The Part of the Primary Care Provider in our National Awakening to Systemic Racism

Abstract

Photo by Markus Spiske on Unsplash

INTRODUCTION

Racism makes people sick. As the United States navigates a social awakening, primary care providers (PCPs) need to join the movement by addressing the impact of racism on our society. As community leaders, all PCPs, including medical doctors, doctors of osteopathy, physician assistants, and advanced practice nurses, are morally called to combat systemic racism. PCPs need to consider how traditional treatment modalities, such as drug prescription and lifestyle modifications, may perpetuate systemic racism and inflict further injustice upon the health of Black Americans. Furthermore, as physical healers, PCPs are professionally bound to address systemic racism as its detrimental physical effects ravage those marginalized by our racialized society.

ANALYSIS

The effects of allostatic overload demonstrate that racism causes physical illness. Allostatic overload refers to the physical effects of chronically adapting to negative experiences over one’s lifetime.^[1] It predisposes people to chronic disease, predicts an increase in all-cause mortality, and is highly correlated with racial discrimination.^[2] After controlling for socioeconomic status and other adverse health behaviors, researchers have shown that Black participants have consistently higher allostatic load scores than white participants.^[3]  The outcomes of the COVID-19 pandemic have dramatically affected communities of color, demonstrating the relationship between the physical effects of allostatic load and racism. During this pandemic, Black Americans are dying at three times the rate of white Americans.^[4] If we are truly committed to providing care that lives up to high ethical standards, we should start by investigating structures of inequity within our practices to improve the health of patients of color. Below, we propose a three-tier intervention strategy, employing interventions in practice, patient, and personal levels of care.

At the practice level, PCPs could use their voices to advocate for patients on a macro scale. For example, they could support initiatives that provide patients with bus fare or child care, prioritize the accessibility of clinic interpreters, or create more flexible clinic hours.^[5] In addition, PCPs should consider using third-party organizations, such as Health Leads, that would connect their patients with social solutions like housing, transportation, and healthy foods.^[6] We also suggest that a clinician pair with a member of the community to create a one-page clinician reference of local resources. This type of intervention is shown to increase referrals to support services, improve patient employment, and raise the number of children accessing childcare, while reducing the use of homeless shelters.^[7]

PCPs may become advocates of social change in two unique ways: by dismantling societal systems that perpetuate inequity and by addressing patients’ manifestations of these systems. Both stem from PCPs’ ethical and fiduciary role; they both require moral agency or the ability to act in the face of deeply rooted systemic obstacles. To address the public health emergency of racism and advocate for their population’s health, PCPs should address the social structures that have an undeniable effect on health. This kind of comprehensive care will often extend past the traditional prescriptive relationship. Social workers are not exclusively responsible for performing assessments of societal effects on healthcare. It is crucial that PCPs perform initial assessments to identify inequities to meet ethical expectations and fulfill their fiduciary role.

On a patient level, PCPs should routinely assess patients’ social determinants of health (SDOH) by discussing their living environment, financial circumstances, education, support systems, and experiences with racial segregation.^[8] It is important to investigate social challenges in a sensitive and empathetic way by using validated and reliable assessment questions, such as “do you ever have difficulty making ends meet at the end of the month?”^[9] Sensitively documenting the results of these screenings of  the medical record allows for a seamless multidisciplinary approach and assessment over time. 

By starting these difficult conversations, PCPs display beneficence toward their patients and a fidelity to their profession. In accordance with the professional commitments of providers, PCPs engage in these conversations to assess and improve patients’ circumstances and to promote their integrated wellness. However, conflict can arise between provider intentions of beneficence and patient autonomy or privacy. Patients may choose not to disclose situations they perceive as embarrassing, ranging from food insecurity to unhealthy housing conditions or debt. In such situations, it is important for PCPs to respect the patient’s desire for confidentiality and personal decision making. It should be the patient’s choice and not the provider’s choice to avoid the conversation. PCPs have demonstrated their ability to investigate other sensitive patient issues such as suicidal ideation, teenage sexual activity, and substance use concerns. PCPs should not avoid the topic of racial inequity due to their own unease surrounding this topic. Regardless of an individual patient’s response to a SDOH assessment, PCPs who routinely screen all of their patients communicate that they truly care about the betterment of their patients, are a trusted resource, and are readily available for future assistance.

