Society teaches us: Biases are bad. So, But when we’re confronted with ours, we tend to get defensive. Our knee-jerk reaction is often denial.
But the truth is: We all have biases. And they’re neither inherently good nor bad; they just are.
That’s the message from Yvonne Dixon, Novant Health’s director of health equity for the UNC School of Medicine Novant Health Charlotte campus.
As part of a new strategy at Novant Health to address disparities in maternal and infant health, Dixon is leading development of a training program for doctors, certified nurse midwives along with physician assistants and family nurse practitioners known as advanced practice providers (APPs) in pediatrics and obstetrics. The goal: Help clinicians recognize biases that stand in the way of delivering the best possible health care to all patients.
“We’re looking inwardly to understand those biases,” Dixon said. “They come instantaneously – without us even thinking about them. And if we’re not managing, or seeking to understand, them,” health care can suffer.
The training is helping clinicians ensure they’re offering equitable maternal and infant health care across all patient populations.
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In 2021, 1 in 6 infants in North Carolina were born to a woman receiving inadequate prenatal care. Research indicates that babies of mothers who don’t receive prenatal care are three times more likely to have a low birth weight and five times more likely to die than those born to mothers who do get adequate care.
Nationally, Black women are 3-to-4 times more likely to die than white women and have the highest rates of maternal mortality, independent of income, age and education. Additionally, infant mortality, fetal death and stillbirths occur at a higher rate in Black children. The drastic disparities centered on the maternal and infant health experience are a central focus of Novant Health’s strategic approach.
The multiyear effort kicked off in February with a screening of the “Aftershock” documentary (streaming on Hulu) and a physician-led Q&A panel discussion. The film follows Omari Maynard and Bruce McIntyre, who became maternal health activists after their partners died during childbirth. The unexpectedly single fathers are among those fighting for institutional reform.
Nearly 420 clinicians attended the three-hour session and the film jolted many who saw it. Dr. Richard Thompson, called it “blatantly shocking.” He’s an OB-GYN in Novant Health’s coastal region and said the true stories depicted in the movie “don’t represent the standard of care anyone should ever expect to receive.”
Dr. Tomas Luley of Novant Health Southeast OB/GYN in Matthews saw the film with his entire office team and has taken anti-bias courses online and over Zoom. His original thought was that cultural biases have no place – and don’t exist – in “a modern health care system.”
“I thought cultural biases – the kind that put minority women at greater risk – must be rare in health care,” he said. “I’ve seen that’s not the case. Women of color are at greater risk of poor outcomes and even increased mortality.
“I did resident training many years ago, and there was nothing like this training at that time. I think it’s wonderful that Novant Health is taking the lead on something so important. There’s a real need – a maternal health crisis in this country – and we all should acknowledge it and work to improve the care women of color receive.”
Training made easy
The new curriculum, much of it written by Dixon and her team, includes more than 25 training modules – some offered in person, some live online and some on-demand. The courses count toward required continuing medical education credits.
All 567 OB-GYNs and pediatricians in the Novant Health network, plus APPs, are taking courses throughout 2023.
Novant Health leaders consider the training so vital that the target audience has been expanded to include team members in women’s and children’s doctors’ offices. New clinicians are also getting a portion of the training during their orientation week when Dixon’s department gets four hours to cover implicit bias. (Implicit bias is defined as “automatic” or “unintentional” bias.)
The curriculum places emphasis on Black maternal health. “This training applies to all expectant mothers,” Dixon said. “But at the same time, we must acknowledge that Black expectant mothers are three times more likely to die from a pregnancy-related cause than White women.”
Thompson’s patient population is largely rural and white, but he sees some patients of color. In fact, his office is about to embark on a study, directed by UNC Chapel Hill’s medical school, that will pair Black expectant mothers with a doula. Doulas provide emotional and physical help to expectant and new mothers. His office has never worked with a doula before, but he said he and his partners are excited to introduce a new concept to their market.
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No matter who he’s seeing, he said, “It’s important that we all try to ‘Walk a mile in someone else’s shoes.’ I’ve had my eyes opened to cultural differences and to ways to circumvent our preconceived perceptions.”
