Discriminatory Healthcare Experiences and Medical Mistrust in Patients With Serious Illness.

CONTEXT: Though discrimination in healthcare settings is increasingly recognized, the discriminatory experiences of patients with serious illness has not been well studied. OBJECTIVES: Describe racial differences in patient-reported experiences with discrimination in the healthcare setting and examine its association with mistrust. METHODS: We used surveys containing patient-reported frequency of discrimination using the Discrimination in Medical Setting (DMS) and Microaggressions in Health Care Settings (MHCS) scales, mistrust using the Group Based Medical Mistrust (GBMM) scale, and patient characteristics including patient-reported race, income, wealth, insurance status, and educational attainment. Univariable and multivariable linear regression models as well as risk ratios were used to examine associations between patient characteristics including self-reported race, and DMS, MHCS, and GBMM scores. RESULTS: In 174 participants with serious illness, racially minoritized patients were more likely to report experiencing discrimination and microaggressions. In adjusted analyses, DMS scores were associated with elements of class and not with race. Black, Native American/Alaskan Native (NA/AN), and multiracial participants had higher MHCS scores compared to White participants with similar levels of income and education. Higher income was associated with lower GBMM scores in participants with similar DMS or MHCS scores, but Black and NA/AN participants still reported higher levels of mistrust. CONCLUSION: In this cross-sectional study of patients with serious illness, discriminatory experiences were associated with worse mistrust in the medical system, particularly for Black and NA/AN participants. These findings suggest that race-conscious approaches are needed to address discrimination and mistrust in marginalized patients with serious illness and their families.

Physician Perspectives on Addressing Anti-Black Racism.

Importance: Uncertainty remains among clinicians regarding processes to address and resolve conflict around anti-Black racism. Objective: To elicit clinicians' perceptions of their role in addressing concerns about anti-Black racism among Black patients with serious illness as well as their families. Design, Setting, and Participants: In this qualitative study, one-on-one semistructured interviews were conducted with 21 physicians at an academic county hospital between August 1 and October 31, 2022. Participants were provided clinical scenarios where anti-Black racism was a concern of a patient with serious illness. Participants were asked open-ended questions about initial impressions, prior similar experiences, potential strategies to address patients' concerns, and additional resources to support these conversations. A framework based on restorative justice was used to guide qualitative analyses. Main Outcomes and Measures: Perspectives on addressing anti-Black racism as described by physicians. Results: A total of 21 medical subspecialists (mean [SD] age, 44.2 [7.8] years) participated in the study. Most physicians were women (14 [66.7%]), 4 were Asian (19.0%), 3 were Black (14.3%), and 14 were White (66.7%). Participants identified practices that are normalized in clinical settings that may perpetuate and exacerbate perceptions of anti-Black racism. Using provided scenarios and personal experiences, participants were able to describe how Black patients are harmed as a result of these practices. Last, participants identified strategies and resources for addressing Black patients' concerns and facilitating conflict resolution, but they stopped short of promoting personal or team accountability for anti-Black racism. Conclusions and Relevance: In this qualitative study, physicians identified resources, skills, and processes that partially aligned with a restorative justice framework to address anti-Black racism and facilitate conflict resolution, but did not provide steps for actualizing accountability. Restorative justice and similar processes may provide space within a mediated setting for clinicians to repair harm, provide accountability, and facilitate racial healing.

Physician Perspectives on Responding to Clinician-Perpetuated Interpersonal Racism Against Black Patients with Serious Illness.

BACKGROUND: Racism negatively affects clinical outcomes in Black patients, but uncertainty remains among physicians regarding how to address interpersonal anti-Black racism incidences involving them to facilitate racial healing and promote accountability. OBJECTIVE: Elicit physician perspectives on addressing concerns from Black patients about interpersonal racism involving them or their team. PARTICIPANTS: Twenty-one physician subspecialists at an urban academic medical center. APPROACH: We conducted one-on-one semi-structured interviews to help inform the development of a clinician-facing component of a program to address the distress of racism experienced by Black patients with serious illness. We asked clinicians to describe experiences discussing racism with patients and identify additional resources to support these conversations. MAIN MEASURES: Physician perspectives, including barriers and facilitators, to promote racial healing and clinician accountability when discussing clinician-perpetuated interpersonal racism with Black patients. KEY RESULTS: Of the 21 participating physicians, 67% were women with a mean age of 44.2 years and mean of 10.8 years of experience as an attending physician. Four identified as Asian, three identified as Black, and 14 identified as White. Participants largely felt unprepared to discuss racism with their patients, especially if the harm was caused by them or their team. Participants felt patients should be given tools to discuss concerns about racism with their clinicians, but worried about adding additional burdens to Black patients to call out racism. Participants believed programs and processes with both patient- and clinicians-facing components had the potential to empower patients while providing resources and tools for clinicians to engage in these highly sensitive discussions without perpetuating more harm. CONCLUSIONS: Addressing and improving communication about interpersonal racism in clinical settings are challenging. Dual-facing programs involving patients and clinicians may help provide additional resources to address experiences of interpersonal racism and hold clinicians accountable.

