Recognizing and confronting discrimination  is essential to eliminating health disparities. Healthy People 2030 highlights discrimination when addressing social determinants of health.1  In this issue of Pediatrics, Lei et al2  contribute to the growing literature that discrimination adversely impacts mental health in young adults. The authors investigated the effect of discrimination (racism, sexism, ageism, physical appearance, other) over time on mental health, substance use, and well-being. Data analysis using the Transition to Adulthood Supplement of the Panel Study of Income Dynamics revealed that increased discrimination frequency was associated with higher levels of mental illness diagnosis, psychological distress, substance use, and languishing for up to 6 years after initial exposure.2  Clinicians should know 3 aspects vital to combating discrimination in health care: the impact of interpersonal discrimination, the role of implicit bias in perpetuating disparities, and decolonizing medical education and training.

First, interpersonal discrimination (sometimes called individual discrimination) refers to conscious or unconscious acts of prejudice committed by a member of a dominant or privileged group toward a member(s) of a marginalized group. Acts of interpersonal discrimination (ie, microaggressions) can manifest as lack of respect toward a person as well as marginalizing, undervaluing, and scapegoating a person. Experiences with acts of interpersonal discrimination have been found to contribute to poor mental health and physical health outcomes in children, adolescents, young adults, and adults. Within the health care setting, this can include making disparaging comments to a patient or colleague about their weight, accented speech, name, or religious affiliation.36  Acts of interpersonal discrimination in health care also include failing to provide translation services for patients who are fluent in languages other than spoken English; making assumptions about a patient’s intelligence on the basis of their economic status, educational level, or geographic origin; or refusing to see patients who are members of sexual or gender minority groups.79 

Secondly, acknowledging, mitigating, and eliminating the impact of implicit biases within the health care system is critical. Evidence suggests that clinicians endorse negative implicit biases toward race, sex, weight, age, and mental illness that are similar to those in the general population.10  Studies have found that clinicians’ negative implicit biases influence how they communicate with their patients, influence the treatments they recommend, and influence patient satisfaction ratings.11  The Joint Commission report on implicit bias in health care suggested useful strategies for addressing implicit bias, including perspective-taking (the cognitive aspect of compassion that can reduce bias and deter unconscious stereotypes and prejudices), emotional self-regulation (experiencing positive emotions during patient encounters to build rapport, trust, and connection), and partnership building (working collaboratively with patients toward a common goal).12 

Lastly, we must address bias and discrimination in trainee curricula and continuing medical education. The Accreditation Council for Graduate Medical Education (ACGME) included in the Common Program Requirements that a trainee must demonstrate competence in “respect and responsiveness to diverse patient populations, including but not limited to diversity in gender, age, culture, race, religion, disabilities, national origin, socioeconomic status, and sexual orientation.”13  ACGME has 6 core educational competencies, but none specifically address bias, discrimination, and inequity. To fill this training gap, a new ACGME competency has been proposed: Structural Competency, Health Equity, and Social Responsibility.14  This includes 3 subthemes that address knowledge, skills, and attitudes: structural competency (eg, understand implicit and/or explicit race and/or gender bias and its effects on health outcomes, health inequities, and patient care), structural action (eg, incorporate direct interventions on patients’ social and structural determinants of health into all physician functions), and structural responsibility (eg, examine the ethics of patient care decisions, with a focus on structural vulnerability and reducing the inequities faced by historically marginalized and oppressed populations).14  The American Board of Pediatrics has an updated entrustable professional activity for general pediatrics, number 14, entitled “Use Population Health Strategies and Quality Improvement Methods to Promote Health and Address Racism, Discrimination, and Other Contributors to Inequities Among Pediatric Populations” to address racism, other social determinants of health, clinician bias, and health inequities.15  This entrustable professional activity is focused on the following: clinician personal responsibility to their community and society, identifying populations at risk for poor health outcomes, cooperating with diverse stakeholders on creating and implementing initiatives to improve health outcomes, analyzing data from various resources for quality improvement and/or population health initiatives, and undoing the systems and processes that are rooted in discrimination that have led to health care inequities.15  To mitigate the influence of implicit biases on clinical decision-making, researchers from the Royal College of Physicians have suggested a checklist for determining if clinicians’ biases influence clinical decision-making.16  This checklist includes items that analyze how one reached a diagnosis and whether stereotypes were used.16 

