As an undergraduate studying health education, I was first exposed to the lack of equity in healthcare when I worked with migrant laborers in rural areas of central Florida. The experience really opened my eyes to the disparities in healthcare, and I knew when I started medical school I wanted to get involved in meaningful programs that would help me to be a better doctor and improve the equity in the delivery of healthcare at the local, state, and national levels.
Now that I’m in my third year of med school and a national leader with the American Medical School Association (AMSA), I’m alerted to special programs and upcoming webinars. When I saw information about AMSA’s Reproductive Justice Leadership Program, I decided that since I had other activities canceled by COVID-19, I would apply. The experience introduced me to aspects of healthcare that aren’t taught in med school but can have a huge impact on the patients we treat and in the communities where we practice.
Med students participating in AMSA’s Reproductive Justice Leadership Program take online courses in “abortion-related training and education opportunities.” Students complete required reading before each course and take a pass/fail exam upon course completion. Through this program, I learned that reproductive justice encompasses the human right to make informed healthcare decisions for oneself, access to medical providers who are open-minded and can communicate to patients regarding their rights to care, as well as safe sex education, contraception, prenatal and maternal care, and transgender health. Reproductive justice also refers to legal representation, the right to vote against laws that restrict access to care, and the opportunity to have reproductive freedom — encompassing economic, environmental, and racial justice unitedly.
That’s not something you’re necessarily taught in medical school: how healthcare policies affect populations of communities.
How healthcare policies affect access to science-based information
Here’s an example. In medical school, we’re introduced to HIPAA through a course that’s designed to help future doctors understand healthcare privacy and teach compliance. What’s not taught is how certain policies can limit what medical information doctors can share, because there are gag laws for procedures like abortion that vary by each state.
According to the Guttmacher Institute, doctors in 27 states are compelled to talk to patients about the risks of abortion – often using a biased, politically motivated and non-science-based script. A new lawsuit in Tennessee seeks to overturn a requirement that abortion providers tell patients that it may be possible to reverse a chemical abortion – despite the fact that there is no scientific data to back up that claim. Meanwhile, healthcare providers in New York don’t have the same restrictions and have more freedom to share science-based education about abortions.
At the most basic level, these differences in healthcare policies directly impact a patient’s ability to even access accurate information about a safe and legal medical procedure. That was something I learned from this program that I would have never learned in my regular coursework in med school.
While abortion remains one of the most common reproductive medical procedures, many med students aren’t taught anything about abortion during med school. Because state-level abortion laws restrict how healthcare providers can even discuss the procedure with patients, medical schools tend to defer most training about sexual health, contraception, and abortion care to OB/GYN rotations. But why should our conversations about sex and reproductive health be limited to OB/GYN training? Whether you’re in family medicine or pediatrics, you’ll likely treat patients who are sexually active or who will become sexually active. Even geriatric specialists are dealing with sexual health as the rate of STDs surges among older Americans.
Doctors should expect that a patient may want to have an open and honest discussion about their sexual history without fear of judgment, and healthcare providers must be prepared to have these conversations. We’re not taught in school how to start an open-ended conversation with someone about sex or pregnancy. I haven’t come across a lecture slide yet that teaches future doctors how to ask, “Okay, you’re concerned about your pregnancy or your sexual activity. What are you concerned about? What fears do you have?”
There are some awesome providers in family medicine, pediatrics, and geriatrics who are having these conversations about reproductive health, but not enough. If it was enough, we would see lower rates of sexually transmitted infections. We wouldn’t see maternal mortality rates that are more than twice the rate of other high-income countries. And how many young girls are still risking at-home abortions as a result of restrictive abortion policies? Access and education are critical to equitable healthcare delivery.
Linking Healthcare Literacy and Healthcare Delivery
In medical school, we’re taught about safety, respecting patients, and are introduced to communicating with patients. Medical schools tend to focus on patient-provider care. But I’ve learned that as a provider, you’re just not limited to your office space, you’re not limited to treating just your patients; instead, you can make a huge difference in your community, in your state, in your region, and in overall healthcare delivery by focusing on health literacy.
The U.S. Department of Health and Human Services defines health literacy as “the degree to which individuals have the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions.” I would add that health literacy also includes understanding the role of big pharma and how companies that mass-produce and mass-market can influence what is being prescribed – even if the drug might not be the best medication. So, health literacy gives patients and providers a better understanding of what drugs are available, what drugs offer the best treatment option, and the most common risk factors and side effects.