Perspectives About Racism and Patient-Clinician Communication Among Black Adults With Serious Illness.

Importance: Black patients with serious illness experience higher-intensity care at the end of life. Little research has used critical, race-conscious approaches to examine factors associated with these outcomes. Objective: To investigate the lived experiences of Black patients with serious illness and how various factors may be associated with patient-clinician communication and medical decision-making. Design, Setting, and Participants: In this qualitative study, one-on-one, semistructured interviews were conducted with 25 Black patients with serious illness hospitalized at an urban academic medical center in Washington State between January 2021 and February 2023. Patients were asked to discuss experiences with racism, how those experiences affected the way they communicated with clinicians, and how racism impacted medical decision-making. Public Health Critical Race Praxis was used as framework and process. Main Outcomes and Measures: The experience and of racism and its association, as described by Black patients who had serious illness, with patient-clinician communication and medical decision-making within a racialized health care setting. Results: A total of 25 Black patients (mean [SD] age, 62.0 [10.3] years; 20 males [80.0%]) with serious illness were interviewed. Participants had substantial socioeconomic disadvantage, with low levels of wealth (10 patients with 0 assets [40.0%]), income (annual income <$25 000 among 19 of 24 patients with income data [79.2%]), educational attainment (mean [SD] 13.4 [2.7] years of schooling), and health literacy (mean [SD] score in the Rapid Estimate of Adult Literacy in Medicine-Short Form, 5.8 [2.0]). Participants reported high levels of medical mistrust and high frequency of discrimination and microaggressions experienced in health care settings. Participants reported epistemic injustice as the most common manifestation of racism: silencing of their own knowledge and lived experiences about their bodies and illness by health care workers. Participants reported that these experiences made them feel isolated and devalued, especially if they had intersecting, marginalized identities, such as being underinsured or unhoused. These experiences were associated with exacerbation of existing medical mistrust and poor patient-clinician communication. Participants described various mechanisms of self-advocacy and medical decision-making based on prior experiences with mistreatment from health care workers and medical trauma. Conclusions and Relevance: This study found that Black patients' experiences with racism, specifically epistemic injustice, were associated with their perspectives on medical care and decision-making during serious illness and end of life. These findings suggest that race-conscious, intersectional approaches may be needed to improve patient-clinician communication and support Black patients with serious illness to alleviate the distress and trauma of racism as these patients near the end of life.

Examining the effects of social and cash transfer programs for homeless adults: Evidence from the Samaritan pilot.

Objective: To conduct a program evaluation of a technology-based intervention for a housing insecure population. Study design: We conduct a quantitative analysis of Samaritan pilot administrative records. Methods: Samaritan conducted an initial single-arm pilot of their technology platform among a housing insecure population (N = 500). Administrative records containing basic demographics and social determinants of health were analyzed as part of this evaluation. Results: Our analysis revealed that among the participants, roughly 60% reported one or more improvements in unmet social determinants of health, showing the greatest improvements in the areas of utilities and nutrition. A gender subgroup analysis also revealed a differential pattern of platform use to address social determinant needs, with women more likely to report improvements in housing and nutrition while men report improvements in income and hope categories. Conclusion: Samaritan, a technology-based intervention targeted at housing insecure individuals, aims to connect users to the financial and social capital necessary to improve their current situations. The results of the pilot demonstrate the potential role the Samaritan platform could play in addressing social determinant needs and insights on potentially useful technology-based intervention features for housing insecure populations.

Addressing hygiene needs of housing insecure populations: A qualitative analysis of Seattle and King County's mobile hygiene station intervention.

Objective: To evaluate the Seattle Public Utility mobile hygiene station program, a program deployed using public funds in response to the large-scale closures of public hygiene facilities due to COVID-19. Study design: We conduct a qualitative analysis using semi-structured interviews. Methods: We interviewed four Seattle Public Utility (SPU) and Public Health Seattle & King County (PHSKC) employees involved in the design, deployment, and management of the hygiene station intervention. Data were also collected from communications and reports released through SPU/PHSKC web sources. Results: Our analysis revealed factors affecting the implementation of the hygiene program included the rental of hygiene trailers, community partnership to mediate between housed and housing insecure populations, funding source and cost-effectiveness, geographic location of the units, and maintenance of the units to continue population hygiene support. Conclusion: The SPU/PHSKC hygiene station was designed to support the housing insecure and homeless by compensating for the large-scale closures of public restrooms and showers. Several logistical and financing challenges need to be addressed to ensure the continuity of the program.