Can Culturally Humble Care Help Correct Historic Wrongs? | Deloitte US has been saved
By Paul Atkins, principal, Deloitte Consulting LLP
Racial and ethnic biases stretch back hundreds of years and can often be deeply engrained in our society. Growing up in the southern United States, I can remember hearing that Black people have a higher pain threshold because they have less-sensitive nerve endings. While running track and playing basketball in high school, I often heard that Black people have more muscle mass and are generally stronger and faster than white people. These myths, and others, were perpetuated throughout the country and may have often resulted in inadequate pain management or delayed treatment (or no treatment) for many Black people.
Look at virtually any health condition—from diabetes to pregnancy to mental health—and you are likely to see differences (in prevention, early detection, access, and treatment quality) by race and ethnicity. Black adults, for example, are 60% more likely than white adults to be diagnosed with diabetes and two to three times more likely to have complications. Black people—regardless of economic or social status—are three to four times more likely than white people to die during pregnancy or childbirth (see Can office staff help improve maternal mortality rates?).
Over the next 10 years, the Deloitte Health Equity Institute (DHEI) will provide $1.5 billion to organizations that are demonstrating impact, innovation, and an ability to help advance health equity. In October 2022, DHEI presented the Morehouse School of Medicine with $1.1 million to expand and strengthen a culturally competent and humble workforce in the US, and to improve maternal mortality rates among Black birthing persons. Among other things, the funding will be used to increase the number of health care providers and to make prenatal care more accessible to medically vulnerable and underserved patients.
I recently had a conversation with Walter D. Conwell, M.D., MBA, a practicing pulmonary, critical care, and sleep medicine physician who is also the chief diversity and inclusion officer at Morehouse School of Medicine, a Historically Black Medical School. The school’s vision is to lead the creation and advancement of health equity. Dr. Conwell told me that this vision resonates profoundly in him, and he believes it has the potential to create great impact in our society. During our call, he provided historic insight into how actions of the distant past can continue to affect the present. I was struck by both his personal journey and his optimism that, despite mistakes that may have been made in the past, true health equity is achievable. Here are some excerpts (and a few video clips) from that conversation:
Paul: Some studies have shown that patients prefer—and respond better to—doctors who are of the same race or ethnicity. About 14% of the US population is Black, but just 5% of all practicing physicians are Black. Why are there so few Black physicians?
Dr. Conwell: It’s important to understand the history of Black medical schools and the role they played in getting us to where we are today. Black colleges and universities emerged during the post-Civil War reconstruction era. Many people know that history, but they might not know that Black medical schools were a part of that era. Prior to 1900, if you wanted to become a doctor, you just needed to work with a practicing physician for a few years as an apprentice. You can imagine the variability that must have existed. In the early 1900s, the Carnegie Institute commissioned Abraham Flexner to evaluate all medical schools in the US and Canada. The idea was to standardize medical education. At the time, there were seven Black medical schools in the US. While the Flexner Report set the standard for medical education, it also introduced biases related to certain marginalized groups, including women and Black people. Flexner wrote that Black medical schools should train students to “humbly serve their people” as “sanitarians.” In other words, Black physicians should prevent disease in the Black community from getting into the white community. Not long after that report was published in 1910, all but two historically Black medical schools—Howard University in Washington, D.C. and Meharry Medical College in Nashville—closed. In the 50 years that followed, those two medical schools went on to produce more than 90% of all Black physicians. Having just two Black medical schools created a bottleneck because they could only produce so many doctors. A recent study estimated that an additional 30,000 Black physicians would have graduated if the five other Black medical colleges had continued to operate. The Civil Rights Act opened other medical schools to Black students. Still, less than 20% of all physicians in the US today are people of color. (Click here for Dr. Conwell’s thoughts on how history continues to shape the present.)
[Last year, CommonSpirit Health and Morehouse School of Medicine announced the More in Common Alliance, a 10-year, $100 million partnership between the two organizations. They are working together to develop three undergraduate and four graduate medical education sites to address the shortage of diverse clinicians and the need for more equitable health care. In addition, the Alliance intends to open five new regional medical school training sites in the US.]
Paul: What sort of an impact can Black medical colleges and HBCUs have on equity?
Dr. Conwell: Historically Black Colleges and Universities (HBCUs) are engines for social justice and economic mobility. The main impact HBCUs can have on health outcomes is actually a consequence of educational and economic opportunity. These organizations not only graduate individuals, but they can help lift entire families out of poverty. They are far more likely than predominantly white institutions to move someone from one socioeconomic quintile to another, and that is regardless of race or ethnicity. A large percentage of people who attend HBCUs today are white, often from rural backgrounds. Pulling people out of poverty, regardless of race or ethnicity, helps to impact downstream health outcomes.
Paul: What was your path for becoming an advocate for health equity and culturally humble care?
