Curbing Judgment: SDOH Series

In this episode, we’re talking about The Joint Commission’s mandate to collect data on patients’ health-related social needs and the importance of portraying a non-judgmental attitude to engender trust between patients and clinicians. 

During this episode, you will: 

• Explore reasons patients may not be willing to share SDOH data with clinicians  
• Reflect on implicit biases that may exist when analyzing SDOH data reported by patients
• Hear about ways to manage personal responses when observing systemic shortcomings that may contribute to disparities in healthcare 

Link to Transcript

Coverys companies are a leading provider of medical professional liability insurance for medical practitioners and health systems. Coverys provides a full range of healthcare liability insurance options, advanced risk analytics, and best-in-class risk mitigation and education resources to help clients anticipate, identify, and manage risk to reduce errors and improve outcomes.

Med-IQ, a Coverys company, is a leading provider of clinical and risk management education, consulting services, and quality improvement solutions, empowering individuals at every level of the healthcare delivery system with the knowledge they need to continuously improve provider performance and patient outcomes.

The information provided through this activity is for educational purposes only. It is not intended and should not be construed as legal or medical advice. Opinions of the panelists are their own and do not reflect the opinions of Coverys or Med-IQ. 

Music and lyrics: Nancy Burger and Scott Weber

Transcript

Geri Amori: Hello, everyone, and welcome to Healthcare Perspectives 360, a podcast dedicated to exploring contemporary healthcare issues from multiple perspectives. 

I'm Geri Amori, and today I am joined by Rebekah Schiefer, a behavioral clinician and educator who focuses on the healing power of the patient-clinician relationship; Josh Hyatt, a healthcare risk manager, bioethicist, lecturer, professor, and author; and Anthony Cheng, MD, a full-spectrum family medicine physician with special interests in addictions treatment, gender-affirming care, digital health, and health equity. Welcome. 

Today, we are going to talk about The Joint Commission's mandate to collect data on patient healthcare disparities and some of the challenges that may be present while we're collecting and analyzing this information. 

So Anthony, I'm going to start with you, if you don't mind. How could a clinician handle a patient refusal to share this healthcare disparities information? It's a mandate from The Joint Commission. We got to do it.

Anthony Cheng, MD: I think we have to be really careful about why we're collecting this information. To say that it's because someone told us to do it is not the right answer. Because we are healthcare professionals, and we need to use our clinical judgment, we need to think about why we're getting that response. 

Is it because the format of the questions are feeling extractive and impersonal? Is it because you are not creating an environment as a healthcare organization where patients feel safe to share that information? Is it because you, as a clinician, have let the patient know that they might not be safe in sharing that information? Or maybe it doesn't matter, and it's okay if they say no, right? 

And when they say no, it's got to be okay. Like we cannot force them to share this information with us, and we should not do that. And one of the reasons why I think that's important to remember is because, as a clinician, I'm acutely aware of the literacy of my patients. 

And what I mean is that I'm not going to be effective making recommendations or helping someone be healthy if they're not absorbing the information. They need to be engaged as a learner and as a participant in these discussions for me to have any therapeutic effect, whether it's taking a new medication or changing a behavior. And there's an important concept called stereotype threat that comes into play when we're talking about identities that are contingent upon bias. 

So, if someone discloses information that they're poor, there's all kinds of societal judgments that go along with that identity. And when someone is aware that that identity is present in the room and in the conversation, there's really good science to show that cognitive function declines. So that means that my ability to impart knowledge and to educate a patient and engage them in a healthcare plan is going to be diminished. 

To the extent that someone is so threatened by this process that they decide that, no, I don't want to share this information, we have to respect that boundary.

Amori: Okay. So Rebekah, I mean, we hear some of that about we have to respect the boundaries and stuff, but why do you think people wouldn't trust their healthcare team? Why would they, like, not want to share it? What's your perspective on that? 

Rebekah Schiefer, MSW, LCSW: Well, where do I start, Geri? I mean, the reasons are vast. In my experience, patients who are resistant to giving information, like even filling out a depression screener or a substance abuse screener, have really legitimate concerns that—it could range from there could be cultural concerns about what is appropriate to ask and what could be too invasive to ask. 

There could be mental health reasons. There could be prior past negative experience that the person has. There could be concern that answering the question could put them at risk for a report to child welfare. 

There's concerns about just stigma and bias, in general, like I think Anthony was referencing. I mean, it could also just be as simple as that they don't feel like they have trust yet because some of their other concerns haven't been addressed. So why would they turn over this even more personal information? 

And I think it's really important that we acknowledge that when patients come in to see their doctor or their mental health providers, in my case, there's already a power differential. And I think some providers like to pretend it doesn't exist, but it does exist. People are coming to you because you are a professional in some way, and they need you to do something that they might not be able to do themselves. I think some people are very sensitive to that for, again, a variety of different reasons. 

