- Open Access
This is our lane: talking with patients about racism
Women's Midlife Health volume 7, Article number: 7 (2021)
Racism has significantly impacted communities of color for centuries. The year 2020 is a reminder that racism is an ongoing public health crisis. Healthcare institutions have an important role in dismantling racism because of their ability to implement innovative solutions that advance diversity, address social determinants of health, and promote health equity. Healthcare professionals have the unique opportunity to support patients by discussing patients’ experiences of bias and racism. Asking about discrimination, however, can be difficult because of the sensitive nature of the topic and lack of appropriate education. This review highlights the importance of addressing patients’ experiences of racism, utilizing the frameworks of trauma-informed care, structural competency, provider bias, and intersectionality. Furthermore, this review provides ways to engage in meaningful dialogue around discrimination and includes important patient-centric resources.
2020 was marked by local and global events that created a national reckoning with the impact of racism on the health and well-being of people of color in the United States (US). The COVID-19 pandemic has inflicted excess harm on Asian, Black, Latinx, and Indigenous communities. Such disparities can be attributed to a long history of US policies and practices that resulted in members of these communities living in multigenerational households, having greater reliance on public transportation, and having more front-line occupations with higher risk of COVID-19 exposure [1, 2]. Disturbingly, the COVID-19 pandemic has been associated with a significant rise in anti-Asian racism, which has culminated in almost 3800 attacks on people of Asian descent . The killings of Mr. George Floyd, Mr. Ahmaud Arbery, and Ms. Breonna Taylor in 2020 sparked a conversation on how structural racism , bias and discriminatory policies and practices that result in inequitable distribution of resources and opportunities, and interpersonal racism ,bias and discriminatory behaviors and attitudes that occur between individuals, result in disproportionate harm to Black communities in the US.
The American Public Health Association (APHA) considers racism a public health crisis . Indeed, many healthcare organizations and professional medical societies have reaffirmed their commitment to addressing racism and promoting health equity [6,7,8]. Healthcare organizations have approached this commitment in a variety of ways, from seeking to address racial biases and inequities within their institutions, to tackling structural racism by addressing social determinants of health in the community [9,10,11]. In particular, increased attention is being given to discussing the impact of racism and other forms of discrimination directly with patients [7, 12, 13]. However, outside of psychotherapy and pediatric literature, there is a dearth of research and resources in the medical field that is dedicated to assisting clinicians with having these conversations [7, 12, 14,15,16].
In this review, we aim to demonstrate the importance of acknowledging and addressing experiences of racism directly with patients. We draw on various theoretical frameworks to illustrate possible approaches for integrating such discussions in the clinical encounter. While the focus is on discussing experiences of racism with patients, these approaches can also be applied to discussions with patients about experiences of discrimination related to sex, gender identity, sexual orientation, disability, immigration status, etc.
Why inquire about racism?
Camara Phyllis Jones, MD, MPH, former president of the APHA, stated that “racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks (race),” that unfairly disadvantages some individuals and communities and unfairly advantages others . Racism operates at various levels in society, and it is important to understand the many ways that racism manifests. Racism can be internalized and manifest as lower scores on standardized testing when students are reminded of their racial/ethnic group (stereotype threat) [4, 18]. Additionally, racism can operate at the interpersonal level whereby racial bias occurs between individuals; at the institutional level (schools, workplaces, etc.) where discriminatory policies can routinely produce racial inequities; and at the structural level, which accounts for the cumulative historical and societal factors that have led to systematic disadvantage of particular racial groups .
Racism and discrimination are fundamental determinants of health and illness [19,20,21,22,23,24,25,26]. Discrimination is a form of stress that can affect both physical and mental well-being [27, 28]. This stress contributes to wear and tear on the body, or allostatic load, which can result in poor health, including impaired cardiovascular health, metabolic disarray, a weakened immune system, low self-esteem, depression, and anxiety [29,30,31,32,33]. Moreover, there is the additional impact of discrimination that occurs within healthcare settings. In a recent report, 1 in 5 Black adults reported having experienced race-based discrimination in healthcare settings in the last year, and participants were overall less likely to express trust in their doctors or the healthcare system . Mistrust and discriminatory experiences discourage patients from seeking care, limit their ability to follow recommendations, and hinder the development of strong patient-physician relationships [33,34,35]. Mistrust of the healthcare system is deeply rooted in the historical exploitation of Black people by the scientific and medical community. Notable examples include the use of Mrs. Henrietta Lacks’ cells for medical and scientific advancement and the Tuskegee Syphilis Study that examined the natural course of syphilis in Black men for decades, even after the availability of curative treatment [36, 37]. Providers must be aware of the historical and current-day factors that contribute to patients’ mistrust of the healthcare system; empowered with this knowledge, providers can then create safe spaces within the clinical encounter that build trust and engagement.
