Has the drive toward diversity stalled during the COVID-19 pandemic?

The May 2020 murder of George Floyd — a Black man in Minneapolis killed by a white police officer — was one of several critical moments in a pandemic year that prompted society to examine cultural and social inequities born out of systemic barriers that have existed and evolved over centuries.

While millions of people globally joined protests to denounce Floyd’s death in the past year, there is debate over how much progress occurred despite the demonstrations and commitments from organizations and businesses across all sectors and industries.

• U.S. Bureau of Labor Statistics 2020 population survey data find that Black Americans are underrepresented (compared to share of total population) in several healthcare occupations, such as nurse practitioners (NPs), pharmacists, physician assistants (PAs), physicians and surgeons.1 
• In pediatrics, a recent study of graduate medical education census data find that the proportion of underrepresented in medicine (URiM) pediatric residents and subspecialty fellows has gone largely unchanged in about 15 years, and that “there is a critical need to recruit and retain” a better racial/ethnic representation of the patient population among the ranks of clinicians.
• Previous studies find that implicit bias among healthcare providers tend to manifest in positive attitudes toward white patients and negative attitudes toward people of color (POC), and that such implicit biases “may contribute to health disparities” for POC.
• At the highest levels of healthcare leadership, women and ethnic minority board membership still lag behind levels of representation in the clinical ranks, according to the Governance Institute’s 2019 Biennial Survey.

However, many healthcare organizations have reaffirmed their commitments to diversity and inclusion a year later, such as recent program and partnership announcements made by The Cleveland Clinic. Furthermore, medical students who train at more diverse schools are shown to be more comfortable treating patients from various ethnic backgrounds besides their own.

A July 6 MGMA Stat poll found that about one in three (32%) medical practices have a formal diversity program, while another 4% of practice leaders say they are considering one. The poll had 830 applicable results.

Battling bias

In June 2020, MGMA launched its “Battling Bias” series to chronicle the role of healthcare executives, administrators, providers and staff in confronting issues of race in their professional lives and communities:

• Part 1: “How intuition and unintentional biases can shape how decisions are made”
• Part 2: “Building diversity in recruiting and hiring”
• Part 3: “Sustaining inclusion through organizational culture”
• Part 4: “Racial bias and its effects on patient care”

MGMA continues efforts to address the intersection of race, social inequities and the healthcare experience. For a more recent examination of health equity, social determinants of health and impacts on at-risk patient populations, listen to the recent MGMA Insights podcast with Nwando “Dr. O” Olayiwola, MD, MPH, FAAFP, chief health equity officer and senior vice president, Humana.

“Why are we talking about diversity again?”

Editor’s note: The following is an adapted excerpt of a feature article by Christine Kalish, MBA, CMPE, president and chief executive officer, Brittain-Kalish Group; Ticily Medley, PhD, counseling psychologist and life coach; and Dawn Adams, MS, PMP, SHRM-SCP, human resources consultant, Brittain-Kalish Group, from the July issue of MGMA Connection magazine.

Why does cultural diversity in healthcare matter? From a patient standpoint, the events of the past 18 months have exposed the disparities in the delivery of care. While COVID-19 has affected everyone, the disease has been especially devastating within communities of color and other vulnerable populations.

But this is not about the pandemic; it is about deep-rooted foundations of cultural and social inequities. These same barriers that providers and staff face in the delivery of care also create challenges in working toward an inclusive workplace.

Healthcare professionals, clinic- or hospital-based, should be working together as a cohesive unit; however, issues surrounding gender, socioeconomic status, weight, racial and ethnic identity often get in the way of productive work and positive outcomes. Recognizing these issues of identity and bias is crucial to begin to transform the culture in our organizations to that of acceptance and inclusion.

Identity, bias and socialization

Consider the intricacies of how our identities are formed, and how socialization influences our opinions and outlook. Our identities are shaped by many aspects of our lives as we mature and assume different roles and personae. An identity wheel (Figure 1) is one type of visual tool that depicts different aspects of how people identify themselves, including gender, race, socioeconomic status, education and other factors.2

These identities or categories of belonging are fundamental to who we are. Communication is the key to understanding; however, there needs to be a safe way to acknowledge our differences and concepts of self. These categories of belonging are also a significant part of who we are in many situations, such as personal, social and work.