One of the most striking examples of a population impacted by health literacy is the opioid crisis among rural communities. It’s now well-documented that for more than 25 years, pharmaceutical companies were behind the massive push to promote opioid use even in cases where a prescription was neither safe nor effective. While we now understand the highly addictive nature of opioids, and the opioid crisis has spread across all geographic, social, and economic groups, rural communities have been particularly vulnerable. According to Rural Health Information Hub, “Substance use can be especially hard to combat in rural communities due to limited resources for prevention, treatment, and recovery.” Health literacy is a critical factor when treating populations who are young, isolated, living in poverty or unemployed, and who may lack access to education about the risks of opioid use and alternatives to treating chronic pain. As a result of this epidemic, the federal government has invested significant resources to educate rural communities about the risks of opioid use and hopefully improve healthcare equity in this population.
If the opioid crisis provides a cautionary tale for medical providers, it’s almost ironic that the other major health emergency of our time, the COVID pandemic, has been a game-changer in the form of telehealth.
As health guidelines limited in-office medical treatment and patient care, more healthcare providers began offering telehealth appointments and virtual visits. Competing platforms offered perks such as medically-certified interpreters to deepen understanding. About 22% of Americans are not native English speakers, so by providing access to a translator during an appointment, providers now had the tools to explain medical information, ensure that patients understood their treatment plan, and offer the chance to ask questions. Because of language barriers, a lot of patients just nod along rather than clarify vital information, like, “Okay, doctor, so you’re saying to take this three times a day after I eat.” As providers, we must take an active role in managing health literacy. In addition to language factoring into healthcare access and literacy, culture plays a big role in health equity.
Cultural Competency in Healthcare
Living in South Florida, we have a diverse population with large Latin American and Caribbean communities. As a med student, I’ve observed that it’s very common that when you take care of the mother, you’re also taking care of the grandmother, the daughter, and maybe the sister. These are communities where there maybe three or four generations in one home, so you have to make sure you’re communicating effectively with the right stakeholders. For example, say you’re treating a patient for diabetes. You just can’t tell the granddaughter what to do. You have to learn who is responsible for cooking for everyone and ensure that everyone in the household understands why you want to limit her carbohydrates and encourage diet and exercise. Cultural competency in healthcare refers to meeting the social, cultural, and linguistic needs of patients, all of which play a huge role in healthcare equity.
In medical school the focus of our training is on clinical signs: this is the presentation, this is what you do for diagnosis, this is how you treat it. As students, we’re so focused on diagnosis and treatment that we’re not looking at the patient as a person. We’re looking at them as a condition, and there’s so much more that we contribute to a patient’s health if we have a better understanding of who they are, and how their experiences shape their relationship to healthcare.
While COVID may have accelerated some positive changes when it comes to health literacy, the pandemic has also highlighted the lack of equity in healthcare – particularly when you look at the disproportionate impact of the virus on the Black community.
When Operation Warp Speed was racing to find an effective COVID vaccine, pharmaceutical companies struggled to find Black people willing to participate in the clinical trials. This was likely because Black people could see the statistics of how our community has higher mortality rates from the virus and it scares people from even wanting to get that vaccine.
Recognizing vaccine hesitancy among Black people, there’s a huge push to promote awareness of the safety of the vaccine. Black celebrities and prominent community leaders are getting vaccinated at high-profile events and sharing photos on social media that say, “Hey, I got my vaccine. Everything is safe.” This effort is to promote healthcare equity but the distrust remains. I’ve heard conversations from people who say, “No, I’ll just wait because I’m not a trial.”
The distrust disproportionately affects certain communities because from the very beginning, Black people have had less access to care. If people had health insurance or if people had their yearly exams, people would have a better health status. We have so many Americans with hypertension. We have so many Americans with diabetes. We have so many Americans who are just immunocompromised because they have chronic illnesses, but they haven’t had access to treatment. So when you add that to a virus, the effects are going to be more detrimental because they have not received care for their chronic illness from before.
Now that we have an approved vaccine, it will be very interesting to look at the demographics of Black COVID patients a year from now because the same communities who have disproportionate access to preventive care and the health insurance that allows them to seek earlier treatment are the same communities who, even after overcoming vaccine hesitancy, will face challenges in accessing the vaccine.
Action: Takeaways for Med Students and Healthcare Providers
Every physician wants to make a difference in the quality of care they provide to their patients. Quality of care begins the moment you say, “Hello, my name is Dr. Such-and-such.” Healthcare equity strives to provide quality of care for all and includes advocating on their behalf for access to medically safe healthcare without judgment. Healthcare equity cannot be achieved without healthcare literacy and effectively communicating with patients the information needed to make informed healthcare decisions. And, finally, healthcare equity requires that physicians consider the patient beyond what’s presented on their chart and evaluate the significance of social, cultural, and language influences in meeting their healthcare needs.