Importance of Inclusivity in a Medical Practice

For the first time in our history, the United States is raising a generation of children who may live sicker and shorter lives than their parents.(1) By 2060, just 36% of all U.S. children will be single-race non-Hispanic white, compared with 52% today.(2) However, even though the racial and ethnic diversity of the U.S. population continues to expand, the physician workforce has been diversifying much more slowly.(3)

The healthcare provider must know that patients who have a choice are more likely to select healthcare professionals of their own racial, cultural, and ethnic background, and gender identity.(4)

What is DEI?

DEI stands for diversity, equity, and inclusion. Each component is necessary to create an inclusive workplace.

Diversity, equity, and inclusion all involve acknowledging the differences among your colleagues and your employees while protecting them from discrimination. It focuses on representation, fairness, and equal opportunities for all genders, ethnicities, nationalities, sexual orientations, religions, disabilities, and ages.

• Diversity refers to how diverse or varied your workforce is. Diversity involves employing people with different demographic characteristics, identities, and experiences. These employees should feel welcome, contributing and bringing fresh perspectives to the table. 

• Equity ensures that underrepresented groups have the same starting point as everyone else or that the practice embraces a level playing field for every person. Equity creates an environment where everyone has similar advantages and opportunities. Therefore, equity is the necessary stepping stone between diversity and inclusion, propelling impactful change within your practice. Equity solves the power imbalance between groups within your organization. This is crucial, because differing power dynamics affect how employees behave, interact with each other, and influence one another. 

• Inclusion refers to a state of belonging, meaning all employees are respected, empowered, and valued. Employees should feel comfortable accepting their authentic selves. Inclusivity should be part of daily operations and work culture.

Why is DEI Important?

Healthcare workers and our patients view the care we provide through a cultural lens. An individual’s cultural affiliations can affect where and how they seek care, how they describe symptoms, how they select treatment options, and whether they follow care recommendations.(5)

Inclusivity also is linked with health literacy. A mutual understanding between patients and providers calls for integrating culturally, linguistically acceptable, and health-literate approaches.(6) Without clear and effective communication, high-quality patient care is in jeopardy.

In a nationally representative survey conducted by the Center for American Progress in 2017, 8% of lesbian, gay, and bisexual respondents and 29% of transgender respondents reported that a healthcare provider had refused to see them because of their sexual orientation or gender identity.(7) Over the same period, 9% of lesbian, gay, and bisexual respondents and 21% of transgender respondents said a provider had used harsh or abusive language when they sought medical care.(6)

The lack of lesbian, gay, bisexual, transgender, queer, intersex, asexual (LGBTQIA)-focused care leaves many LGBTQIA individuals less willing to seek healthcare. For example, a transgender patient is repeatedly misgendered and discharged early, only to continue self-harming or possibly even attempting suicide. Other individuals may go without medications or treatment that would otherwise improve their overall health out of fear of being judged or discriminated against by a care provider.

Discrimination against LGBTQIA persons has been associated with high rates of psychiatric disorders, substance abuse, and suicide.

Multiple studies have shown that diverse teams drive better performance practices with greater diversity and become more resilient and innovative. And inclusion is required for diverse groups to thrive. Yet there is little point in considering how to recruit a more diverse workforce, nor how to ensure talented individuals from different backgrounds are fully included, if your practice has not yet considered what different people need to be successful. And to do that, you need to understand equity. Equity is fair and contextually appropriate access to the resources required for an individual to attain their full potential. Organizations must go beyond diversity and inclusion to see real, sustainable change and leverage the full potential of all their talent to focus on equity, diversity, and inclusion in the workplace. Leading with equity is about recognizing different patients’ needs and being committed to giving people what they need to succeed. When that happens, everyone wins, including doctors, staff, and patients.

Research suggests that LGBTQIA individuals face health disparities linked to societal stigma, discrimination, and denial of their civil and human rights. Discrimination against LGBTQIA persons has been associated with high rates of psychiatric disorders,(8) substance abuse,(9) and suicide.(10) Experiences of violence and victimization are frequent for LGBTQIA individuals, and these have long-lasting effects on the individual and the community. Sexual orientation and gender identity affect the mental health and safety of LGBTQIA individuals.