Within this concept of self and identity, biases are formed. By definition, bias equals preference. Everyone has preferences: Bias in and of itself is not a bad thing — it is simply a reflection of your preferences. Ask yourself: How do the people in your close friend group identify? Most likely, you will find that your friend groups are more culturally similar to you as opposed to diverse. You are biased toward people who are similar to you. Now think about this: Are you more likely to harbor a negative bias against people with a certain characteristic? Before you emphatically respond, “No, I don’t,” know that research tells us that many of these types of cultural biases often operate at an unconscious or implicit level. Most of the time these thoughts or feelings occur without us intentionally thinking about them.

Socialization or social shaping can happen through explicit means or more subtle implicit means. Socialization is a concept that covers the learned norms around gender, attractiveness, career expectations and stereotypes, among other characteristics (think about the stereotypical expectation that women are nurses and men are physicians).

It is an entire process of learning along the course of life and influences behavior, beliefs and actions. It tells you what is reinforced and what gets punished. Biases are the result of socialization. In the process of dismantling any bias you recognize, try to connect the origin of the bias to a specific message you received while growing up.

Perception and perspective

Biases and prejudices are based on how we perceive people, and they may be real or perceived. For example, just because someone does not have insurance does not mean they cannot pay for their healthcare services. Oftentimes, though, that is the perception. Perception is unreliable, at best, because it is shaped by one’s socialization and life experiences. Often, we perceive that we are right and the other person is wrong simply because we are standing on different sides of a picture. Depending on the perspective, both can be right. But when this perspective mismatch happens, work is halted, processes become inefficient, and toxic environments are created when the seeds of misperception are allowed to take root and grow unchallenged.

To prevent misperceptions:

• Address the overall environment and interpersonal dynamics from an internal and external perspective.
• Look internally. Assess how your socialization, identity and experiences have affected the way you see the world and others.
• Look externally. Consider how your patients and staff see and experience the world.
• Look for commonalities between your view and theirs and determine if you can make a shift.

Integrating diversity into your culture

With this new awareness and information, the key challenge for a practice leader is to integrate these changes into the practice’s culture; however, this can take a considerable amount of time to shape the people, processes, policies and practices within the organization. After gaining an understanding around these basic concepts, the hard work of culture transformation can begin.

Take these actions to begin integrating diversity within your organization’s culture:

• Sharpen your lens of awareness. This may seem like an easy thing to do, but it can be difficult because we do not know what we do not know. We typically do not seek information if we are unaware that an information gap exists. Increasing your awareness will require you to consistently assess your interactions with others, especially those who are different than you. Question the assumptions you make about people. Ask yourself, are your decisions based on facts and objective information or are they influenced by stereotypes and biases? As you develop this new awareness, you may want others to be as aware as you are. That may be a tough order. Make it simple and change your awareness and actions. Think about the adage, “actions speak louder than words.” In this case, it may well be true.
• Build cultural empathy. Cultural empathy is about communication and respect. The goal is to acknowledge the feelings of others and be able to consider those feelings regardless of our experiences. Think about how to step into another person’s shoes. Listen to understand. Be aware of finishing sentences and offering advice when your understanding of the person and their culture may be limited. Avoid generalizing a person’s experience based on their culture. Cultural empathy helps to build positive relationships, no matter the differences. In return, the practice environment can become more positive and supportive.
• Look for allies and become an ally. Allyship provides an opportunity to educate ourselves and others through a long process based on trust and accountability. Everyone has an opportunity or ability to be an ally because everyone has privilege, and that privilege crosses many lines. It is about using privilege to benefit others who are different than you. Being an ally is about taking small actions that make big impacts. Know that you will make mistakes but hold yourself accountable. Accept the impact of your mistake, apologize and rethink what needs to change.
• Be open to crucial and courageous conversations. Understand that offenses may occur on both sides of an issue. There are two sides to every story; while addressing your biases can be scary, living as the object of oppression is hard and scary, too. Be willing to have open and honest discussions. Ask questions. Listen and speak without judgment. Be open and receptive to feedback.
• Take care of yourself. This is incredibly important because pushing back against ingrained systems of inequity is hard work. It is frustrating and tiring, so make sure that you set aside time for personal care and recovery. This can take many forms, but make sure it happens.

No matter what, you should get comfortable with being uncomfortable. Listen to all voices. Be inclusive with inclusive language. Be aware and educate yourself. We have a responsibility to ourselves, our organizations and the populations we serve. This is about the journey and all the experiences along the way, one step at a time.

Notes:

1. Caruso M. “Healthcare employment diversity.” Modern Healthcare. Feb. 15, 2021, 
2. IDARE | Office of Inclusion, Diversity, Anti-Racism, and Equity. “Resources.” Johns Hopkins Bloomberg School of Public Health. Available from: bit.ly/2SRVfh1.