Luley’s approach to care has changed as a result of the training. “I feel more equipped to understand certain challenges and barriers to care patients may have,” he said. “In the past, if a patient was arriving late for appointments, or missing them entirely, I may not have thought much about it. Knowing what I know now, I’m inclined to do a deeper dive and ask if there are issues that make it difficult for the patient to get to her appointments. If she doesn’t have her own transportation, maybe we can help. If she has a hard time getting off work, maybe we offer her a telemedicine appointment.
“Instead of assuming, I now ask my patient about her challenges. And I also ask: How can we help?”
One goal of the training is to increase the satisfaction Black women have with their Novant Health OB-GYNs and pediatricians. It’s being measured, in part, by patient surveys.
We are generally oblivious to our biases. “Everyone thinks they’re the exception,” said Josh Tucker, senior director of the Novant Health Women and Children’s Institute. “But as people start seeing the statistics, they get it.”
The clinicians undergoing training learn that what the CDC says is true: “Social determinants of health prevent many people from racial and ethnic minority groups from having fair opportunities for economic, physical and emotional health. Research shows that systemic racism and implicit bias are correlated with increased morbidity and mortality of women of color and their children.”
While trainees in live classes may have to confront their own biases, they do so in a safe, comfortable space. Dixon is the kind of person others open up to – without fear of judgment. Under her tutelage, people begin owning their biases. And they start to see that being “colorblind” – as some claim to be – does a disservice to patients.
“If a doctor tells me they ‘don’t see color,’ I tell them: ‘Look under your microscope. It may tell you a different story,’” Dixon said. “I want my physician to see me as an African American woman because there are some conditions – like sickle cell disease – that only impact African Americans and people of Mediterranean cultures.
Race plays a role in our health, so it’s important that providers take it into account.”
Many of us think of bias only in terms of race, but biases take many forms, Dixon said.
Weight bias is a real thing. Dixon cites the story of a woman who was dealing with obesity before she got pregnant. She went to her OB, and her weight was all he could talk about. While the doctor may have had the woman’s overall health top of mind, the dejected patient left the office feeling judged.
Postpartum depression is a topic even some doctors dismiss. “Not every woman will have it, but every woman is susceptible to it,” Dixon said. “If you’re having these serious issues and your doctor says, ‘Oh, just give it time,’ that’s not useful.”
Dixon tells trainees: “Just saying, ‘This will pass’ doesn’t help your patient. We must listen to what patients have to say.” Active listening is a big component of the training.
A physician who watched “Aftershock” and took a class from Dixon told her she’s now listening much more closely. Doctors are busy and every minute with a patient matters, Dixon said. “It’s important they make it count.”
Thompson has talked to colleagues who have learned a lot about the importance of active listening. He’s always tried to make it part of his practice. “One of the first questions I ask a patient is: ‘Do you have any questions for me?’ A couple of years ago, I asked a new patient what questions she had, and she said, ‘You’re the first doctor who’s ever asked me that.’
Luley, too, has become a more active listener as a result of the training. “Before I walk in a patient’s room, I clear my mind and remove any expectations or biases. I try to put myself in the patient’s shoes. Let’s say a patient has diabetes and hasn’t been checking her glucose as often as she should. Or maybe she’s not compliant all the time with her medication. I’m grateful there’s a staff dietitian we can refer them to.
“But I now think about opportunities to go even deeper and really impact patient care. I ask: 'Is there something preventing you from checking your blood sugar?’ If there’s a financial issue that makes the test strips unaffordable, I try to find financial resources to help.”
Training for all
Dixon’s team is working to ensure the information they share with OBs, pediatricians and their staffs will “stick.”
At the end of every live training – in person and virtual – there’s a “call to action” where the trainer asks, “How will you use your new knowledge?”
Education is useless if not put into practice, Dixon notes. “We’re asking for accountability,” she said. “We’ll ask: ‘How do you think your training will show up in your practice in the next six months?’ It's up to them to operationalize what they’ve learned, and that starts with the self.”
Some doctors and APPs who take the training learn as much about themselves as they do about the nature of implicit bias and the harm it can do. And that’s even more valuable than a continuing education credit and points.
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