“We are all here because we care about delivering good, quality, and equal care, which is impacted by patient communication, treatment decisions, and the physician-patient relation,” said Shubhada M. Dhage, MD, FACS, assistant professor of surgery, New York University School of Medicine, NY, to open a Tuesday Panel Session on Improving Outcomes by Enhancing Cultural Competency and Addressing Bias.
Dr. Dhage, the session moderator, spoke of some of the known quantities that affect patient outcomes—insurance status, income, age, and severity of a medical condition—but noted that less visible interpersonal factors are becoming more understood. “We now know that the impact of bias and cultural competency causes differences in the delivery of care, and therefore affects patient outcomes,” she said.
The first panelist, Brian E. Gittens, EdD, associate dean for human resources, equity, and inclusion, University of Wisconsin–Madison School of Medicine and Public Health, presented a video showcasing the “McGurk effect,” which illustrated that people can hear different sounds based upon the visual to which it is attached. “This is how bias works,” Dr. Gittens said. “You think you know something about a group of people, about a medical student, or a type of patient, and that association is so powerful that you’ll ignore the reality of what you see.”
Not all bias is pejorative; in fact, it can help to create meaning, allow mental shortcuts, and enable us to screen information so that we can choose what to afford our concentration, which is especially important for surgeons. But our backgrounds and experiences can “create micro-behaviors or messages, and if we repeat them, it can create advantages for some and disadvantages for others, and can systematically result in inequity and exclusion” both between colleagues and between surgeons and patients, Dr. Gittens said. He described some ways to mitigate bias, including accepting that it exists, self-reflection, and engaging with people you consider “others.”
Danny Takanishi, Jr., MD, FACS, professor of surgery, University of Hawaii, Honolulu, suggested that bias and cultural competency are part of a “unifying theme” that affects behaviors, serving as a foundation on which to base the way we interact with the world. He went on to define cultural competence as it is currently understood but focused on “congruence.”
“You want to be able to be sure that, within the framework of individuality, there is a sense of being able to work together with a degree of mutual understanding and respect,” Dr. Takanishi said, noting that it is of particular importance in the patient care setting. The ability to communicate effectively with patients of disparate socioeconomic and cultural backgrounds is key to improving patient outcomes in a time of changing demographics, both on the patient side and the surgeon side. Dr. Takanishi also addressed the failures of the health care system to adequately address cultural competency, and how that “leaves us with some ethical implications that we must address. We must take this cognitive disequilibrium and translate it into changes that are going to lead to improvement in care,” he said.
Dr. Takanishi then reviewed some of the steps that are being taken by health care organizations, such as the Accreditation Council for Graduate Medical Education, to address the cultural competency gaps and how the medical education paradigm should look going forward.
Disparities in health care clearly exist, as clearly as overt institutional racism existed in the past, according to Willie Underwood III, MD, MPH, MSCi, FACS, a urologic surgeon at Roswell Park Cancer Institute, Buffalo, NY. He noted that that the panel was about knowing oneself, society, culture, and what he called “the enemy.”
“The enemy is every time we fail to provide optimal, quality care to our patients. That’s our enemy,” said Dr. Underwood, explaining that a part of combating that adversary is understanding the things that surgeons aren’t taught in medical school or residency, including cultural competence. He discussed how racial bias, conscious or not, can often bleed into health care, citing multiple studies that African Americans and other minorities were less likely, on average, to receive treatment for common procedures, which directly leads to overall lower demographic health.
And the impact is as much economic as it is emotional—the progressive costs of treating these patients after missing an earlier, simpler problem runs into the hundreds of billions and trillions of dollars. Addressing that divide will involve a better understanding of bias and cultural education, as the other panelists noted. “The actions of organizations inside must match the mission objectives of the organization outside,” Dr. Underwood said. “Who we say we are must be who we are.”