Did you know that women make up a staggering 80% of healthcare buying and usage decisions?
Women also make up 65% of the workforce. Yet, only 13% of healthcare CEOs are women.1 These statistics are troubling in any industry, but more so in the healthcare arena where patient care quality depends on equity from the top. The numbers literally mean life or death for some patients and drive home the need to “break the bias.”
The question then becomes, is this a healthcare issue or a women’s equality issue?
Considering that today marks International Women’s Day (IWD), a day that celebrates women’s achievements, raises awareness against bias, and takes action for equality, I would like to consider the latter. This year’s global campaign is “break the bias” and challenges individuals to:
Imagine a gender-equal world.
A world free of bias, stereotypes, and discrimination.
A world that is diverse, equitable, and inclusive.
A world where difference is valued and celebrated.
Together we can forge women’s equality.
Collectively we can all #BreakTheBias.
To raise bias awareness around gender, I will discuss some of the healthcare industry’s most troubling areas.
It is well-documented that stereotypes3 about gender influence how providers treat patients. From chronic pain management4 to basic labor and delivery needs5, female patients encounter their providers with more than just a set of symptoms; they also face their providers’ presumptions and prejudices, whether unconscious or not. This experience for women can lead to delayed diagnoses, poor symptom management, and a distrust of medical care.
Shanoor Seervia, a researcher and writer for The Commonwealth Fund, argues, “Bias in medicine—based on race and sex—is a well-documented problem. It’s a problem because the health care system has historically marginalized the medical concerns of people of color and women, which has led to worse health outcomes…Bias is not just a concern at the individual provider level; it’s actually baked into the system, starting in medical school.”2
Seervia points out that first-year medical students arrive with pre-established sets of biases. While often unidentified, their biases can be exacerbated by the medical landscape, from the way providers document in short-form to how easy it is to apply social narratives to diagnosis and outcome.
Joia Crear-Perry, the founder and president of the National Birth Equity Collaborative, explains: “because the images that we were all taught about race and gender come from some assumptions we have around black and brown people, around women. And so, they are socialized not just in how we teach in medical school, but they’re in the media, they’re in our schoolbooks, they’re in our history.” 2
Ann-Gel Palermo, who works on diversity and inclusion at New York’s Icahn School of Medicine at Mount Sinai, suggests a change management approach to addressing racism and bias at the provider level, beginning in medical school. Mt. Sinai has developed a curriculum that focuses on training. She explains: “It starts in orientation … to a series of interactive activities that’s about building community, identity formation—exploring that, unpacking that. To their two-year doctoring chorus, where we thread through all the concepts and topics discussed. And what — we teach them how to literally interview a patient, is recognizing their biases at play.” 2
By teaching medicine through the lens of bias from day one of medical school—we ask eventual providers to raise the awareness through which they practice medicine. However, prejudice and blind spots are not easily overcome, nor do they disappear after a course of study. Patients should expect, or demand, that their providers receive ongoing bias education, awareness, and framework for action. In dreaming of what’s possible for the future of healthcare and gender equality, I wonder how often providers are assessed for their bias and blind spots and then held accountable for addressing them. Would that be the key to change? Or, at least, it might be one small step in improving a complicated gender equity issue.
Gender equity is not only an issue in the patient-provider relationship. There is also a hugely disproportionate representation of women at the top of the healthcare industry. I’ll remind you—women make up only 13% of healthcare CEOs. That is a hard statistic to swallow when the healthcare industry is primarily comprised of a female workforce.
In an extensive study by Oliver Wyman, a consulting firm known for its expertise and insight in the healthcare industry, researchers noted that both male and female healthcare leaders wanted the same thing: gender parity at the top. Support of the issue and a desire for change represented by both genders made it difficult for researchers to point to clear causes of inequity.
Men and women in a work setting really do operate differently (backed by science1), from the way we listen, build relationships, determine qualifications for promotion, and even what drives decision making and action. Oliver Wyman researchers concluded that subtle forces, such as a gender difference in the way we measure trust, impact, and leadership potential, were at play that obstructs women from C-suite access.
Trust. Impact. Leadership Potential. These forces take on greater significance once candidates reach the C-suite level, when “trust” is a predominant indicator of C-suite success. Furthermore, the ambiguity on “leadership potential” drives bias from the earliest moments in a woman’s career and, according to researchers, forces women to rely on the results of their work versus relationships.
