Our twins were born too early, at 31 weeks. We were grateful they survived their placental infection but desperately disappointed to see them so small. Our other children, ages 4 and 2, would come and visit, settling into the family room at the neonatal intensive care unit (NICU), where a smiling nurse would give them sweet hot chocolate and put Snow White on the VCR. I felt split into four and could not provide enough for them all, with the pumping and watching and plotting of weights of the two babies in incubators, and then driving home in the dark to make it in time for bedtime stories.
Eventually, I reached my breaking point and begged the nurses for a solution. “Why of course,” they chorused, “you can stay in our mother’s suite!” All NICU moms were theoretically entitled to spend two nights in these rooms while they practiced with their babies before taking them home. It seemed extraordinarily luxurious — a double bed and a coffee brought to you in the morning. Unfortunately, the rooms were not always available.
The incubator next door to my twins held another two little babies, also born too early but bonny and bouncy. Their mom was young, with a young boyfriend. They shared with me that every day they rose at 5 a.m. and took three buses to arrive in time to be proper parents and do that first feed of the day, as we were all encouraged to do. They were brown and poor. I do not think they knew about the special suite. I watched them stay all day in that ward with their babies, and then take the last bus home every night.
I have often wondered how that couple coped, eventually taking those premature infants home to a place three bus rides away. I have also thought hard about who I was — a white doctor — and who they were. Did we get the same quality of care? And if not, how much of this reflects the decisions and omissions made by clinical staff, and for reasons unrelated to the condition of our babies?
The Institute of Medicine (IOM) published Unequal Treatment 15 years ago, describing consistent racial and ethnic disparities in the quality of health care across a range of clinical conditions and specialties, independent of ability to financially access services. The book categorized the factors contributing to racial/ethnic inequities in care: those occurring at the level of the health care system, the patient, and patient-provider interactions. This latter category includes issues of communication, as well as care decisions related to bias and stereotyping.
Implicit biases are unintentional “negative evaluations of one group relative to another” and are made by doctors, as by the rest of society. Studies show these biases can negatively impact the quality of the clinical encounter and patients’ experience of health care — including access to investigations, pain management, and critical therapeutic interventions. In addition to being associated with worse outcomes in cancer, cardiovascular disease, HIV, diabetes, and other illnesses, racial and ethnic inequity in care has been shown consistently to be both inefficient and expensive.
Public policy responses to health care quality issues have traditionally employed one of two approaches: top-down and bottom-up. The former has used mechanisms such as regulation and legislation, while the latter has emphasized STAR ratings, consumer empowerment, and report cards. The same is true of strategies and policies employed to target racial and ethnic disparities in health care quality. Since the IOM publication, there have been admirable top-down efforts to reduce inequities, including establishing the Commission to End Health Care Disparities, annual monitoring of aggregate national data through the National Healthcare Quality & Disparities Reports, and policies to improve access to care. These approaches importantly target the systems-level and institutional factors that contribute to inequities in care. Bottom-up strategies — such as patient navigators for cancer care, interpreter services, and collaborations between health care providers and community leaders — have also been employed in successful local projects.
Yet racial/ethnic health care inequities persist, despite these multiple and varied approaches. In this article, I suggest there is also a “middle” strategy, driven by the actions and voices of “middle men and women.” It features clinician-led approaches that acknowledge their role in this issue and that drive coordinated, health care worker–targeted efforts to reduce racial/ethnic disparities. I use the “Choosing Wisely” campaign as a model and consider three tenets to help inform a clinician-led strategy: acknowledgment and collective action, using data, and development of innovative interventions.
Action from the “Middle” — Choosing Wisely
Choosing Wisely was developed by the American Board of Internal Medicine Foundation as a partnership between professional medical societies and consumer interest groups. It discourages the use of “low-value” tests, treatments, and services for which there is little evidence of benefit to the patient, and which may even cause harm. The campaign promotes cultural change around health care utilization, encouraging patients and physicians to consider that the best management may be no investigation or treatment.
This program illustrates how medical professionals can mobilize and show accountability for the care they deliver, with coordination across multiple specialties. It is neither top-down, nor bottom-up; it is a profession-driven “middle” approach to improve health care quality. The program has several critical success factors that can be applied to health care inequities.
