Towards a better system of caring
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It has been 20 years since the Institute of Medicine's report, Unequal Treatment: Confronting Racial and Ethnic Disparities in Healthcare, identified long-standing systemic racism, disenfranchisement, and individual biases as root causes of disparities in patient care.1 Alongside the data that Black, Brown, and Indigenous patients experience higher morbidity and mortality than White patients, there were sentiments of disbelief and denial2 that the differences could be the result of our own actions. The recent racial justice movement and the racial disparities of coronavirus disease 2019 (COVID-19) have compelled healthcare institutions and individuals to re-examine our complicity in working within a health system inculcated by racism and classism.
During this time of reignited conversations about the structural and interpersonal causes of health inequities, Browne et al. observed how physicians have reckoned with racial, ethnic, and socioeconomic disparities in caring for patients with COVID-19.3 While the study set out to explore general stressors of the COVID-19 pandemic on hospital-based physicians, the impact of working within an inequitable system emerged as an important contributor to physician grief, guilt, moral distress, and burnout. Through qualitative, semistructured interviews in four cities across the United States, physicians identified societal, organizational, and individual factors as contributing to inequities in COVID-19 exposure, care, and outcomes, and constraining their ability to intervene and protect marginalized populations. This study importantly demonstrates that physicians are not only aware of the inequities their patients' experience but are also negatively impacted by bearing witness to these inequities.3
While physicians participating in the study came from hospitals diverse in funding structure, size, and patient population, the demographic characteristics of these physicians are notably less diverse, with the majority identifying as White and non-Hispanic. Any discussion of the impact of practice within systems made to marginalize certain communities must uphold that these inequities disproportionately weigh on physicians who come from marginalized communities, often physicians who identify as Black, Indigenous, and People of Color. It is also essential to recognize the additional burden of often uncompensated work done by health professionals with identities that are underrepresented in medicine.4 However, this study importantly provides an additional perspective of the negative impact of working within an inequitable system on this group of mostly White physicians. Perhaps this study is evidence of emerging allyship from those physicians who are not from communities of color, and of readiness and need among all physicians to more openly address racism in medicine.
In reflecting on the societal and organizational barriers to equitable care, physicians in this study describe feelings of helplessness.3 While it may feel to individual physicians that we have little control over the systemic, cultural, and historical context in which patients receive care, physicians have an essential role in identifying and dismantling structures that limit our ability to provide that care. Recognizing this mandate may improve well-being, allowing physicians to be empowered to better care for patients rather than feeling complicit in perpetuating harm.5
Some in healthcare may have concerns that drawing attention to the bias and discrimination inherent to our health system and our own practices could increase burnout among healthcare professionals who already experience unprecedented levels of stress. However, it may be that we can all be made better by turning into the power that allows us to build more equitable systems of care. In caring for individual patients, we are particularly attuned to the upstream determinants of health that bring them into hospitals for care. Restoring health may include attention to fundamental tenets of recognizing healthcare as a human right, reforming the criminal justice system, ending exclusionary policies and violence at the border, and addressing food insecurity and homelessness.6 The curtain has been drawn back, and herein lies an opportunity for physicians, interdisciplinary colleagues, administrators, and policymakers to engage at societal, organizational, and individual levels to dismantle harmful structures and create a more equitable, sustainable, and good system of care.