Approaches to discussing racism with patients: trauma-informed care as a framework
Beyond mistrust of the healthcare system, racism and discrimination have led to significant trauma [16, 38]. A systematic review investigating racism and trauma found a moderate to strong positive association between experiences of racial discrimination and trauma symptoms . Race-based trauma includes cumulative experiences of racism and discrimination over one’s lifetime as well as intergenerational trauma [16, 38].
Trauma‐informed care provides an approach to discussing trauma from racism with patients. Trauma-informed care acknowledges and addresses the intersection and cumulative effects of interpersonal and structural forms of violence on people’s lives and health . Trauma-informed care has been used in the setting of intimate partner or gender-based violence; and has been integrated into social services, behavioral health, and medical settings. Race-based traumatic stress injury is a consideration in mental healthcare . Racism and discrimination can take many forms, such as racism in the form of systematic exclusion (e.g., voter suppression), interpersonal racism (e.g., microaggressions), or discrimination (e.g., denial of promotion at work) . Racism occurs in a sociocultural context and the emotional impact of racism should not be attributed to an individual’s failings .
The Substance Abuse and Mental Health Service Administration (SAMHSA) provides guidance for implementing trauma-informed approaches in behavioral health services delivery, which can be extrapolated to other healthcare settings . SAMHSA emphasizes the importance of developing a shared understanding among care providers of the impact of trauma on patients, implementing trauma screening and assessment, developing policies to respond to trauma at the individual and institutional level, and resisting re-traumatization . SAMHSA further delineates six key principles to a trauma-informed approach: creating a culture and environment of safety, maintaining transparency and trust, providing peer support and connection around trauma, fostering collaboration between staff and patients, empowering patients and staff, and promoting an understanding of trauma in relation to structural and historical factors .
Discussing discrimination can lead to re-traumatization and patients may struggle with disclosing past experiences due to feelings of shame or concerns about stigma . Thus, it is important to use trauma-informed care as a universal precaution so that care can be delivered without causing harm. Moreover, providers do not need to know the details of the trauma to exert a positive influence [41, 42]. Continuing education and training on discussing discrimination should improve providers’ competence and increase screening for discrimination .
Microaggressions and healthcare
Microaggressions are brief and subtle verbal or non-verbal negative messages directed towards members of minority identity groups [44,45,46]. In addition to experiencing microaggressions in the wider society, patients may experience microaggressions in the healthcare setting [14, 46,47,48,49,50,51,52,53]. Similar to members of the wider community, healthcare providers have unconscious or implicit bias [54, 55], which can manifest as microaggressions [46, 53]. Additionally, provider-held unconscious bias can negatively impact care delivery and patients’ health outcomes, despite providers’ best intentions [54, 56,57,58]. Thus, it is imperative that healthcare providers focus on reducing their unconscious bias and learn about microaggressions, which can be done through self-directed learning or curricula that many hospitals are implementing. Healthcare providers should utilize frameworks and language that are inclusive and respect affirming , as well as appreciate that certain phrases or questions may be offensive or stigmatizing [46, 60, 61]. Moreover, continued emphasis on understanding the lived experiences of patients and exercising empathy are critical to building a harmonious relationship with the diverse populations whom we serve .
Considerations for discussing racism with patients: structural competency
A key component of implementing a trauma-informed approach to effectively screening and responding to patients’ experiences of discrimination involves educating providers on the structural and historical forces that fuel racism. Experiences of racism and other forms of discrimination are the result of historical and current political and institutional factors. Understanding these structural drivers of racism is important, as research suggests that healthcare providers are more likely to attribute health inequities to individual characteristics as opposed to structural barriers [62, 63]. Providers should therefore have a shared understanding of how structural racism impacts patients before asking patients about those experiences. Structural competency is a framework that can be used to educate providers on how to understand and address the effects of discrimination on health and well-being [64,65,66].
