ugly work of upending structural inequality. Inertia is hard to overcome in the best
of circumstances after all. But if we are serious about the work of saving Black women and other birthing people, we must do the hard work of changing organizations and not just individuals. Fin.