Lesbians are less likely to get preventive services for cancer.(11) Gay men are at higher risk of HIV and other STDs, especially in communities of color.(12) Lesbians and bisexual females are more likely to be overweight or obese.(13) Transgender individuals have a high prevalence of HIV and STDs, victimization, mental health issues, and suicide. They are less likely to have health insurance than heterosexual or LGBTQIA individuals.(14)

Elderly LGBTQIA individuals face additional barriers to healthcare because of isolation and a lack of social services and culturally competent providers. LGBTQIA populations have the highest rates of tobacco, alcohol, and other drug use.(15)
Research has demonstrated the health disparity among members of the LGBTQIA community. It underscores a call for action, which includes education at the medical school and nursing school level, and sensitivity training for healthcare professionals focused on the care and treatment of LGBTQIA patients.

Despite advances and policy changes, stigma and a lack of awareness persist in our society, including our healthcare system. For instance, lesbian, gay, bisexual, and transgender persons continue to report negative experiences with healthcare professionals, including homophobia and unsatisfactory or unequal healthcare treatment.(16)

Providing continuing medical education to physicians and other clinicians to fulfill the goal of providing comprehensive, compassionate, and culturally competent patient-centered care is fundamental. Accomplishing this goal also requires raising physicians’ self-awareness about their assumptions, biases, and values that they may convey, directly or indirectly, during doctor–patient interactions.

The first encounter with an LGBTQIA patient is important, because that first encounter will either make the patient comfortable with the caregiver or create a negative impression, resulting in the patient avoiding healthcare.

Eliminating LGBTQIA health disparities and enhancing efforts to improve LGBTQIA health are necessary to ensure that LGBTQIA individuals can lead long, healthy lives. The many benefits of addressing health concerns and reducing disparities include:

• Reductions in disease transmission and progression;

• Increased mental and physical well-being;

• Reduced healthcare costs; and

• Increased longevity.

The healthcare profession has a unique opportunity to improve the lives of the LGBTQIA community. No one recommendation has the highest priority, or that one change will make a difference and close the healthcare gap in the LGBTQIA community. Here are a few suggestions:

1. Understand your pronouns. Consider asking patients on the intake demographics and health questionnaire how they would like to be referred to. Note this in the electronic record, so anyone accessing the patient records uses the preferred pronouns.

2. Consider various role-playing scenarios at a staff meeting. This exercise lets everyone in practice know the importance of cultural competency and the role of diversity.

3. Know your baseline. Thoroughly assessing your practice’s culture in relation to LGBTQIA patients will help determine how well you’re performing and indicate how far you need to go. For example, conducting patient and employee surveys or focus groups before implementing changes helps the practice learn more about their current perception of the disparity that the LGBTQIA community faces.

4. Select goals for narrowing the healthcare disparity in the LGBTQIA community. Begin by selecting two or three factors that can be focused on over a fixed time (e.g., six months or one year).

5. Monitor success. You might conduct surveys of staff and patients before and after implementing an inclusivity program. For example, measure the number of staff, including physicians, with diverse backgrounds.

6. Include everyone in the practice—not only physicians, nurses, and allied health providers, but also the receptionist, the coders, and the IT personnel. 

7. Examine your marketing and educational materials. You might consider the visuals used in marketing or the accessibility of information and services for various populations, such as having patient education materials available in multiple languages.

8. It starts at the top. To truly have an inclusive practice, the leaders and doctors must fully commit and set the tone for the rest of the practice to follow. The leaders must express in writing that the practice takes inclusivity seriously. 

9. Provide education on cultural competency and continuing diversity training as a requirement for employees. Consider having training with qualified instructors to minimize implicit bias. Include required education as part of new hire onboarding and orientation. Additional courses also can be included and scheduled for follow-up training as needed.

Importance of Cultural Competence

Some studies have shown the benefits of cultural competency training in healthcare settings specific to provider-related outcomes (e.g., post-test competencies, knowledge, changes in attitudes); patient- or client-related outcomes (e.g., physiologic, patient perception of care, patient satisfaction, trust); and outcomes related to healthcare service access and utilization. The reality, however, is that everyone on the healthcare team, including non-clinical staff, requires education to create and support an environment that is nonjudgmental and welcoming for all patients.

Patient satisfaction is significantly enhanced when all members on the healthcare team communicate respectfully and sensitively with patients. LGBTQIA patients are more willing to share their personal information, including their preferred gender and chosen pronoun, when they feel they are understood and respected. Although seemingly basic, these initial welcoming rituals can shape and transform previous negative experiences, which often are faced and described by LGBTQIA patients as stressful due to “anticipated, perceived, and actual insensitivity or rejection” by healthcare team members.