Structural competency promotes an understanding of how forces, such as racism, impact health and exacerbate inequities (e.g., residential segregation affecting access to healthcare services), and how those forces can also shape the clinical encounter (e.g., implicit biases that shape provider perceptions about patients on the basis of race). Structural competency also advocates for clinician engagement in identifying structural solutions, for example, by having clinicians address food insecurity for patients with diabetes struggling to adhere to dietary recommendations. Structural competency curricula have been employed at various levels of clinician training and across a variety of disciplines within healthcare [67,68,69,70]. The principles of structural competency can be used to develop trainings and curricula for providers as part of implementing racism and discrimination screening tools or practices. Such a curricula could include education on the history of racism in medical research, the social construct of race within medicine, and the various policies that led to persistent racial inequities in housing, food access, and wealth. Empowered with this knowledge, clinicians should feel better prepared to discuss racism with patients.
Considerations for discussing racism with patients: provider-held bias
In addition to cultivating a comprehensive understanding of the structural components of racism, clinicians should develop an awareness of provider-held biases that may affect their clinical interactions and screening practices. Integrating discussions about experiences of racism into the clinical encounter requires that providers acknowledge and address individually-held biases that could impact such conversations. Implicit bias refers to “learned stereotypes and prejudices that are automatically and unconsciously exercised” [55, 71, 72]. Notably, implicit bias involves both favorable and unfavorable attitudes about different groups and can lead to preferential treatment of certain groups.
Implicit bias has been associated with diagnosis disparities, treatment disparities, and lower quality of care [54, 56, 73]. Clinicians with more bias against Black people have been consistently evaluated as providing less patient-centered care by their Black patients as compared to clinicians with little or no such implicit bias . Several systematic reviews have examined provider-held bias and its impact on healthcare [54, 56, 73, 75,76,77,78,79]. Notably provider-held implicit racial bias has been associated with racial disparities in pain management and maternal healthcare [54, 56, 73].
To address clinician-held bias and create a safe space for all patients, both systems and individuals need to adopt new practices. The implicit association test (IAT) is a tool to assist providers in recognizing and acknowledging their own biases as a means to understanding how these biases can lead to poor health outcomes for patients [71, 80]. To mitigate against bias, there must be both individual and institutional action. Individuals should continuously reflect upon their attitudes and actions related to bias. For example, clinicians should feel empowered to intervene if they witness overtly or covertly biased exchanges or if they identify a racist policy or process. At the institutional level, organizations should actively reflect on their engagement with internal and external communities, delivery of education, approach to clinical care, conduct of research, and approach to leadership development from an equity or anti-racism lens. Additionally, to facilitate the needed culture change, institutions must equip providers with structural competency education so that providers understand how racism is impacting their patients’ experiences and how racism (overt or covert) is impacting the delivery of care and other institutional missions.
Considerations for discussing racism with patients: intersectionality
When asking about a patient’s experience of racial discrimination, it is important to recognize that individuals hold various identities that interact with each other and that impact the experience of discrimination. Women of color, who are in the mid-life, may have experienced the combined negative impacts of racism, sexism (discrimination on the basis of sex or gender), and ageism (discrimination on the basis of age), a framework called, intersectionality. Kimberly Crenshaw shared that, “Black women can experience discrimination in ways that are both similar and different from those experienced by White women and Black men” . Transwomen of color may experience particularly high levels of discrimination and adverse health outcomes [60, 62]. Discrimination experienced by women of color in midlife is associated with increased risk of hypertension and metabolic syndrome, higher levels of C-reactive protein, a nonspecific marker of inflammation, as well as reduced breast and cervical cancer screening [82,83,84]. Given the interconnectedness of social identities, discrimination, and health outcomes, it is particularly important for providers to create space during clinical encounters for patients to share their experiences. In so doing, providers will better understand the social factors impacting patients’ health.
If you screen what do you say?
Discussing discrimination, and racism specifically, is challenging and especially difficult if providers feel unequipped to do so and constrained by time. Similar to other topics, starting with open-ended questions (Table 1), e.g., “How are you doing during this challenging time” allows for the topic to be introduced in a general way. Follow-up questions or statements include: “How are you feeling about what’s going on in the world/our country right now as it relates to racism;”  or “The experience of racism is a major contributor to stress. As your physician, I would like to create a safe space for you to discuss key life experiences that contribute to your mental and physical health. Would you be comfortable talking with me about some of your experiences?” If permission is not given let your patient know that you are there for them in the future. Additional questions include those from the Everyday Discrimination Scale (“Do you feel like you are treated with less respect than other people? Do you feel like you are treated unfairly at restaurants or stores? Do you feel discriminated against in other ways?”) and those that reflect discrimination related to being a member of different minority groups (“If you have experienced discrimination because of a combination of factors, for example, your gender and your age, we can talk about that too”) .
