Paul DeChant MD, MBA
Structural Racism in Healthcare
Earlier this year, I had the good fortune to talk with Dr. Nicole Rochester, who took some time from her busy schedule to discuss her experiences and expertise in two realms, one helping patients and families navigate the healthcare system, the other addressing the challenges of structural racism in the healthcare industry.
Dr. Rochester practiced pediatrics for 20 years. Then in 2017, after the experience of caring for her late father through his health challenges, refocused her career on healthcare advocacy. Her company, Your GPS Doc, helps patients and family caregivers navigate the complexities of the healthcare system and empowers families to better understand the health issues of their loved ones.
When asked for a take-away regarding the COVID 19 pandemic, Dr Rochester has a clear answer: “The biggest lesson from the pandemic is that we in healthcare don’t learn from our mistakes[..] It’s like that saying if you don’t learn from history you’re bound to repeat it”
Health Disparities - Recognized But Not Addressed
Dr Rochester cites the Heckler Report which was published in 1985 and looked at how people identified as “minorities” (Blacks, Hispanics, Native Americans and Asian/Pacific Islanders) were affected by health disparities, focusing attention to how much higher death rates were per year for Black individuals, especially compared to whites. It was the first of what are now many documents, studies, and publications documenting health disparities, but until very recently, Dr Rochester notes that little had been done to actually address these disparities despite the nearly 40 years of evidence that has been accumulating.
“Despite the hard work and recommendations of many health disparities researchers, the healthcare industry hasn’t done the work to correct the inequities, [there’s been] a lot of policy statements and commitments without many true substantial changes that will create the transformation that needs to happen.”
These enormous disparities, still largely unaddressed, are a significant part of why Dr. Rochester thinks the COVID-19 response has gone as poorly as it has in the United States. “If we’d addressed health and healthcare disparities twenty or thirty years ago, fewer people of color would have died”.
Impacts on Patients and Clinicians
Marginalized communities remain underserved by the medical industry at every level. Dr Rochester emphasizes that even seemingly mundane or innocuous healthcare practices and policies can unwittingly skew to be exclusionary or excessively punishing toward Black patients and providers. An example she describes is how patient late-policies often are more likely to affect Black or other marginalized patients due to the social determinants of health - these patients are more likely to be reliant on public transportation and have less flexibility with work to take time off to attend a medical appointment.
Racial discrimination, whether intended or not, impacts physicians as well. She reports stories of numerous colleagues, especially Black male doctors, being pulled over by police or harassed by neighbors with the assumption that their car or home is not theirs. In her professional role as a physician, she has faced overt racism in addition to being asked to do work outside of the scope of a physician due to her race. She recounts her own experiences of patients assuming she is a nurse, case manager, dietary employee, or part of the housekeeping staff in hospital settings, even after introducing herself as a physician, in addition to some instances where the patients she was to care for refused her care due to her race. Patients, employers, and the public itself all contribute to the added stress on Black healthcare providers.
When organizations do attempt to address the inequities in their organizations, such efforts are often lacking. Historically marginalized individuals are asked to shoulder the labor of engaging in inclusivity and diversity initiatives in addition to their workload, without additional compensation or protected time. In some cases, a diversity position is created in a corporate environment, someone is hired into the position to investigate culture and make policy changes, and then they are not given the authority to enact change in the system in a meaningful way.
Dr. Rochester does have some ideas for solutions for these problems. Ultimately, she states, there is a need for complete dismantling and rebuilding of the current structures with the lens focused on each policy that may be in place both in the micro and macro environments related to healthcare. She supports the suggestion of renowned physician, epidemiologist, and anti-racism activist Dr. Camara Jones, who proposes going line-by-line and policy-by-policy, with an “equity lens”, identifying those policies that offer benefits or cause harm to different segments of the population.
I want to thank Dr. Rochester for her willingness to share her time and expertise with me, and recommend one of her blog posts 4 Questions You Should Ask During Every Hospitalization for those whose families, friends or communities may be dealing with the stress of hospitalization of themselves or a loved one.