Background: Health Inequities Exist, and Change Is Hard
Decades of evidence illustrate health injustices in prevention,1 treatment,2 and rehabilitation3 based on racialized identity. Racial inequities affect not only patients, but also clinical learners who observe a mismatch between personal and institutional values around racial equity. Moral distress and cognitive dissonance can result.4,5
Despite mounting data illustrating health inequities, barriers exist to creating and sustaining actionable health equity improvements. Like other “wicked,” seemingly unsolvable problems, the problem of health injustice invokes emotional responses.6 Human-centered design (HCD) and its mindsets (see Table for a complete list), such as creative confidence (we all can make a difference) or failing hard and early (recognizing the importance of a growth mindset), may help to shift the focus from blame to solution and can make the work more meaningful and relevant while promoting self-compassion. HCD has an evidence base in social movements8 and medicine9,10 ; however, it has been less used in racial inequity. Having used HCD extensively in our quality improvement work, our perspective piece reflects our opinions on how adopting HCD mindsets and tools may permit graduate medical education (GME) stakeholders to bridge the gap between the status quo and desired practices of providing racially equitable patient care.
HCD: Selected Tools to Overcome Inertia and Promote Improvement
HCD employs several readily available and translatable tools, such as stakeholder mapping, journey maps, and idea-generating and idea-selecting activities that help to facilitate authentic discovery, thoughtful planning, and measurable improvement.
Stakeholder Mapping
Stakeholder mapping is crucial to understanding who is involved in or affected by a problem. For example, for racially inequitable preventative screening services such as colorectal screening, the direct stakeholders involved in the activity are the clinician and the patient; however, many more stakeholders, such as schedulers, community members that influence the patients’ health-seeking behavior, reimbursement agencies, or policymakers need to be included in an accurate stakeholder mapping, which is essential for allocating limited financial or human resources to yield the most meaningful possible change. Two questions can help guide this exploration: (1) What are the stakeholders’ interests and motivation?; and (2) How much power do these stakeholders have to make a change? Depending on the findings, stakeholders can be grouped into 4 categories (Figure 1); strategies to promote change differ per stakeholder type. Multilevel stakeholder participatory approaches have led to uncovering hidden intrapersonal, interpersonal, and institutional perspectives and barriers in health care preventive services11 ; contribute to trust-building between stakeholders; and can reduce racial inequities.
A Power-Interest Matrix Grouping Potential Stakeholders by Their Power and Interest (to Make a Difference)
Note: See online supplementary data for more details.
A Power-Interest Matrix Grouping Potential Stakeholders by Their Power and Interest (to Make a Difference)
Note: See online supplementary data for more details.
Journey Maps
Journey maps provide a detailed timeline, breaking an activity into its many components (online supplementary data Figure). They focus on behavioral, cognitive, and emotional barriers to change. Coming to the emergency department may be necessary, but depending on the mode of transport and the reason for the presentation, the patient may experience a variety of emotions, such as fear, anxiety, or worry, at different stages. When a clinician decides to restrain or seclude patients based on their presentations, health professionals may experience stress, power, exhilaration, guilt, or a combination of emotions in the short term. In the long term, they may feel confused at having acted out or witnessed behaviors that went against their values and moral beliefs (ie, moral injury). They may also feel that they were part of a situation that seemed to proceed without rational thoughts, or one in which beliefs did not line up with actions (ie, cognitive dissonance). Making behaviors, thoughts, and emotions explicit at different stages expands the lens to reflect on ideas to improve the status quo.
Idea-Generating and Idea-Selecting Tools
Idea generation in the problem and solution spaces requires divergence (exploring and generating as many ideas as possible without judgment or criticism) and convergence (selecting, evaluating, and refining the most promising ideas from the divergence phase). For a patient presenting to the emergency department with chest pain, it would be premature to close the problem space by adjudicating a diagnosis of myocardial infarction. The job of first assessing the complaint is generating as many differential diagnoses as possible, even in the face of additional hints about the actual diagnosis. Next, a patient-centered history, a clinical examination, appropriate labs, and perhaps imaging or further procedures would narrow the differential diagnosis and help specify the cause of the symptoms that one can then target for treatment. Again, clinicians may prematurely close the solution space if they just prescribed the same first-line treatment to everyone with the same symptoms. They need to carefully consider clinical, demographic, and pharmacological variables of various medication before choosing one medication or another.
While health professionals have been trained to apply divergent and convergent thinking in clinical care, they do not necessarily use the same approach in other areas, or they are not able to fully explore the problem and solution spaces due to other constraints. For example, clinicians are often forced to explore only a limited set of discharge options due to financial constraints (ie, pressure from insurance companies to discharge the patient) instead of thinking creatively about alternatives with the patients and their families. Patients may get discharged to a skilled nursing facility (SNF), but not everyone benefits equally from that.
In fact, Black patients may be harmed by being more likely to be discharged to SNFs that have a higher 30-day rehospitalization rate.3 This lack of full exploration of the problem and solutions spaces extends to the racial inequities field, in which focusing on what is already known and evident is customary. Applying solutions that have worked elsewhere risks ignoring the inadequacy of a one-size-fits-all approach to different institutions. Divergent and convergent modes of thinking can help individuals expand generated ideas from intrapersonal, interpersonal, institutional, and systematic spaces.
After idea generation comes the task of selecting an action. The “Now-Wow-Ciao-How” matrix (Figure 2) is an idea-selecting tool that can help to brainstorm, plan ideas, and organize thoughts (ie, alternative discharge options within an environment of constraints). Using the matrix, ideas can be categorized based on their originality (not very innovative to innovative) and ease of implementation (easy to difficult to implement).
The “Now-Wow-Ciao-How” Matrix As an Idea-Selecting Tool
Note: See online supplementary data for more details.
The “Now-Wow-Ciao-How” Matrix As an Idea-Selecting Tool
Note: See online supplementary data for more details.
Using HCD Tools to Champion Change
Evidence from racial health injustice research serves as a mirror to clinicians, educators, and administrators and should be the impetus to commit to meaningful change. Through the help of HCD tools, stakeholders at our institution implemented the Brøset Violence Checklist, which led to, among other outcomes, an increased sense of the stakeholders to own the problem of disproportionately higher triage of Black patients to the locked area of the emergency department and to solve it. At its core, HCD has the potential to involve empathetic engagement with various stakeholders in GME. At the same time, because of its nature, including broad stakeholder involvement and testing/reiterative cycles, HCD can be resource-consuming (human and financial), which can be a barrier. The outcome of HCD activities is also specific to a given problem at a given institution at a given time and may or may not be generalizable; however, generally, HCD tools, such as stakeholder and journey mapping or idea-generating and idea-selecting activities, have the potential to solve complex challenges, including how we might provide racially equitable patient care.
References
Editor’s Note
The online supplementary data contains further data from the study.