As healthcare providers, we must also recognize the power differential that exists between providers and patients. This power dynamic, may at times, prevent discussion of sensitive topics such as discrimination. This is likely exacerbated by ethnic or racial discordance between providers and patients. Given the power differential, it is important to assuage patients’ concerns through emphasizing allyship and to appreciate that it might take time for a patient to disclose their experiences with discrimination. Phrases such as those mentioned in Table 1 provide a framework for broaching these discussions in a gentle manner.
The Southern Jamaica Plain Health Center toolkit for addressing racial justice in the clinical setting includes suggested language for discussing race and racism with patients . When asking about experiences in the healthcare system, providers could say “Many of my patients experience racism in healthcare. Are there any experiences that you would like to share with me?” With regards to life experiences, a clinician could ask: “Are there important life events that you’ve experienced that have or are currently affecting your health?” This toolkit includes the following key approaches: thanking the individual for sharing their story; validating the experience; and adopting a position that acknowledges the injustice, trauma, and pain, and which also affirms the patient’s dignity and strengths. Finally, providers should commit to partnering with patients to address their needs and incorporate their concerns in a shared care plan (Table 1) .
If you screen what should you do next?
When a patient shares a discriminatory experience, the provider must actively listen and validate the patient’s experience. It is important to acknowledge the impact of the experience on the patient and avoid attempts to explain or defend the perceived act of discrimination. Providers should offer help through continued conversation and additional support if needed. Patients may experience mental health sequelae from racism or discrimination and benefit from referral to psychiatry and behavioral health services (Table 2). Patients who experience discrimination in the healthcare setting should be connected to local patient advocacy programs or national organizations, if local services are unavailable (Table 3). Those who experience discrimination related to employment, housing, education, or the criminal justice system may need to be directed to civil rights legal aid. Healthcare institutions and individual clinicians should commit to developing pathways to support patients impacted by racism. For example, medical-legal partnerships are one model of addressing social and structural determinants of health by integrating legal services within the healthcare setting.
Impact on providers of color
While it is important for providers to create a safe space for patients to share their experience of racism, providers should also appreciate how such discussions affect their own well-being. Discussing patients’ experiences of discrimination or racism can be difficult for providers of color because it may remind them of their own experiences of discrimination or racism. Conversely, having these conversations may empower providers of color through their creation of a safe space for patients with whom they share racial or ethnic identity.
Impact on providers who self-identify as White
Discussing racism may raise other challenges. Inquiring about experiences of racism requires that White providers confront race-based discrimination that they may be unaware of or that they may have been socialized to not believe in. Furthermore, conversations about a patient’s experience of discrimination may lead a White provider to appreciate the privilege that they experience because of race, which may have previously been invisible to them. The process of screening a patient about discrimination may thus cause a White provider to experience discomfort that can act as a barrier to continued screening. Hearing about patients’ experiences of discrimination may also provoke other emotions, such as sadness and anger, among White providers. Despite not experiencing this trauma personally, when White providers listen to patients’ experiences of racial trauma, it can shift their world view, a phenomenon called vicarious trauma .
Impact on all providers
Vicarious trauma can impact healthcare providers of all racial/ethnic backgrounds. Clinicians should appreciate that the continuous exposure to vicarious trauma can lead to compassion fatigue and possibly burnout within themselves . Balancing emotions through meditation, prioritizing social connections with family or loved ones, and exercise are a few examples of ways to mitigate vicarious trauma . Finally, using the lens of trauma-informed care as aforementioned is critical in advancing the provider-patient relationship while preventing re-traumatization.
The events of 2020 highlight the ways in which racism affects the daily realities of communities of color. It is of paramount importance that healthcare providers equip themselves with an understanding of how racism impacts patients, provide space for patients to discuss their experiences, and connect patients with resources and support. Trauma-informed care frameworks may assist providers and healthcare institutions in having these conversations with patients. Additionally, structural competency curricula and implicit bias training may serve as important resources to provide clinicians with social, historical, and political context and personal awareness prior to interacting with patients. Importantly, toolkits on eliciting patients’ experiences of racism exist. Finally, patients’ disclosures about racism must be affirmed and providers should know the behavioral health and legal resources that are available for patients, who are navigating experiences of racism. Discussing racism with our patients—this is our lane.
Availability of data and materials
The American Public Health Association
Substance Abuse and Mental Health Service Administration
Implicit association test
Lopez L 3rd, Hart LH 3rd, Katz MH. Racial and ethnic health disparities related to COVID-19. JAMA. 2021;325(8):719–20.
