While these social influences and environmental factors play a role in our overall health, women—especially Black women—regularly face worse health outcomes as a result of the convergence of social and structural barriers, such as racial inequalities, stereotypes, generalizations, and language that can undermine the patient-provider relationship.
The persistent bias in our health-care system
The studies are clear: Direct, indirect, and unconscious bias negatively affects health care for Black people. One study revealed that doctors may recommend more advanced and effective medical treatments for white patients than for Black patients. And the influential 2003 Institute of Medicine report on racial and ethnic disparities in health care found that “stereotyping, biases and uncertainty on the part of health-care providers can all contribute to unequal treatment."
When we look at women’s health more closely, we see that inequities are most significant for Black women when it comes to maternity care. Black women have three to four times the rate of maternal death compared to white women, as well as twice the rate of maternal morbidities.
This data is reinforced and brought to life by real-world experiences. At CVS Health, where I am the chief medical officer of Women’s Health, we recently heard from members of our Black Colleagues Resource Group (BCRG) on how they manage their experiences within the health-care system. Black women told us they often anticipate their health-care concerns and questions will be dismissed or ignored during encounters with providers and other members of the health-care system. Black colleagues shared instances in which they adjusted behavior as a defensive strategy to sidestep those barriers, including trying to optimize their speech, appearance, behavior, and expression in the hopes of receiving fair(er) treatment and better care—also known as code-switching. BCRG members even mentioned having to reference their professional or educational credentials to their providers in order to signal their worthiness.
Unfortunately, we hear these stories far too often. Regardless of socioeconomic background and race, patients should feel supported and informed in order to make their health-care decisions without these additional stressors. As health-care providers, we need to partner with our patients, listen to their needs and desires, and work together toward good outcomes. The health-care industry, meanwhile, should take the opportunity to examine the biases that we know exist and shift its thinking and approaches to help ensure patients are being heard.
The role of language in health care
The bias present in our society and current health-care environment harms communication among providers and patients, ultimately diminishing the quality of care and causing potentially deadly consequences for Black patients. Additionally, in a highly complex health-care system that features ever-shorter provider-patient interactions, providers often have little time to learn their patients’ stories and life circumstances. This makes quickly building trust and rapport even more critical. In my experience as a practicing OB/GYN, paying attention to language choices and taking the time to understand what people want from their health care can help improve communication and outcomes.
Ensuring that providers and other members of the health-care system listen to and hear patients’ concerns and desires in their health journeys is key to quality outcomes and positive patient experiences. Comprehensive, culturally competent care begins with language. Using more inclusive language that acknowledges people and the systems that oppress them is a start. This approach allows us to personalize care to people’s specific circumstances and reflect on the biases we carry in our communication.
For instance, terms like “non-compliant” (used to describe patients who miss medications or tests) appear to blame the patient instead of starting a conversation about what barriers might exist that prevent them from getting the care they need. Maternity-related phrases like “failed pregnancy” label the patient as inadequate, while “geriatric pregnancy” ages women inappropriately.
Additionally, often-used but exclusionary terms like “underserved,” “poor,” and “minority” perpetuate rather than dispel disparities. These terms can be inaccurate and undermining. Using the phrase “historically underinvested or underrepresented,” on the other hand, acknowledges the decisions, ideas, and social structures that negatively impact Black and brown communities.
Equally important are words we use in everyday conversation. According to the Center for Practice Transformation, “a person’s identity and self-image are closely linked to the words used to describe them.” Bias can come through in the assumptions we make about people, such as assuming someone’s pronouns or reaching inappropriate conclusions about their family relationships or structure. These assumptions don't just lead to hurt feelings but can also create a situation where a person doesn't receive the care they need. (For example, assuming a person is a certain gender by how they present might mean that they don't receive reproductive health care appropriate for their bodies.)
With our world evolving and becoming more fluid than ever, from the way families are built to how people define their gender or relationship status, we as providers need to be more mindful of the way we speak and be more aware of the language we use. By taking time to reflect on ways we might be inadvertently perpetuating health-care disparities, we can be more attentive in our interactions and hear people when they share their health concerns, hopes and goals.
Mapping the future of equitable care
Amending language is just a small step in fighting systemic issues and closing the gaps in health care. But it is a necessary one. We must collectively do more and do better. Events from this past year alone have further highlighted the need for us all to reflect upon the persistent racism in the country and our role in it. By making care more personalized to an individual’s unique circumstances and partnering with patients on their health care journeys, we can help people receive better health and achieve their maximal health.
Improving health-care inequities is a grand undertaking, but small and immediate steps we can take to advance this cause include training in unconscious bias, compassionate language and discussions, a better cultural understanding and sense of humility, community-based medical education, and maintaining an open mind and heart. Within our communities and health-care system, we can all play a role to help people receive better care and achieve their maximal health. This won’t just be better for some of us, but for all of us.
Joanne Armstrong, MD, MPH, is the executive medical director and CMO for Women’s Health and Genomics at CVS Health. She is also a practicing OB/GYN.
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