Answering these questions could make them feel even more disempowered. It could shift the power differential even more when they're maybe just trying to come in and feel like they're on the same kind of level playing field as you. And I think the thing that equalizes the power differential is the relationship, is having a real and true and trusting relationship with someone that becomes reciprocal. When that's not there, these sorts of questions can feel like they just shift that imbalance even further.

Amori: Okay. That makes a lot of sense. 

Talking about imbalance, I'm going to ask you a question, Josh. So, let's face it. Let's get real here. Human beings have moral values, right? We all have things that we think are right and we think are wrong. And of course, whatever we think are right and we think are wrong, we think the world should think is right and wrong. That's just the way humans are. 

So here we go, we're going to be asking people questions about their behaviors or about their life circumstances. And we're going to run into people that say they have limited resources for food or meds or whatever. And yet, we know they smoke two packs per day or they drink or they buy a Starbucks giant-size latte every day. And it's going to be hard for some people, for some of us, to not feel something about that, like, hey, you're taking food out of the…you know, something. 

How do you, from an ethical perspective, suggest that we all curb our human tendency towards having a judgment, while we ask these questions that people might be afraid to tell us because they're afraid we're going to judge, and work with it? 

Josh Hyatt, DHS, MBE, MHL, DFASHRM, CPHRM, HEC-C, CPPS: Feeling something is okay; acting negatively to that is different, right? So what this is—like the smoking and the Starbucks—this is a great example of implicit bias. In this example, we are assigning value and judgment to a patient based on habits. And it implies that the patient is either lying or placing their life at risk for vices, which is counterintuitive to what we do in healthcare. But the $5 Starbucks coffee might be the one thing that that person gets to look forward to every day. So it's important to not have those judgments. 

I remember, as a young child, we were at a grocery store with my grandmother. And there was this lady who paid for her groceries with food stamps, and then when we walked out of the store, she got into a brand new Cadillac and drove away. And my grandmother lost her mind in the parking lot. She was just furious because she made this assumption that this woman was taking advantage of the system. We don't know the circumstances; who knows what was going on, right? But we all do that. 

And so I think the first component of this is really acknowledging and being aware of implicit bias in ourselves and knowing that we all have it. Implicit bias is natural, it all exists, but it takes a lot of self-reflection to acknowledge that bias is there. Once you're able to get into that place of implicit bias…and I recognize I have implicit biases, I have privileges. And every once in a while, I'll say to myself, wow, that statement was really privileged of you, Josh; why would you say something like that? And then I’ll have to go back and self-edit and correct and then move forward. 

So the way I've seen the interactions is, if you have honest, nonjudgmental, and collaborative conversations with patients, and you take into account their values, you're able to help build those better relationships to get hopefully better outcomes. I mean, you can ask questions like, I understand that you lack the money for your meds; are there lifestyle changes that you can make so that you can afford it? Or, would you consider trying a nicotine reduction program so you can free up some of your money to do other things? Just exploring these options creates a bond or relationship that you're able to kind of move forward with, and that's where I would kind of start.

Amori: Good. Thank you so much, Josh. 

So Anthony, I have a question for you. Clinicians are biased, too, about the system. You have signed into a system. You've signed on. You’re a soldier for this system, right? You’re a healthcare provider. The system is asking you to ask all these questions, expecting you to do all this stuff but not giving you the resources. 

How might clinicians blame the healthcare system for this disparity in healthcare? And how can they manage these feelings about the system—not just about patients but about the system itself? 

Cheng: So first of all, I think it's really important that we are careful about the stories that we tell ourselves about the system that we're in and that we make sure that that's based on an understanding of what's actually happening. It's pretty easy to say it's the system's fault, the system is broken, and just stop there. And while that may be true, as a generality, I think we have to tap into a deeper understanding of the fact that, as a country, we are actually trying to make some substantial changes relative to these very challenging issues. 

And so, why is it that The Joint Commission is requiring these screenings, and maybe we need to look at how coordinated care organizations are using this data to incentivize healthcare organizations to take social determinants of health more seriously, and how, at an organizational level, these kinds of incentives might actually move the needle. There are some bright spots. And this is part of a longer narrative that, if you look at it in a different way, there's some hope there. 

And then secondly, there is going to be moments in our day, in our clinical practice, when there is huge amounts of frustration and despair and anger related to these issues. And so then we have to remember that, while these bigger conversations are happening, that sometimes we just have to live into the more beautiful moments that we have with our patients, and let that sustain us, and just look for those bright spots. And remember that staying involved and staying in the game is really important, and it's not going to help anyone or fix the system for a well-intentioned and high-performing clinician to step away from clinical practice—taking the big with the small.