Yan B, W, Ng F, Chu J, Tsoh J, Nguyen T. 2020. Available from: https://www.healthaffairs.org/do/10.1377/hblog20200708.894552/full/.
Hauser C. Asian-Americans were targeted in nearly 3,800 hate incidents in the past year. New York: New York Times; 2021. https://www.nytimes.com/2021/03/17/us/hate-crimes-against-asian-americans-community.html.
Jones CP. Levels of racism: a theoretic framework and a gardener’s tale. Am J Public Health. 2000;90(8):1212–5.
Racism is an ongoing public health crisis that needs our attention now [press release]. Washington, DC: American Public Health Association; 2020. https://apha.org/news-and-media/news-releases/apha-news-releases/2020/racism-is-a-public-health-crisis.
Serchen J, Doherty R, Atiq O, Hilden D. Racism and health in the United States: a policy statement from the American College of Physicians. Ann Intern Med. 2020;173(7):556–7.
Trent M, Dooley DG, Douge J, Section On Adolescent H, Council On Community P, Committee On A. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765.
The American Medical Association. AMA: Racism is a threat to public health 2020 [updated 11/16/2020. Available from: https://www.ama-assn.org/delivering-care/health-equity/ama-racism-threat-public-health.
South EC, Butler PD, Merchant RM. Toward an equitable society: building a culture of antiracism in health care. J Clin Invest. 2020;130(10):5039–41.
Sivashanker K. Dismantling racism and inequity in health care: the critical interplay between equity, quality, and safety. In: Seth MN, editor. NEJM catalyst. Waltham, MA: New England Journal of Medicine; 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0598.
Horwitz LI, Chang C, Arcilla HN, Knickman JR. Quantifying health systems’ investment in social determinants of health, by sector, 2017–19. Health Aff (Millwood). 2020;39(2):192–8.
Polanco Walters F, Anyane-Yeboa A, Landry AM. The not-so-silent killer missing in medical-training curricula: racism. Nat Med. 2020;26(8):1160–1.
Ncube N. The conversations we’ve been having. N Engl J Med. 2020;383(7):e51.
Kanter JW, Rosen DC, Manbeck KE, Branstetter HML, Kuczynski AM, Corey MD, et al. Addressing microaggressions in racially charged patient-provider interactions: a pilot randomized trial. BMC Med Educ. 2020;20(1):88.
Southern Jamaica Plain Health Center. Liberation in the exam room: racial justice and equity in healthcare. Massachusetts: Southern Jamaica Plain Health Center; 2017. http://www.ihi.org/resources/Pages/Tools/Liberation-in-the-Exam-Room-Racial-Justice-Equity-in-Health-Care.aspx.
Carter RT. Racism and psychological and emotional injury: recognizing and assessing race-based traumatic stress. Couns Psychol. 2007;35(1):13–105.
Jones CP, Truman BI, Elam-Evans LD, Jones CA, Jones CY, Jiles R, et al. Using “socially assigned race” to probe white advantages in health status. Ethn Dis. 2008;18(4):496–504.
Steele CM, Aronson J. Stereotype threat and the intellectual test performance of African Americans. J Pers Soc Psychol. 1995;69(5):797–811.
Link BG, Phelan J. Social conditions as fundamental causes of disease. J Health Soc Behav. 1995;Spec No:80–94.
Paradies Y, Priest N, Ben J, Truong M, Gupta A, Pieterse A, et al. Racism as a determinant of health: a protocol for conducting a systematic review and meta-analysis. Syst Rev. 2013;2:85.
Brondolo E, Brady Ver Halen N, Pencille M, Beatty D, Contrada RJ. Coping with racism: a selective review of the literature and a theoretical and methodological critique. J Behav Med. 2009;32(1):64–88.
Brondolo E, Gallo LC, Myers HF. Race, racism and health: disparities, mechanisms, and interventions. J Behav Med. 2009;32(1):1–8.
Williams DR, Collins C. Racial residential segregation: a fundamental cause of racial disparities in health. Public Health Rep. 2001;116(5):404–16.
Williams DR, Mohammed SA. Discrimination and racial disparities in health: evidence and needed research. J Behav Med. 2009;32(1):20–47.
Williams DR, Mohammed SA. Racism and health: pathways and scientific evidence. Am Behav Sci. 2013;57(8):1152–73.