Future of Diversity or Inclusivity

Several issues will need to continue to be evaluated and addressed in the future, including:

• Nationally representative data on LGBTQIA Americans;

• Prevention of violence and homicide toward the LGBTQIA community, and especially the transgender population;

• Resiliency in LGBTQIA communities;

• LGBTQIA parenting issues throughout the life course;

• Elder health and well-being;

• Exploration of sexual and gender identity among youth;

• Need for an LGBTQIA wellness model; and

• Recognition of transgender health needs as medically necessary.

Bottom Line: In an era where medical practices pay more attention to diversity, equity, and inclusion, inclusion remains the most difficult metric to track. Many practices struggle to measure their strategies’ impact and communicate that impact to a growing number of stakeholders. There’s no doubt that in 2023 and beyond, practices will continue to devote more attention and resources to advancing diversity, equity, and inclusion.

References

1. Life Expectancy: Could Where You Live Influence How Long You Live? Robert Wood Johnson Foundation; 2020. www.rwjf.org/en/library/interactives/whereyouliveaffectshowlongyoulive . Accessed October 22, 2020.

2. Colby SL, Ortman JM. Projections of the Size and Composition of the U.S. Population: 2014 – 2016. www.census.gov/content/dam/Census/library/publications/2015/demo/p25-1143.pdf . Accessed October 22, 2020.

3. Saha S, Taggart SH, Komaromy M, Bindman AB. Do patients choose physicians of their own race? Health Affairs (Project Hope). 2000;19(4):76-83. https://doi.org/10.1377/hlthaff.19.4.76

4. Xierali IM, Nivet MA. The racial and ethnic composition and distribution of primary care physicians. J Health Care Poor Underserved. 2018;29:556-570. https://doi.org/10.1353/hpu.2018.0036

5. Andrulis DP, Brach C. Integrating literacy, culture, and language improves healthcare equality for diverse populations. Am J Health Behav. 2007;31 Suppl 1:, S122–S133. DOI: 10.5555/ajhb.2007.31.supp.S122. https://doi.org/10.5993/AJHB.31.s1.16

6. Mirza SA, Rooney C. Discrimination prevents LGBTQ people from accessing health care. Center for American Progress. January 18, 2018. www.americanprogress.org/issues/lgbtq-rights/news/2018/01/18/​445130/discrimination-prevents-LGBTQ-people-accessing-health-care . Accessed October 22, 2020.

7. Vadas J. Current state of LGBTQIA+ Healthcare. Beaumont Health; June 2021. https://scholarlyworks.beaumont.org/cgi/viewcontent.cgi?article=1056&context=radiation_oncology_confabstract

8. McLaughlin KA, Hatzenbuehler ML, Keyes KM. Responses to discrimination and psychiatric disorders among black, Hispanic, female, and lesbian, gay, and bisexual individuals. Am J Public Health. 2010;100:1477-1484. https://doi.org/10.2105/AJPH.2009.181586

9. Herek GM, Garnets LD. Sexual orientation and mental health. Annu Rev Clin Psychol. 2007;3:353-375. https://doi.org/10.1146/annurev.clinpsy.3.022806.091510

10. Remafedi G, French S, Story M, et al. The relationship between suicide risk and sexual orientation: results of a population-based study. Am J Public Health. 1998;88(1):57-60. https://doi.org/10.2105/AJPH.88.1.57

11. Buchmueller T, Carpenter CS. Disparities in health insurance coverage, access, and outcomes for individuals in same-sex versus different-sex relationships, 2000–2007. Am J Public Health. 2010;100:489-495. https://doi.org/10.2105/AJPH.2009.160804

12. Centers for Disease Control and Prevention (CDC). HIV among Gay and Bisexual Men. CDC Fact Sheet. Atlanta: CDC; 2017. www.cdc.gov/nchhstp/newsroom/docs/factsheets/cdc-msm-508.pdf .

13. Struble CB, Lindley LL, Montgomery K, et al. Overweight and obesity in lesbian and bisexual college women. J Am College Health. 2010;59(1):51-56. https://doi.org/10.1080/07448481.2010.483703

14. National Gay and Lesbian Taskforce. National transgender discrimination survey: preliminary findings. Washington, DC: National Gay and Lesbian Taskforce; 2009 Nov.

15. Hughes TL. Chapter 9: Alcohol use and alcohol-related problems among lesbians and gay men. Ann Rev of Nurs Res. 2005;23:283-325. https://doi.org/10.1891/0739-6686.23.1.283

16. Daniel H. Lesbian, gay, bisexual, and transgender health disparities: executive summary of a policy position paper from the American College of Physicians. Ann. Intern Med. 2015;163(2):135-137. https://doi.org/10.7326/M14-2482