On a personal level, all PCPs should understand their implicit bias by taking a confidential racial implicit bias assessment. This commitment to self-assessment requires introspection and confrontation of automatic, pervasive cultural assumptions. It is essential that all PCPs take time to identify their subconscious biases because without knowledge of the problem, no solution would be offered. PCPs should also consider supporting the social movements and political parties that align with racial justice initiatives. As we begin to envision new policies under a new presidential administration, focus should be placed upon expanding coverage and quality of healthcare for people of color.

While this process of introspection may be jarring and unfamiliar, all PCPs have a professional responsibility to be aware of deeply rooted assumptions that inform biased assessments or behaviors. Eradicating bias is necessary. Otherwise, unchecked biases can lead to unintended harm in the form of both subtle micro-aggressions, which erode the trust between PCP and patient, and overt differences in patient care. The effect of provider racial bias has been shown to delay referrals to specialists, to create disparity in assessment and treatment of pain, to defer routine cancer screenings, and even to reduce the rate of cardiac catheterization for Black patients experiencing chest pain.[10] The deleterious effect of bias reaches nearly every corner of healthcare. Non-maleficence should serve as the natural ethical motivation for PCPs to check their implicit bias on a regular basis. Providers acting on implicit or explicit bias harm those  they are responsible for protecting. Once aware of the existence and impact of bias, introspective PCPs will recognize the moral impetus to make changes.

CONCLUSION

Both the Hippocratic Oath and the American Nurses Association’s Code of Ethics and Interpretive Statements imply that PCPs are united in their professional and ethical obligations to serve the whole patient. One manifestation of these obligations is taking actionable steps to reduce racism. The task of addressing the SDOH can be daunting in scope; however, to identify the effects of systematic racism or social injustice at the practice, patient, and personal levels is a concrete action. Connecting marginalized patient populations to local resources can make small differences that produce significant change. PCPs are important leaders in making systemic changes due to the unique role they play in communities. It is vital that they work toward identifying and dismantling structures of racial oppression in our society as we seek to improve the health of our nation.

“Not everything that is faced can be changed, but nothing can be changed until it is faced.” - James Baldwin

^[1] Finlayson, Judith.”You are what Your Grandparents Ate: What you need to know about Nutrition, Experience, Epigenetics & the Origins of Chronic Disease.” Toronto, Robert Rose Inc. 2019.

^[2] Tomfohr, Lianne M., Meredith A. Pung, and Joel E. Dimsdale. "Mediators of the relationship between race and allostatic load in African and White Americans." Health Psychology 35.4 (2016): 322.

^[3] Duru, O. Kenrik, et al. "Allostatic load burden and racial disparities in mortality." Journal of the National Medical Association 104.1-2 (2012): 89-95.

^[4] Pilkington, Ed. “Black Americans dying of Covid-19 at three times the rate of white people.” May 20, 2020, The Guardian, https://www.theguardian.com/world/2020/may/20/black-americans-death-rate-covid-19-coronavirus, Accessed on 6/24/2020. 

^[5] Andermann, Anne. "Taking action on the social determinants of health in clinical practice: a framework for health professionals." Cmaj 188.17-18 (2016): E474-E483.

^[6] Health Leads. “Health Leads.” 2020, healthleadsusa.org/ Accessed on 6/24/2020.

^[7] Garg, Arvin, et al. "Addressing social determinants of health at well child care visits: a cluster RCT." Pediatrics 135.2 (2015): e296-e304.

^[8] Artiga, Samantha and Orgera, Kendall.  “Key Facts on Health and Health Care by Race and Ethnicity.” Kaiser Family Foundation, November 12, 2019, https://www.kff.org/report-section/key-facts-on-health-and-health-care-by-race-and-ethnicity-health-status/ , Accessed 6/24/2020.

^[9] Brcic, V., Eberdt, C., & Kaczorowski, J. (2011). Development of a tool to identify poverty in a family practice setting: a pilot study. International journal of family medicine, 2011.

[10] IOM. Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care (with CD). National Academies Press, 2003, p. 12875. DOI.org (Crossref), doi:10.17226/12875.