Kaufman JS, Cooper RS, McGee DL. Socioeconomic status and health in blacks and whites: the problem of residual confounding and the resiliency of race. Epidemiology. 1997;8(6):621–8.
Carter RT, Forsyth J. Reactions to racial discrimination: emotional stress and help-seeking behaviors. Psychol Trauma Theory Res Pract Policy. 2010;2(3):183–91.
Gazard B, Chui Z, Harber-Aschan L, MacCrimmon S, Bakolis I, Rimes K, et al. Barrier or stressor? The role of discrimination experiences in health service use. BMC Public Health. 2018;18(1):1354.
Lewis TT, Cogburn CD, Williams DR. Self-reported experiences of discrimination and health: scientific advances, ongoing controversies, and emerging issues. Annu Rev Clin Psychol. 2015;11:407–40.
Versey HS, Curtin N. The differential impact of discrimination on health among Black and White women. Soc Sci Res. 2016;57:99–115.
Pascoe EA, Smart RL. Perceived discrimination and health: a meta-analytic review. Psychol Bull. 2009;135(4):531–54.
Schmitt MT, Branscombe NR, Postmes T, Garcia A. The consequences of perceived discrimination for psychological well-being: a meta-analytic review. Psychol Bull. 2014;140(4):921–48.
Williams DR, Lawrence JA, Davis BA, Vu C. Understanding how discrimination can affect health. Health Serv Res. 2019;54(Suppl 2):1374–88.
Hamel L, Lopes L, Munana C, Artiga S, Brodie M. The undefeated survey on race and health. San Francisco: Kaiser Family Foundation; 2020. https://www.kff.org/racial-equity-and-health-policy/repot/kff-the-undefeated-survey-on-race-and-health/.
D’Anna LH, Hansen M, Mull B, Canjura C, Lee E, Sumstine S. Social discrimination and health care: a multidimensional framework of experiences among a low-income multiethnic sample. Soc Work Public Health. 2018;33(3):187–201.
Wolinetz CD, Collins FS. Recognition of research participants’ need for autonomy: remembering the legacy of Henrietta Lacks. JAMA. 2020;324(11):1027–8.
Alsan M, Wanamaker M, Hardeman RR. The Tuskegee study of untreated syphilis: a case study in peripheral trauma with implications for health professionals. J Gen Intern Med. 2020;35(1):322–5.
Kirkinis K, Pieterse AL, Martin C, Agiliga A, Brownell A. Racism, racial discrimination, and trauma: a systematic review of the social science literature. Ethn Health. 2021;26(3):392–12. https://0-doi-org.brum.beds.ac.uk/10.1080/13557858.2018.1514453. Epub 2018 Aug 30.
Ford-Gilboe M, Wathen CN, Varcoe C, Herbert C, Jackson BE, Lavoie JG, et al. How equity-oriented health care affects health: key mechanisms and implications for primary health care practice and policy. Milbank Q. 2018;96(4):635–71.
SAMHSA’s_Trauma_and_Justice_Strategic_Initiative. SAMHSA’s concept of trauma and guidance for a trauma-informed approach. 2014.
Ravi A, Little V. Providing trauma-informed care. Am Fam Physician. 2017;95(10):655–7.
Ravi A, Pfeiffer MR, Rosner Z, Shea JA. Trafficking and trauma: insight and advice for the healthcare system from sex-trafficked women incarcerated on Rikers island. Med Care. 2017;55(12):1017–22.
Dueweke AR, Hanson RF, Wallis E, Fanguy E, Newman C. Training pediatric primary care residents in trauma-informed care: a feasibility trial. Clin Pediatr (Phila). 2019;58(11–12):1239–49.
Sue DW, Alsaidi S, Awad MN, Glaeser E, Calle CZ, Mendez N. Disarming racial microaggressions: microintervention strategies for targets, White allies, and bystanders. Am Psychol. 2019;74(1):128–42.
Pierce CM, Carew JV, Pierce-Gonzalez D, Wills D. An experiment in racism: TV commercials. Educ Urban Soc. 1977;10(1):61–87.
Sue DW, Capodilupo CM, Torino GC, Bucceri JM, Holder AM, Nadal KL, et al. Racial microaggressions in everyday life: implications for clinical practice. Am Psychol. 2007;62(4):271–86.
Walls ML, Gonzalez J, Gladney T, Onello E. Unconscious biases: racial microaggressions in American Indian health care. J Am Board Fam Med. 2015;28(2):231–9.
Snyder CR, Wang PZ, Truitt AR. Multiracial patient experiences with racial microaggressions in health care settings. J Patient Cent Res Rev. 2018;5(3):229–38.
