Monique Jindal, left, and Maria Trent in the Johns Hopkins Children’s Center.
Adolescent-medicine specialist Maria Trent, academic pediatrics fellow Monique Jindal and education specialist Cheri Wilson discuss how bias and racism affect children’s health and what pediatricians can do.
How do discrimination and racism affect young children early on?
Trent: Children can see the subtle differences in people around them starting in infancy, so the impact of parental and societal behavior begins early. They see what their family looks like, and as they grow and move through society, they see the variation in packaging that we all have. The problem is that they also start to observe how adults assign value to different groups of people. Racism is a socially transmitted disease because it is taught and passed down, but the impact on children, adolescents and families is significant from a health perspective.
Trent: There is this ongoing stress of living with racism that can lead to biological changes such as inflammation and hormonal dysregulation. Perceiving that they are living in a threatening world, children may exhibit behavioral characteristics such as hypervigilance and remain in a crisis mode, unable to resolve or predict the next threat.
Jindal: You hear all these negative messages that you are part of and you start to believe and internalize them. That can really have detrimental effects regarding your identity, what you choose to pursue, what you see for yourself.
Wilson: Discrimination and racism can affect the child’s perception and use of health care, too. If the child observes his or her parents disrespected in a very poor manner and treated awful by doctors, the child will say, “I’m not going there.” The parents bring the child in for a well-child visit and now the child is afraid to go. When they become adults, they do not trust the health care system. This distrust affects their participation in clinical trials, too. Early experiences do spill over.
What can pediatricians do?
Trent: An easy first start is to make sure that everyone feels welcome in the pediatrician’s office. Are there images of diverse families on the clinic walls and multicultural books, videos and toys in the waiting area? Are staff diverse and able to deliver culturally and linguistically appropriate services to all families? Are you performing quality assurance assessments to determine if your patients are having similar outcomes regardless of race, and are you acting to improve quality when possible? Can you improve your own behavior in practice, emphasizing that all children should receive the best quality of care? Doing that requires that we examine our own biases, acknowledge the role of racism in child and adolescent health, and then commit to proactive change that leads to strategies that optimize clinical care, training behavior and research to reduce the health effects of all forms of racism.
Trent: In adolescent medicine, we developed a program to train health professionals in cultural competency and communication using a variety of teaching techniques. One of the most effective approaches has been to use the Johns Hopkins simulation center to allow pediatric trainees to practice managing cultural communication and use of interpreters. When we engage in this work, we have to ask ourselves if we are working and living in line with the principles we embrace. How do we talk to and treat our adolescents? How do we interface with young people in public spaces? For parents and families, we focus on what kind of advice and guidance around race and racism we should be giving them.
Jindal: During residency, I looked into the scientific literature and was amazed to see a ton of literature linking racism to poor health, and how our actions as health professionals when driven by racist policies impact quality of care. Therefore, we created a racism in medicine curriculum as part of resident training. We needed to have something that does not just talk about poverty and social economics but instead addresses racism head on.
Cheri Wilson, M.A., M.H.S., C.P.H.Q.
Jindal: Self-awareness is the first step. Studies show being aware of racist beliefs and tendencies, our own implicit biases, makes a difference. Practicing empathy and perspective taking — actively putting yourself in the patient’s shoes — has been shown to be helpful. In addition, physicians can focus on a common group identity to connect with patients, to make it a humanizing encounter. We also educated medical professionals about the history of structural racism, like redlining and racial segregation, and how that impacts a child. This subject is not mandatory in medical schools.
How has the training been received?
Jindal: The curriculum has been well received — some people cited it as the best part of medical education up to this point in their career. However, some scientists do not like us focusing on empathy, even if our whole job is about making human connections. If you cannot understand one’s life story, what it might be like to live in their skin, I do not think you get very far. I was initially surprised how difficult it was for providers to admit they might have some unconscious biases and need to work to move forward. This is a group of people who went into this profession to presumably help other people, so it might be very threatening to say you might be doing something that leads to less than ideal care for people.
Wilson: As human beings, we operate on autopilot in a world where we have to make a conscious decision about every little thing. With everything and everyone we interact with, some preconceived notion or stereotype comes to mind driven by the lens we bring to the world through our upbringing, school and media, what we learn about a group of people. When we meet someone, we quickly size the person up even before the person opens their mouth. In a matter of seconds, we determine everything we need to know about the person, whether they are safe or not — originating from the whole concept of “friend or foe.” From a health care perspective, we look at how a patient is dressed and make assumptions about whether someone is educated, has good insurance or is going to be a compliant patient. As a result, we may do the bare minimum for this patient so we can get to the next patient, who we are more comfortable with and prefer to work with. That is how implicit bias comes into play, and it can be very harmful.
How do you mitigate bias?
Wilson: By realizing that none of us is perfect! Recognize that every single one of us has many biases of which we are unaware. If we are called on it, the first inclination is to get defensive, to say, “I treat all of my patients the same,” or, “My intentions were good.” We cannot focus on the intention — it is the impact of the bias. The answer is in seeing it, owning it, engaging in introspection. After an encounter with a patient, you may ask yourself, “Why did I react that way and come to that decision?” Get feedback from other people.
What are the benefits of self-awareness and empathy?
Jindal: The reward is the patient’s wellbeing. It is the exact opposite of what happens if you do not have that empathy. We see that providers who have higher levels of bias are less likely to provide high-quality care, are less likely to be trusted by their patients. Research also shows that higher levels of empathy decrease the impact of racist tendencies among healthcare professionals and lead to higher quality care. If you do lean into this, you will gain stronger relationships with your patients and your patients will have reason to confide in you and come to you. You the health professional get something out of it, too. In a profession in which you are constantly interacting with people all day, every day, a warm and meaningful interaction leads to you having a better day. When you do better by your patients, you feel better as a physician, as well.
Maria Trent, director of the Division of Adolescent/Young Adult Medicine at Johns Hopkins Children’s Center, sat on the American Academy of Pediatrics (AAP) Section on Adolescent Health for over a decade and was the lead author of the AAP’s 2019 policy statement on racism’s impact on children’s health. Monique Jindal, as a chief resident at Cincinnati Children’s Hospital, created a racial bias curriculum for residents there. Now at Johns Hopkins she is evaluating the impact of the curriculum, along with leading efforts to improve the diversity of books offered through the Children’s Center’s Reach Out and Read program. Cheri Wilson, the education and training manager in the Johns Hopkins Office of Diversity, Inclusion and Health Equity, focuses on implicit bias among health professionals and how it affects patients’ health.