Amori: That's beautiful. Thank you. So we've got both sides of that issue. You know, how do we not blame patients? And how do we not blame the system? 

And so, Rebekah, now I want to ask you…I know that you're an educator on communication for the clinician-patient relationship. Are there tips that you might have for how to ask some of these questions in a way that is less likely to trigger defensiveness?

Schiefer: Yeah, definitely. I think if the clinician is sort of cold asking, what would be really important is to preface it, to explain why—and not because The Joint Commission told you to—and to just have a really pithy statement…you know, I ask all my patients, right? And I just want to add, you know, social determinants of health screening should be universal, right? When we decide we're only going to screen a certain population, bias is already at play. 

Being able to say, I ask all my patients this question, so reassuring them that you're not singling them out and then explaining why. Because we know that things in your social environment can impact your health more than almost anything we do in this room together, and so that's why I'm asking. It's up to you whether you want to answer these questions or not. Please let me know if you have any concerns. 

I think just framing it that way allows people to understand what's behind the question, while also acknowledging that it is sensitive information and giving them permission to say no. This is something that I'll train residents to do when you ask sensitive things about substance use, you know? Here's the reason why we're asking about alcohol use today because we know it can impact your health in these ways. And I also know it can be a sensitive question, but as your doctor, it's really helpful for me to know for your overall health. So just being able to train people to have a statement to make. 

And it's really important that they don't also undermine that screening process by rolling their eyes or saying that it's not important or saying, oh, I got to ask you these questions. That's not helpful, either. It's to Anthony's point. I do think this is coming from a good place, and it is important that we do it, but it also is important that we train people to be able to give the reason why we're doing this in a meaningful way.

Amori: Thank you. That's really important. We need to wrap this up. But before we do, really quickly, Josh, could you tell us from a risk management perspective: if we're not skillful in avoiding being judgmental, do we run some risks? Like a risk of discrimination accusation?

Hyatt: You could. I mean, when somebody says discrimination, there are multiple flags that go off, and we need to be conscious of what these flags are. Is it somebody that feels unjustly treated that you can address, or does somebody actually have an allegation of discrimination where you may need to get legal involvement at that point? Because any allegations of discrimination in and of themselves can be very serious criminally and civilly. I would balance those out. Is this a sense of being unjust, or is this really true discrimination? So I would say it really is circumstantial in that.

Amori: Okay, thank you, Josh. All right. My last question for today.

If you have one thing that you want—all of our audience who've been listening today because today was a very rich conversation—[to take away] what would that one thing be? And, Anthony, I'm going to ask you to go first.

Cheng: Thank you. Well, I think the one thing I want us to remember, as healthcare providers, is that we really care about our work, we treat our jobs as a profession. And rightly so, our jobs consume a lot of our energy and attention. But we also have to realize that we have other callings—we’re parents, children, friends. And we also have responsibilities to our fellow citizens. 

And I include myself in “we,” but we find ourselves in a place where work has become so all-consuming that we have very little left for civic engagement. And I really think that's a big part of this problem. And it's not really a deficit of empathy or concern. We really do care about these issues. But it's, in many ways, a deficit of civic engagement and investment. 

So can we allow ourselves to believe that America can be better, that we can build a country that lifts up the poor and invest in our youth? And I think this policy is a reflection of society's recognition of this problem, but the solution doesn't stop there. And it really needs us to look inside of ourselves as individuals to address our own biases, the racism that's inside of us, and also how we're allocating our time and energy on a personal level.

Amori: Thank you, Anthony. 

Josh, would you like to make your final statement, one thing you'd like everyone to take away?

Hyatt: I'm not sure that I could say it better than Anthony did. I agree with everything that he said. I felt it's really about self-awareness of your own biases but then also taking care of yourself and recognizing that your health is more important to you than anything else, and you need to keep that in the forefront of your mind.

Amori: Rebekah?

Schiefer: Really difficult to follow that up, Anthony. I think the takeaway from this conversation, for me, is just remembering that people have very legitimate and complicated reasons for not wanting to engage in this process. And one of the best things that we can do is really find out more, and build that relationship, and recognize that these questions don't exist in a vacuum, and their life doesn't exist in a vacuum, and that it's really important that we have context.

Amori: Thank you so much, Rebekah. 

Today's discussion has been touching, and I appreciate the honesty and humanity that each of you have brought to today's talk. These are hard issues. 

So I want to thank everyone for joining us today. It's been an amazing conversation, and I want to give a special thanks to our panelists for sharing your thoughts, your feelings, and your perspectives. See everyone at our next podcast.

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