Hook JN, Farrell JE, Davis DE, DeBlaere C, Van Tongeren DR, Utsey SO. Cultural humility and racial microaggressions in counseling. J Couns Psychol. 2016;63(3):269–77.
Bleich SN, Findling MG, Casey LS, Blendon RJ, Benson JM, SteelFisher GK, et al. Discrimination in the United States: experiences of black Americans. Health Serv Res. 2019;54(Suppl 2):1399–408.
Miller LR, Peck BM. A prospective examination of racial microaggressions in the medical encounter. J Racial Ethn Health Disparities. 2020;7(3):519–27.
Turner J, Higgins R, Childs E. Microaggression and implicit bias. Am Surg. 2021:31348211023418. https://0-doi-org.brum.beds.ac.uk/10.1177/00031348211023418. Online ahead of print. PMID: 34078131.
Cruz D, Rodriguez Y, Mastropaolo C. Perceived microaggressions in health care: A measurement study. PLoS One. 2019;14(2):e0211620.
Institute of Medicine (US) Committee on Understanding and Eliminating Racial and Ethnic Disparities in Health Care. Washington (DC): National Academies Press (US); 2003.
The Joint Commision. Implicit bias in health care 2016. Available from: https://www.jointcommission.org/-/media/deprecated-unorganized/imported-assets/tjc/system-folders/joint-commission-online/quick_safety_issue_23_apr_2016pdf.pdf?db=web&hash=A5852411BCA02D1A918284EBAA775988.
FitzGerald C, Hurst S. Implicit bias in healthcare professionals: a systematic review. BMC Med Ethics. 2017;18(1):19.
Schulman KA, Berlin JA, Harless W, Kerner JF, Sistrunk S, Gersh BJ, et al. The effect of race and sex on physicians’ recommendations for cardiac catheterization. N Engl J Med. 1999;340(8):618–26.
Green AR, Carney DR, Pallin DJ, Ngo LH, Raymond KL, Iezzoni LI, et al. Implicit bias among physicians and its prediction of thrombolysis decisions for black and white patients. J Gen Intern Med. 2007;22(9):1231–8.
White AA 3rd, Stubblefield-Tave B. Some advice for physicians and other clinicians treating minorities, women, and other patients at risk of receiving health care disparities. J Racial Ethn Health Disparities. 2017;4(3):472–9.
Goddu A, O’Conor KJ, Lanzkron S, Saheed MO, Saha S, Peek ME, et al. Do words matter? Stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med. 2018;33(5):685–91.
Goddu AP, O’Conor KJ, Lanzkron S, Saheed MO, Saha S, Peek ME, et al. Correction to: Do words matter? Stigmatizing language and the transmission of bias in the medical record. J Gen Intern Med. 2019;34(1):164.
Malat J, Purcell D, van Ryn M. Factors affecting whites’ and blacks’ attitudes toward race concordance with doctors. J Natl Med Assoc. 2010;102(9):787–93.
Wear D. Insurgent multiculturalism: rethinking how and why we teach culture in medical education. Acad Med. 2003;78(6):549–54.
Metzl JM, Roberts DE. Structural competency meets structural racism: race, politics, and the structure of medical knowledge. Virtual Mentor. 2014;16(9):674–90.
Metzl JM, Hansen H. Structural competency: theorizing a new medical engagement with stigma and inequality. Soc Sci Med. 2014;103:126–33.
Hansen H, Metzl JM. New medicine for the U.S. health care system: training physicians for structural interventions. Acad Med. 2017;92(3):279–81.
Metzl JM, Petty J, Olowojoba OV. Using a structural competency framework to teach structural racism in pre-health education. Soc Sci Med. 2018;199:189–201.
Neff J, Holmes SM, Knight KR, Strong S, Thompson-Lastad A, McGuinness C, et al. Structural competency: curriculum for medical students, residents, and interprofessional teams on the structural factors that produce health disparities. MedEdPORTAL. 2020;16:10888.
Paul EG, Curran M, Tobin TE. The medical-legal partnership approach to teaching social determinants of health and structural competency in residency programs. Acad Med. 2017;92(3):292–8.
Garcia D. Structural competencies in migration health. Austin TX: Migrant Clinicians Network. https://www.migrantclinician.org/mcn/clinical-education/structural-competency/index.html.
Banaji MR, Greenwald AG. Implicit gender stereotyping in judgments of fame. J Pers Soc Psychol. 1995;68(2):181–98.