Dr. Conwell: I’m the product of an under-represented pathway to medicine. I was born and raised in a single-parent home in Gary, Indiana—outside of Chicago. Gary is about 90% Black and surrounded by communities that are majority white. It had once been a boomtown built off the steel industry. As that industry crumbled, so too did Gary. The unemployment rate rose and everyone who had the means to leave the city left. What remained was a population of very poor Black people. That’s the context I grew up in. I was the first member of my family to go to college. After graduating high school, I went to Florida A&M University (FAMU) and I thrived! It was a surprise to me because I had none of the skills or resources that I needed to thrive. I thrived because of the system of support I found there. FAMU—like other HBCUs—was built to bring about equitable outcomes for people like me. The system in Gary was intentionally built to perpetuate inequitable outcomes. I could clearly see the juxtaposition. That revelation set forth my underlying motivation, which is to identify people who have the greatest need and help them through their greatest times of need. I also wanted to improve systems that can bring about more equitable health outcomes. I took those motivations with me to medical school at the University of Chicago where I became the first Black student in that university’s history to be inducted into Alpha Omega Alpha (AoA)—the national honor society for medical schools. I continued to focus on equity during my residency at the University of Chicago, where I was one of the first Black chief residents. I did my pulmonary critical care fellowship at the University of Colorado, and later pursued my MBA and an administrative fellowship on diversity, equity, and inclusion [DEI]. I wanted to understand how I could help bring about more equitable health outcomes. (Click here to learn more about Dr. Conwell experiences growing up.)
Paul: How might biases impact quality and health outcomes if they are allowed to go unchecked?
Dr. Conwell: We know biases are present within our society, and they can be reflected within medicine. That does not mean people who hold biases are bad people, or that they are intentionally trying to harm someone else. Our biases are built into our neurobiology to make it easier for us to process the world around us. All humans are wired to come up with cognitive shortcuts so that they can process information more effectively. We are continually mapping new experiences onto old experiences. If we couldn’t do that, we would go into cognitive overload and wouldn’t be able to do even small things like cross the street. But, when we allow our brains to go into autopilot mode too often, we run the risk of making assumptions that can harm us or harm others. Physicians, clinicians, and medical students have an immense amount of power over decisions that will impact a patient. Even the words the clinician uses to describe the patient in the medical chart could impact that patient for years. It is important that we understand that power and check our biases. If we fail to do that, our biases could affect the care that our patients receive. (Click here to hear Dr. Conwell explain the similarities between human nature and diagnostic tools.)
Paul: As part of Deloitte’s collaboration with Morehouse School of Medicine, we are talking about ways to create a scalable and culturally humble training platform for health care providers. How do you define culturally humble care and culturally competent care?
Dr. Conwell: Cultural competency was a construct that was developed in the early 1990s to get at this issue of disparate care. It is a well-intentioned construct, but it can lend itself to perpetuating stereotypes. Cultural competence means you have a list of mental checkboxes whenever you are going to interact with someone who is different from you. If you are a doctor interacting with a Black patient or a transgender patient, there might be 10 things to keep in mind. But it is also important to acknowledge that not everyone within an identity group is going to experience the world in the same way. A Black man from the Midwest is going to have different life experiences than a Black man who grew up in New York or Miami. That’s where cultural humility comes in. This concept was developed by two doctors [Melanie Tervalon, MD, MPH, and Jann Murray-García, MD, MPH] in the early 1990s after the police beating of Rodney King triggered social uprisings in Los Angeles. The doctors were trying to authentically engage and help people of the community heal. What they proposed was lifelong learning and self-reflection. Much like humility generally, cultural humility is a journey, not a destination.
Paul: One of the focus areas for our collaboration is around building innovative models and advancing health equity for ethnically diverse birthing persons. What is the ideal impact of culturally humble care practices, specifically around maternal health?
Dr. Conwell: The potential impact is multi-fold. The first impact would be to narrow, or ideally eliminate, the gap in maternal and fetal morbidity. The idea that a Black woman in the US might have worse birthing outcomes than a Black woman in another part of the world should be of grave concern to all of us. Inequities impact the entire population. Health inequities is one reason health outcomes in the US are worse than in many other countries. We are hoping that our collaborations with DHEI and CommonSpirit Health can help change this. CommonSpirit is not just donating money to the Morehouse School of Medicine. This is a bilateral mutual effort where each group understands the value and the worth. We are moving together, and we are excited that other organizations are following our lead. We need to ensure that this is a movement, and not just a moment. We have seen over the past 150 years in times of social and political unrest, people invest in these types of efforts. But our memories are short. We need to make sure that the institutions stay accountable and that those who are in positions of power are truly invested in this work.
Paul: What should clinicians, and the rest of us, consider doing to advance culturally humble care?
Dr. Conwell: It starts first with lifelong learning and critical self-reflection. We really have to start with ourselves. We have to build our own knowledge. We have to create opportunities to listen authentically to others and reflect upon the privilege and power that we all have, regardless of our identity group. Whether we are Black, White, differently-abled, or LGBTQIA, we have to understand the power and privilege that we may or may not have within each context. When we understand that, we can understand how we can leverage our power and privilege to give a voice to those who might have less power and privilege.
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