May 6th, 2019
The Atlantic, in partnership with STAT, recently hosted its third annual conference on health care in Boston. Pulse: The Atlantic Summit on Health Care featured experts on a wide range of topics, from Medicare for All, to discrimination and sexism in medicine, to social determinants of health. There was also plenty of discussion on “fixes” for these tough problems in health care. Making health care access and quality more equitable was an important topic of discussion throughout the conference.
The US has the unfortunate distinction of being the only developed country in which maternal mortality rates are rising. There are a myriad of reasons behind this pattern, including lack of access to prenatal and postnatal care, lack of quality control, overuse of c-section, and discrimination and lack of shared decision making.
In many cases, the medical system does not care enough about women’s experiences in childbirth. “We treat women as vessels for pregnancy,” Dr. Neel Shah, Assistant Professor, Harvard Medical School and Obstetrician at the Beth Israel Deaconess Medical Center, put it plainly. (This is the same mindset that has led to the high rate of unnecessary hysterectomies.)
We need a shift in how we think about childbirth, both in medical culture and in society more generally. “Women have goals in labor more than just surviving the process,” said Shah. “Why not aim for the ceiling, to have maternal health be not just safe but supportive and empowering?”
In terms of practical changes to improve safety, Dr. Laura Riley, Obstetrician and Gynecologist-in-Chief at New York-Presbyterian/ Weill Cornell Medical Center, emphasized expanding maternal care coverage beyond the delivery period. Although we often think of maternal deaths as happening during childbirth, about one third of deaths happen before delivery and one third of deaths happen after. However, once the baby is born, the mother may not see their physician again until six weeks later, and then lose their coverage completely.
“Many women will have access to prenatal care and coverage until the six week visit and then, boom — they’re dropped off,” said Riley. She also noted that women with chronic conditions may not see their doctor again until their next pregnancy, at which point they will be at even greater risk of complications. “We need to extend the coverage,” said Riley. “We can’t drop people off at six weeks.”
Gender discrimination and sexual harassment are widespread in health care, threatening the careers and safety of many health care professionals. Yet health care institutions seem at a loss to solve this problem and little progress has been made in recent years.
How do we begin to fix this systemic problem? Start by treating it like we treat other health care quality problem, said Dr. Esther Choo, Founding Member and Strategic Lead of TIME’S UP Healthcare.
We have processes for identifying health care quality problems, implementing interventions, and evaluating progress in a robust and systematic way. But when it comes to improving the quality of health care culture, “we do none of it,” said Choo, “We don’t even measure the problem adequately.”
Rather than measuring, investigating, treating, and evaluating these systemic problems, we mostly ignore them until they become major scandals. “If sexism and racism and harassment were cancers, we would just kind of would wait until they are full-blown and metastatic before we address them, and then we expect them to be able cure them,” said Choo. “That is not how you can eradicate a system.”
We have address the smaller sexist and racist actions that we see every day in healthcare, said Choo. One way to do this could be an “M&M” (Morbidity and mortality case conference) type session, where everyone comes together to talk about an incident of sexism or racism and discuss how they can make sure it doesn’t happen again.
We also have to measure these factors regularly and evaluate which interventions are working or not working. “We want to bring the framework of health care quality to these issues of harassment and discrimination,” said Choo.
Bias and discrimination towards patients is another systemic problem in medicine. This is not just because of the lack of representation of racial and ethnic minorities in medicine, but also because of how health professionals are trained to identify health problems.
“We profile people for a living! And when our biases work well, we celebrate our ‘intuition,'” said Dr. Neel Shah.
“In medicine, you’re taught to stereotype.” concurred Dr. Damon Tweedy, Associate Professor, Duke Medical School and Author of Black Man in a White Coat. Doctors are often taught to assume things about patients based on their age, race, and gender. Then these assumptions are written into their medical record and perpetuated in future visits with other doctors.
Doctors have “tremendous power” in being able to tell their patients’ stories for other providers, which can be problematic when these stories are based on racist or sexist assumptions, said Tweedy.
How do clinicians avoid perpetuating racist assumptions, while still looking for the most likely options? One way is to undergo implicit bias training to acknowledge subconscious biases. Another is to put themselves in patient’s shoes when writing clinical notes to recognize how the framing and information in medical charts sets up patients for future interactions in the health care system.
“Having open notes made me rethink why I’m putting certain information in the charts,” said Tweedy.