Experts: It's Time to Flip the Historical 'Script' Toward Health Equity

Aine Cryts

December 13, 2021

Unfortunately, it's easy to find evidence of racial disparities in the US healthcare system, according to experts. But rather than fall back on mistakes of the past, medical professionals can change things to create a better future.

Jann Murray-García, MD, MPH, associate professor at the Betty Irene Moore School of Nursing and director for social justice and immersive learning in the Office of Health, Equity, and Diversity at UC Davis Health in Sacramento.

Dr Jann Murray-García

She pointed to a 2015 study in JAMA Pediatrics, which found that Black children with documented cases of appendicitis and pain scores were less likely to receive pain medication for moderate pain than white children. Black children were also less likely to receive opioid-based pain relief as a result of severe pain, per the study. The co-authors' take-away: There's a different threshold for pain treatment experienced by Black children.

In addition, a 2017 study in the Journal of the National Medical Association found that the visitors of Black patients were more than twice as likely to be subject to calls for security personnel than visitors of White and other patients.

"[It's] easy to push this away as something that's happening in other countries and other cities, and not in our healthcare institutions, but that is not what the data say," said Murray-García. "No matter how we think we are doing as a healthcare profession. No matter how well we think we are training people. We are responsible for both the intent and the outcome."

Rewriting the Clinician "Script"

The outcome is "pretty consistent," said Murray-García, referring to the inadequate pain medication provided to young Black children during episodes of appendicitis. She pointed to "scripts" that guide healthcare professionals' approach to caring for patients. These are "scripts that keep resulting in the same outcomes, in this case, especially for black folks," she said.

Informing these scripts, in part, are movies and TV shows that tell stories about Black people. To support her point, Murray-García showed a video of young children commenting on a White man (who happened to be a young Timothy McVeigh, the terrorist who was responsible for the 1995 Oklahoma City bombing that killed 168 people) and an anonymous Black man. While the children said the White man looked like a teacher, likely occupations for the Black man were professional athlete or criminal, according to the children.

Murray-García directs an anti-racism and cultural humility training program the Betty Irene Moore School of Nursing at UC Davis, where she's an associate clinical professor. Three factors of the program for nurse leaders include:

  • Focusing on the self and collective identity

  • Grounding the training in the context of US race relations history

  • Building the capacity of the institution to "doggedly pursue equity"

The 3-day training includes 15 leaders in each section. To date, the mandatory training has included 97 managers. The first cohort of nursing executives participated in the training in September 2020 and the last cohort of nursing managers participated in April.

The cultural humility aspect of the curriculum relies on four tenets:

  1. Nurturing a lifelong commitment to self-evaluation and self-critique

  2. Redressing power imbalances in the patient–clinician, educator–student, colleague–colleague, and academic center–community dynamics

  3. Developing mutually beneficial and nonpaternalistic clinical and advocacy partnerships with communities

  4. Stewarding an organizational-level developmental process that's ongoing

Support from Clinical Leadership Is Key

The focus on healthcare equity is growing larger, with various national healthcare groups calling for more attention to this issue.

Toby Marsh

"As national healthcare leaders, all of our professional organizations call on us to address racism and equity in healthcare," said Toby Marsh, RN, MSA, MSN, chief nursing and patient care services officer at UC Davis Health. "The American Nurses Association's membership assembly specifically calls out racism as a public health crisis."

Murray-García's advice for healthcare leaders is simple: "Hold your leaders — or yourself — to your words," she tells Medscape Medical News.

"As a leader, update your teams on the commitments made and be transparent on the progress the organization is making toward equity," she says. "Go back to the summer of 2020 and the carefully crafted declarations your organization made to employees or patients about how important racial equity is and how angry and powerless we felt about the 8 minutes we collectively witnessed [during the death of George Floyd]."

Physicians and nurses also have a role to play, she tells Medscape Medical News. "If you aren't honing the skill of identifying the historical scripts of our nation's dysfunctional race relations, you won't recognize or be able to interrupt these scripts as they are performed every day in your interactions with colleagues, and in the broader sense, in your service to patients and communities."

Murray-García calls on nurses and physicians to insist on high quality, well-funded, well-staffed programs that lead "through — not around — the discomfort and resistance [associated with racism and cultural humility]" from their employers. "Many point to that discomfort and resistance as a product of the training, when it really is in part the unearthed manifestation of the original, deeply entrenched script of inequality," she says.

Murray-García and Marsh made their comments during a session called "Cultural Humility Meets Anti-Racism: Systems-Level Capacity for Health Equity."

IHI Forum on Quality Improvement: Session A11: "Cultural Humility Meets Anti-Racism: Systems-Level Capacity for Health Equity." Presented December 7, 2021.

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