A: As a speaker on health equity, one of the reasons why I start my talks by discussing the definition of race is because we need to understand what race is and what it is not. It’s a social construct that we as a society created — it’s not genetics. Many of us do not understand who we are from a racial perspective. If we don’t understand and acknowledge who we are, how can we have conversations with patients who may be different from us? This doesn’t mean that because I may be of a different race than my patient, I’m unable to care for them. It does mean there may be some things to keep in mind and questions to ask of myself so I can provide better care.
A: When we talk about equality, we mean everybody getting the same thing. However, to make health care truly equitable, some people in our society won’t need any help to get the care that they need, and some will need extra help. If you give everyone the same exact thing, it’s furthering the divide between those who have and those who have not.
In the health care field, this can take shape in a number of ways. Health care providers may need to take more time with some patients to explain things multiple ways, try multiple modalities or make a treatment suggestion more than once. It can look like engaging in discussion and bringing the history of race and inequality into the conversation to address a patient’s fears.
It also involves looking at social determinants of health — where we live, learn, work and play. It’s not that some patients don’t want to improve their health, it’s that they don’t have access to the same resources as other patients. Food deserts can result in poor nutrition, neighborhood violence or a lack of clean air can lead to limited outdoor activity and outdated technology can restrict the use of telehealth in Health Professional Shortage Areas (HPSAs). What’s more, these disproportionately affect patients of color, so health care providers need an understanding of where race and social determinants of health intersect.
A: The reason why most of us entered this profession is because we want to positively impact the lives of our patients. That said, patients who have experienced bias or who feel uncomfortable when accessing care may never return. If patients don’t come to you, you can’t help them. If they don’t return for follow-up care, you can’t help them.
If we can identify and acknowledge some of these barriers, it’s not to say that we’ll solve all problems, but we can start to create an environment where people feel comfortable accessing the care they need. For example, I met a personal friend of mine who I hadn’t seen in a long time, and he could barely walk. He said he was diagnosed with spinal stenosis. I told him to see a neurologist, who then diagnosed him with multiple sclerosis (MS). Between the time my friend’s symptoms first appeared and the time he saw a neurologist, eight years had passed, and he was still afraid to start treatment. What made a huge difference was when he and his neurologist began discussing treatment, the neurologist said, “This isn’t Tuskegee, and we are not conducting an experiment.” By showing that he had this knowledge of how black people have been mistreated by medical professionals in this country, the neurologist was able to alleviate my friend’s fears in a very real way. By acknowledging race and the history of racism in this country, it helped eliminate my friend’s barrier to accessing proper treatment.
A: I absolutely loved the work I was doing at my primary care practice, but the issue was that not only was I the first black nurse practitioner (NP), physician or physician assistant (PA) to be hired by the company in New York City in 2013, but I was also the company’s only black health care provider on the entire east coast. It’s not unusual or rare for me to be the first or only black provider. African Americans make up 11% to 15% of the population, and our representation in health care is low. Even so, I had never experienced anything like that before.
I am a proud graduate of a historically black college. New York City is one of the most diverse environments in the country, if not the world. Research has shown that patients of color respond best to health care providers who look like them and who they can identify with. In my work, I saw a large number of patients of color even though the company’s demographics were largely white patients. I often heard patients say, “I looked on the website until I saw a face that looked like mine.”
Patients also shared their health disparities, such as misdiagnoses, a lack of provider knowledge of the differences in the way certain conditions present in patients of color or a lack of attention placed on conditions that are more prevalent in different racial or ethnic groups. For example, I had a patient who identified as black and presented with malar rash. She had been referred to a dermatologist and was treated for rosacea. In general, people with darker skin do not tend to get rosacea, but there is a high prevalence of lupus. However, none of her other providers had considered a blood test for lupus. I suggested it, and it turns out that she did, in fact, have lupus.
Experiences like this led to me applying for and being accepted to the Duke-Johnson & Johnson Nurse Leadership Program, where I designed a project exploring implicit bias in primary care. I developed two clinical rounds: “What Is Race and Why Does it Matter?” and “Race and Primary Care.” Since then, I have been offering a version of these two programs through my speaking engagements, including at AANP national conferences.
A: Leaders set the tone. When everyone seated around the table looks like you or has had similar backgrounds and experiences, it can lead to groupthink. It can also lead to a situation of silencing those who say, “There may be someone sitting here who has a unique perspective or a passion for this topic.” If you are the only person in the room with a different viewpoint, it can be difficult to speak up. To paraphrase Brené Brown, it’s about having the courage to lead and the courage to have difficult conversations.