Perdomo J, Tolliver D, Hsu H, He Y, Nash KA, Donatelli S, et al. Health equity rounds: an interdisciplinary case conference to address implicit bias and structural racism for faculty and trainees. MedEdPORTAL. 2019;15:10858.
Maina IW, Belton TD, Ginzberg S, Singh A, Johnson TJ. A decade of studying implicit racial/ethnic bias in healthcare providers using the implicit association test. Soc Sci Med. 2018;199:219–29.
Blair IV, Steiner JF, Fairclough DL, Hanratty R, Price DW, Hirsh HK, et al. Clinicians’ implicit ethnic/racial bias and perceptions of care among Black and Latino patients. Ann Fam Med. 2013;11(1):43–52.
Byrne A, Tanesini A. Instilling new habits: addressing implicit bias in healthcare professionals. Adv Health Sci Educ Theory Pract. 2015;20(5):1255–62.
Cahn PS. Recognizing and reckoning with unconscious bias: a workshop for health professions faculty search committees. MedEdPORTAL. 2017;13:10544.
Dehon E, Weiss N, Jones J, Faulconer W, Hinton E, Sterling S. A systematic review of the impact of physician implicit racial bias on clinical decision making. Acad Emerg Med. 2017;24(8):895–904.
Hall WJ, Chapman MV, Lee KM, Merino YM, Thomas TW, Payne BK, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health. 2015;105(12):e60-76.
Oliver MN, Wells KM, Joy-Gaba JA, Hawkins CB, Nosek BA. Do physicians’ implicit views of African Americans affect clinical decision making? J Am Board Fam Med. 2014;27(2):177–88.
Marcelin JR, Siraj DS, Victor R, Kotadia S, Maldonado YA. The impact of unconscious bias in healthcare: how to recognize and mitigate it. J Infect Dis. 2019;220(220 Suppl 2):S62–73.
Crenshaw K. Demarginalizing the intersection of race and sex: a black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. Univ Chic Legal Forum. 1989;1989(8):149. https://chicagounbound.uchicago.edu/uclf/vol1989/iss1/8.
Moody DB, Chang Y, Brown C, Bromberger JT, Matthews KA. Everyday discrimination and metabolic syndrome incidence in a racially/ethnically diverse sample: study of women’s health across the nation. Psychosom Med. 2018;80(1):114–21.
Moody DLB, Chang YF, Pantesco EJ, Darden TM, Lewis TT, Brown C, et al. Everyday discrimination prospectively predicts blood pressure across 10 years in racially/ethnically diverse midlife women: study of women’s health across the nation. Ann Behav Med. 2019;53(7):608–20.
Jacobs EA, Rathouz PJ, Karavolos K, Everson-Rose SA, Janssen I, Kravitz HM, et al. Perceived discrimination is associated with reduced breast and cervical cancer screening: the Study of Women’s Health Across the Nation (SWAN). J Womens Health (Larchmt). 2014;23(2):138–45.
Barker J. Racism and children’s health: What providers need to know 2020 [updated 6/12/2020]. Available from: https://discoveries.childrenshospital.org/racism-health-care-children/#:~:text=You%20can%E2%80%99t%20put%20a%20cast%20on%20racism%20and,themselves%20through%20daily%20microaggressions%2C%20this%20is%20powerful%20medicine.
Shariff-Marco S, Breen N, Landrine H, Reeve BB, Krieger N, Gee GC, et al. MEASURING EVERYDAY RACIAL/ETHNIC DISCRIMINATION IN HEALTH SURVEYS: how best to ask the questions, in one or two stages, across multiple racial/ethnic groups? Du Bois Rev. 2011;8(1):159–77.
Williams MT, Pena A, Mier-Chairez J. Tools for assessing racism-related stress and trauma among Latinos. In: Benuto L, editor. Toolkit for counseling Spanish-speaking clients. Cham: Springer; 2017. p. 71–95.
Jenkins SR, Baird S. Secondary traumatic stress and vicarious trauma: a validational study. J Trauma Stress. 2002;15(5):423–32.
Pfifferling J-H, Giley K. Overcoming compassion fatigue 2000. Available from: https://www.aafp.org/fpm/2000/0400/p39.html.
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Diop, M.S., Taylor, C.N., Murillo, S.N. et al. This is our lane: talking with patients about racism. womens midlife health 7, 7 (2021). https://0-doi-org.brum.beds.ac.uk/10.1186/s40695-021-00066-3
- Structural competency
- African American