1. Clinician Acknowledgment and Collective Action
Overuse contributes substantially to overall health expenditures, and the burgeoning health care budget concerns us all. Health care workers play a pivotal part in this problem by facilitating the receipt of these services. Having clinicians acknowledge their contribution to low-value care was an important prerequisite to the success of the campaign, both at the individual and professional level. Currently 75 professional societies support Choosing Wisely; this leadership has been instrumental in gaining buy-in from physicians while also encouraging innovation and competition.
In the same way, meaningful reduction of racial/ethnic disparities in health care quality requires clinicians to seriously consider their personal contribution to inequities, and to provide leadership in creating solutions. We can learn from trailblazing campaigns of the 2000s, such as the multi-organizational “Why the Difference” intervention (spearheaded by the Robert Wood Johnson Foundation), and “Heads Up!” from the American Academy of Physician Assistants, both of which aimed to raise awareness of the role clinical staff play in mediating racial/ethnic disparities in health care quality.
2. Using Data
Central to understanding low-value care has been the exploration of variation in utilization patterns. Data facilitate peer comparison, raise questions, and provide benchmarks against which to measure improvement. Applying an equity lens to variations in care delivered by practitioners would be similarly illustrative, particularly if it were linked explicitly to performance.
In this age of electronic health records and related technologies, the vision should be for routine analysis of process-of-care indicators (such as adherence to guidelines, referral rates, and medication regimes) by race/ethnicity. Although collecting complete and accurate organizational race/ethnicity data can be challenging, the first step is for clinicians to insist on exploring process and outcome data by this characteristic, if only to highlight where there are data deficiencies.
3. Innovative and Far-Reaching Interventions
Initiatives in low-value care include the use of health information technology to encourage adherence to best practice guidelines, internal competitions around decreasing unnecessary procedures, and awareness campaigns, such as “Lose the Tube” to lower catheter-associated urinary tract infection rates. These strategies have penetrated organizations across all levels of the health sector, including some medical schools that now incorporate education around low-value care in their curricula.
The same level of energy and creativity, and the use of modern technologies and marketing strategies, could produce as-yet-unimagined initiatives to target inequities in care. For example, could predictive analytic models be used to counter the impact of implicit bias among providers toward racial and ethnic minority patients?
The use of patient-facing technologies, such as online health records, may help circumvent some of the resource and operational concerns around obtaining accurate and complete race and ethnicity identification information. Additionally, having organizations and/or providers monitor and report racial and ethnic differences in health care quality may drive improvements and competition. As medical professionals, we need to support and push these interventions in the same way that we have endorsed those aimed at low-value care.
In summary, Choosing Wisely has shown that clinician-led approaches can produce coordinated and exciting professional movement to improve quality of care. I suggest that three key success factors from this program can also be applied to a “middle-led” strategy to reduce racial/ethnic disparities in care: collective clinician acknowledgment and professional action, using data to understand and scrutinize practice, and the development of innovative and far-reaching interventions. I believe policy approaches from “the middle” may be critical to targeting the pervasive and persistent racial and ethnic inequities in health care quality.
My twins are 8 now. Despite their early arrival, they have thrived and are healthy, robust, noisy children. I suspect their current constitution is in part due to their receipt of consistently high-quality health care, both in the community and hospital setting. I wonder . . . Have those other twins received the same level of care over their 8 years? And if not, could we, as a medical community, have done something about it? This year, my twins read the Harry Potter series; in the wise words of Hogwarts headmaster Albus Dumbledore, “Understanding is the first step to acceptance, and only with acceptance can there be recovery.”
Acknowledgments: The author thanks Dr. Rawiri Jansen (National Hauora Coalition, New Zealand) and Dr. Christine Cassel (Executive Advisor to the Dean, Kaiser Permanente School of Medicine) for their peer review and helpful edits to drafts of the manuscript.
Source of Funding: Support for this research was made possible by a Harkness Fellowship in Healthcare Policy and Practice, awarded to Dr. Rumball-Smith by The Commonwealth Fund. The content and opinions expressed in this article are solely the author’s responsibility and do not reflect the official position of The Commonwealth Fund or its directors, officers, or staff.