Oliver Wyman researchers elaborated: “The higher up you go, the more intangible attributes about leadership potential and ‘fit’ factor into promotion consideration…We concluded it is much more difficult for women to achieve the same level of implicit trust in male-dominated workplaces. If we are not purposeful in understanding and addressing the subterranean barriers to building trust, we will not make meaningful progress.”1
To address the equity issue head-on, healthcare organizations will need to reconsider how leaders build relationships, improve their teams' diversity, and dismantle misperceptions from entry-level employees through leadership teams and C-suite execs. While support for gender parity at the C-suite level is unilateral, it will take focused effort to make real progress.
ELECTRONIC HEALTH RECORDS
EHRs are powerful tools subject to the imperfections of the humans who create and use them. In terms of equity, EHRs have three significant challenges: data for research, access, and AI.
As EHRs become the predominant tool of hospitals, they likewise become treasure troves of valuable data, particularly for medical research. Medical research is no stranger to bias, though. Before the 1990s, a large portion of research only included male participants to avoid female “research outliers” such as menstruation or potential for pregnancy.6 However, excluding fifty percent of a research population for diseases that affect both genders seems unwise. With a history of bias in medical research, one would expect a technology such as an EHR system to provide a new era for scientists.
Researchers at Ohio State University put this theory to test by examining EHR data for indicators of cardiovascular disease. What they found via data told a troubling story. They explain: “When using EHR data for surveillance, we unintentionally condition on patients being ill for inclusion into the study. The exception to this is records that capture preventive care interactions. Yet, these too are subject to selection bias because factors such as education, health insurance coverage, and transportation might influence who uses these primary care services.”7
Access to medical centers that use EHRs is not a given for many poorer communities or rural areas. If studies primarily use EHR data as a source for analysis, their research is inevitably fraught with bias. Furthermore, these populations are hit with a double bias – access to higher quality care and inclusion in health science to improve their health. To circumvent this exclusion, Ohio State researchers argued for a “bias indicator” when using EHR data as a source for medical research. Scientists need to closely examine the background of data in the same way they would assess in-person research candidates' qualifications and study design. While EHR data supplies a large quantity of information, it may only tell a partial story. When it comes to health science and making decisions on care recommendations, researchers require a judicious eye when using EHR data.
When both data and access are riddled with bias issues, it is no wonder that the new trend in using artificial intelligence will also come with bias implications. Becker’s Health IT reviewed a study on how EHR and AI complicate healthcare: “Artificial intelligence tools built into EHR may help health systems implement strategies such as targeted overbooking; however, the technology presents various layers of potential bias toward vulnerable patient populations.”8 In this scenario, a San Francisco hospital attempted to use AI to predict which patients were least likely to show up for an appointment and then double book the slot to prevent an empty slot on a provider’s schedule. However, this use of AI could divert medical resources from marginalized societies, especially in the case above, single working mothers. Instead of the “quick fix” from the hospital’s perspective (double book the appointment), hospitals should use the insight to help those identified patients make their appointments. This could be in the form of ensuring transportation or childcare. By changing how we apply AI, we can make our healthcare system more equitable. But healthcare leaders will need diverse perspectives and forward-looking mindsets to analyze the reciprocating effects of AI usage in EHRs.
A LOOK TO THE FUTURE: #BREAKTHEBIAS
The intent of raising awareness is to assess where we are currently. To be clear, we have come a long way in improving gender parity. Women are significant participants in the healthcare industry, both as patients and providers. However, hidden blind spots and biases are still at play that prevent women from having equal access to healthcare and leadership positions. The good news is that both genders support forward progress. Now comes the time for action. How can your organization improve its support for gender parity?
To learn more about the significance of March 8th worldwide, visit the Internal Women’s Day website.
- WiHCL-journal (oliverwyman.com)
- Health Care Has a Bias Problem: Here’s How to Fix It | Commonwealth Fund
- “Brave Men” and “Emotional Women”: A Theory-Guided Literature Review on Gender Bias in Health Care and Gendered Norms towards Patients with Chronic Pain (hindawi.com)
- Implicit Bias Curricula In Medical School: Student And Faculty Perspectives | Health Affairs
- Study: AI tools built into EHRs present potential biases to vulnerable patient populations (beckershospitalreview.com)