Diversity, equity, and inclusion in pathology: A profound impact on patient care

Three years ago, Dina Greene, PhD, clinical associate professor of laboratory medicine and pathology at the University of Washington, heard an administrator question the need for a women's faculty day. She also was told many times that she didn't “fit in with our culture” by her peers and senior male faculty. “And I thought, ‘Well you're defining the culture,’” she says. image

Dr. Greene sees diversity as fundamental to well-rounded critical thinking and problem-solving, but she believes that the recent growth of DEI committees has yet to change the entrenched culture of many academic institutions. “While they want to talk a lot about diversity, equity, and inclusion, they don't actually tend to fulfill that model even when they have increased the amount of diversity, perhaps in their medical students,” she says. “At the same time, there's often a lot of push back when the students try to call things out, and there is retaliation. It's very hard to encourage students to speak their mind when you know that there will be punitive action for doing that.”

As medical schools and departments struggle to confront a legacy of systemic racism and exclusion, researchers and students are trying to broker honest and open conversations by drawing a direct line from workforce and educational disparities to substandard patient care. It has not been easy, however.

Addressing Structural Harms

Elle Lett, PhD, MA, a statistical epidemiologist and MD candidate at the Perelman School of Medicine at the University of Pennsylvania, has coauthored studies chronicling a persistent lack of racial and ethnic representation among medical faculty and among medical students in the United States.1, 2 Dr. Lett, who is Black and transgender, says that a diverse and representative population in the medical workforce can improve the learning environment for everyone and help to set realistic and impactful research agendas.

On an individual level, racial concordance can aid patient interactions by breaking down some cultural barriers, she says. Providers who do not understand a patient's culture, language, or vernacular, for example, can deliver suboptimal care. On a scaled-up level, the missed nuances can lead to “structural oppression and disproportionately poor care given to people from backgrounds that are dissimilar to the physicians who are practicing with them,” Dr. Lett says. “And that is independent of intent. That's just a lack of cultural context that you can't have because you aren't in those cultures. So that's why representation matters.”

The lack of progress has not been lost on students. “In the years during which I've been a medical student, I've had very few faculty members who look like me,” says Henrietta Fasanya, who received her PhD in cancer biology and is now an MD candidate at the University of Florida College of Medicine. Dr. Fasanya, who is Black, says that one of the clearest indicators of a medical school's success in its DEI efforts is whether its faculty is diverse and representative—not just the student body—and whether any minority faculty members are in prominent leadership positions. “I think that, unfortunately, a lot of faculty of color are not seen in leadership positions outside of areas of diversity,” she says.

Beyond the matter of representation in medical schools, Dr. Fasanya says that the default education curriculum views race as a genetic or biological construct instead of a social one. For decades, she and 3 coauthors wrote in a recent editorial, “medical students have been taught to interpret their patients' presenting clinical features to make diagnoses based on a centralized factor of race.”3 The biased perceptions and care, in turn, can contribute to and reinforce disparities.

When learning about renal pathology, for example, Dr. Fasanya and other students were taught that estimated glomerular filtration rate values differed between White and Black patients because Black individuals had higher muscle mass and thus higher renal function. “And it was just kind of fluffed over, like, ‘Yes, of course, this is a fact. This is something that's been proven,’” she says. Only it was not: Multiple studies have since suggested that the “race-corrected” estimated glomerular filtration rate algorithms are deeply flawed.

“We really haven't done the work to think about why we see differences in race and how we should talk about race in relation to these differences,” Dr. Fasanya says of the scientific and medical community. Instead, she believes that more work should go into understanding the historical, social, economic, and political factors that contribute to the differences seen in health care outcomes based on race.

“We really haven't done the work to think about why we see differences in race and how we should talk about race in relation to these differences.”

–Henrietta Fasanya, PhD, MD candidate

Confronting Discrimination and Exclusion

Dr. Lett says that she does not use implicit and explicit bias terminology when describing medicine's shortcomings “because it's a watered-down version of saying things like racism and transphobia and homophobia.” Medical school curricula have avoided naming the larger systemic issues because of the potential for discomfort, she says, whereas she sees the necessity of acknowledging how someone can be complicit in systems of oppression. Dr. Lett points to the recent firestorm over a Journal of the American Medical Association editor's podcast and linked Twitter post that asserted, “No physician is racist, so how can there be structural racism in health care?,” as evidence of the continuing harms. “That's a reflection of the fact that our medical system refuses to acknowledge and own the existence of racism and its role in perpetuating racism in today's society.”

For transgender people, Dr. Lett points to an even more fundamental problem: neither medical workers nor individuals are counted, even by the US Census. “You can't measure representation or under-representation with high accuracy if people aren't counted,” she says. The challenges have grown even more acute through the explicit exclusion of transgender health coverage and care in the Medicaid policies of multiple states. Arkansas also allows private insurers to deny coverage for gender-affirming care and bans best practice medical care for transgender youth, and similar laws are pending in other states.

Even without laws, Dr. Lett says that some physicians have declined to provide care under the excuse that they are not educated in transgender issues and need to refer a patient elsewhere. Some transgender men have been denied cervical cancer screening and reproductive services, whereas transgender women have been turned away from prostate cancer screening services. “That could be mitigated by creating a workforce that's more inclusive of trans voices so that we're in place to have power to change those structures,” Dr. Lett says. In addition, she says that transgender community members could be called upon, and compensated, to help to identify failings in patient care and to design contextually relevant medical curricula.

Hearing physicians say that they cannot help a patient is “unfathomable to those of us who have always been treated respectfully by medical providers,” Dr. Greene says. To help to fill some of the gaps, she has published multiple studies establishing more relevant laboratory reference intervals for transgender patients. In one line of research on hematology reference intervals, her group's data showed that someone on testosterone gender-affirming hormone therapy can use the cisgender male reference intervals, whereas someone on estradiol can use the cisgender female reference intervals.4 Despite the barriers to change, Dr. Greene says that she is seeing some signs of progress. A residency coordinator, for example, recently sought her help in teaching faculty how to use gender-neutral pronouns for a resident who identifies as nonbinary, although the coordinator also anticipated that a lengthy educational process would be needed.

Dr. Fasanya, who is interested in cytopathology as a specialty, points to the See, Test & Treat program sponsored by the College of American Pathologists Foundation as another example of how physicians can advocate for their patients. During a single day, women receive a pelvic and breast examination, Papanicolaou test, and screening mammogram with rapid turnaround times, culturally and linguistically appropriate services and educational materials, and a healthy meal. Ultimately, she says, better integration with social sciences such as medical anthropology and journalism may help to facilitate both the services and the conversations needed to shift the culture of medicine toward a more representative and welcoming environment for both its workforce and its patients.

References

1Lett LA, Orji WU, Sebro R. Declining racial and ethnic representation in clinical academic medicine: a longitudinal study of 16 US medical specialties. PLoS One. 2018; 13:e0207274. doi:10.1371/journal.pone.0207274 2Lett LA, Murdock HM, Orji WU, et al. Trends in racial/ethnic representation among US medical students. JAMA Netw Open. 2019; 2:e1910490. doi:10.1001/jamanetworkopen.2019.10490 3Fasanya HO, Kwenda EP, Michel M, Parker DM. The medical students' perspective of health disparities and a race-based curriculum: addressing disparities in medical education. J Appl Lab Med. 2021; 6: 307- 309. doi:10.1093/jalm/jfaa168 4Greene DN, McPherson GW, Rongitsch J, et al. Hematology reference intervals for transgender adults on stable hormone therapy. Clin Chim Acta. 2019; 492: 84- 90. doi:10.1016/j.cca.2019.02.011

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