A 1985 report on racial health disparities in the U.S. was meant to "mark the beginning of the end" of differences in health outcomes based on race or minority status. The Heckler Report, which led to the creation of the U.S. Office of Minority Health, has influenced policy since that time, leading to a reduction in some health disparities. In large part, however, these disparities are still present in the system. Unfortunately, they are so present that the American Medical Association (AMA) formally recognized racism as a public health threat in 2020.
For OB/GYNs and other private practitioners, addressing racial health disparities seems like a tall order. After all, physicians only care for one patient at a time. The good news is that this approach — one patient at a time — is the ideal starting point.
Understanding National Health Disparities
The Office of Disease Prevention and Health Promotions defines a health disparity as when "a health outcome is seen to a greater or lesser extent between populations." The U.S. Government Accountability Office (GAO) writes that health disparities between racial and ethnic groups can be caused by many factors, including economic inequities, discrimination and "lack of healthcare access."
A fact sheet published by the Center for American Progress identifies the most significant health disparities facing people of color in the U.S., specifically African American or Black; Hispanic or Latinx; Asian Americans; American Indians or Alaska Natives; and Native Hawaiians and Pacific Islanders. This fact sheet shows that, compared to non-Hispanic white patients, the following applies to all of these groups:
- They are less likely to have insurance.
- They report fair or poor health more often.
- They experience infant deaths at a higher rate.
Black patients have the highest burden of death from all cancers, while Asian Americans have lower rates of cancer but twice as much liver cancer and inflammatory bowel disease.
It is especially pertinent for OB/GYNs to be aware of the fact that Black women are more likely to experience maternal mortality, as well as specific gynecological conditions such as infertility and uterine fibroids, according to the Endometriosis Foundation of America.
Before delving into how practices can tackle racial inequities head-on, the AMA offers a word of caution. Although the AMA has declared racism a public health threat, it urges physicians to "recognize that race is a social construct and is distinct from ethnicity, genetic ancestry or biology." Examine a patient's individual genetics, biology, environment and lived experience of racism instead of attributing an issue to their race or ethnicity.
The AMA urges physicians to seek out their own unconscious biases in caring for a person's needs and to avoid making racial or ethnic assumptions about patients. For example, do not assume a patient needs a higher or lower dose of pain medication based on their race.
Addressing Health Disparities in Private Practice
For private gynecology practitioners, health disparities can only be addressed one patient at a time. This means speaking to the key factors that cause racial disparities, such as "discrimination, economic instability and lack of health care access" as identified by the GAO. Private practices should ensure that employees are aware of their commitment to these principles and create an inclusive environment for all patients with these issues in mind.
Discrimination
The Centers for Disease Control and Prevention (CDC) emphasizes the need for "inclusive communication" in addressing health disparities in the medical system in its Gateway to Health Communication. It stresses the need to see patients through the lens of health equity, realizing that racism and discrimination have created health disparities. The system cannot approach all patients in the same way. Each patient needs information that is relevant and appropriate to their situation. There is also diversity within individual demographics (for example, a patient that may list Hispanic as a racial category on intake forms but personally identify as Chicano or Afro-Latina). Generalizations can lead to incorrect assumptions (for example, that Hispanic people have a narrow range of skin colors).
Clinicians should be aware of stigmatizing language and strive to use people-first language. Instead of referring to a person as "disabled," the CDC suggests "person with a disability" instead. Some other examples are saying "people who do not have health insurance" instead of "the uninsured," or "undocumented workers" or "immigrants" instead of "illegal immigrants" or "foreigners."
Economic Inequity
A patient's first thought when seeking healthcare is sometimes, unfortunately, "I can't afford this." Private practices have more flexibility to tackle this issue than hospital-employed physicians by reducing the costs for patients. A few ways practices are accomplishing this are as follows:
- Employing more non-physician professional providers, such as nurse practitioners.
- Using ultrasound in the office when appropriate instead of automatically referring patients out for MRIs.
- Reducing practice overhead costs when making purchases versus lease decisions for medical equipment.
Something as simple as financial counseling with a biller in the office before planning extensive tests or ensuring the lab work is performed in-network can prevent unexpected bills for patients.
Lack of Access
Even when gynecology practices are centrally located, clinicians should consider that some patients may have traveled a long way to their particular office, including by public transit, because of a lack of local access. Office staff should know in advance if patients are traveling a long way so that services can be streamlined. Similarly, when scheduling follow-ups or referrals, take advantage of telehealth visits or teleconsults, which may be more cost-effective, as well.
Lack of access can also be caused by other barriers, including language. Practices with large local populations whose first language is not English may consider employing bilingual office staff and medical professionals. Strive to provide office forms and patient education materials in the most common languages spoken by the local community and to seek out interpreters if necessary.
Looking Toward the Future
Patients are not defined by their race or ethnicity. Physician awareness of someone's background and culture is important, but it is also not the most important thing: Your patient is most concerned about treating their pelvic pain, menopausal symptoms or infertility. A patient may have genetic factors that interact with their health status, but genetics and race are not the same.
Patients who walk through the doors seeking healthcare often worry that their provider is going to treat them differently on the basis of their race or ethnicity. By creating an environment that actively works to remove the barriers between race and healthcare, you can make a critical difference in patient comfort.
The Endometriosis Foundation reports that coverage, access to and use of care improved for all racial and ethnic groups between 2013 and 2018. With participation from clinicians at all levels, including private practice owners, there's a real opportunity to reduce racial disparities in healthcare.