Interpersonal discrimination contributes to poor physical and mental health outcomes for children, adolescents, and adults. Clinician biases and discriminatory actions in practice and/or in training against patients based on their demographic characteristics can lead to serious health consequences. Clinicians play a central role in recognizing and addressing interpersonal discrimination in health care settings and during patient encounters. Institutions have a responsibility of addressing interpersonal discrimination within the work environment and with patient care activities. Committing to reducing and eliminating interpersonal discrimination in health care will promote a healthier society.

FUNDING: No external funding.

COMPANION PAPER: A companion to this article can be found online at www.pediatrics.org/cgi/doi/10.1542/peds.2021-051378.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.

     
  • ACGME

    Accreditation Council for Graduate Medical Education

1
US Department of Health and Human Services, Office of Disease Prevention and Health Promotion
.
Discrimination
.
2
Lei
Y
,
Shah
V
,
Biely
C
, et al
.
Discrimination and subsequent mental health, substance use, and well-being in young adults
.
Pediatrics
.
2021
;
148
(
6
):
e2021051378
3
Remmert
JE
,
Convertino
AD
,
Roberts
SR
,
Godfrey
KM
,
Butryn
ML
.
Stigmatizing weight experiences in health care: associations with BMI and eating behaviours
.
Obes Sci Pract
.
2019
;
5
(
6
):
555
563
4
Freeman
L
,
Stewart
H
.
Microaggressions in clinical medicine
.
Kennedy Inst Ethics J
.
2018
;
28
(
4
):
411
449
5
Young
K
,
Punnett
A
,
Suleman
S
.
A little hurts a lot: exploring the impact of microaggressions in pediatric medical education
.
Pediatrics
.
2020
;
146
(
1
):
e20201636
6
Serafini
K
,
Coyer
C
,
Brown Speights
J
, et al
.
Racism as experienced by physicians of color in the health care setting
.
Fam Med
.
2020
;
52
(
4
):
282
287
7
Steinberg
EM
,
Valenzuela-Araujo
D
,
Zickafoose
JS
,
Kieffer
E
,
DeCamp
LR
.
The “battle” of managing language barriers in health care
.
Clin Pediatr (Phila)
.
2016
;
55
(
14
):
1318
1327
8
Stepanikova
I
,
Oates
GR
.
Perceived discrimination and privilege in health care: the role of socioeconomic status and race
.
Am J Prev Med
.
2017
;
52
(
1
,
suppl 1
):
S86
S94
9
Ayhan
CHB
,
Bilgin
H
,
Uluman
OT
,
Sukut
O
,
Yilmaz
S
,
Buzlu
S
.
A systematic review of the discrimination against sexual and gender minority in health care settings
.
Int J Health Serv
.
2020
;
50
(
1
):
44
61
10
FitzGerald
C
,
Hurst
S
.
Implicit bias in healthcare professionals: a systematic review
.
BMC Med Ethics
.
2017
;
18
(
1
):
19
11
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
229
12
The Joint Commission
.
Quick safety issue 23: Implicit bias in health care
.
2016
.
13
Accreditation Council for Graduate Medical Education
.
ACGME common program requirements (residency)
.
2020
.
14
Castillo
EG
,
Isom
J
,
DeBonis
KL
,
Jordan
A
,
Braslow
JT
,
Rohrbaugh
R
.
Reconsidering systems-based practice: advancing structural competency, health equity, and social responsibility in graduate medical education
.
Acad Med
.
2020
;
95
(
12
):
1817
1822
15
The American Board of Pediatrics
.
Entrustable professional activities for general pediatrics
.
2021
.
Available at: https://www.abp.org/entrustable-professional-activities-epas. Accessed September 17, 2021
16
Gopal
DP
,
Chetty
U
,
O’Donnell
P
,
Gajria
C
,
Blackadder-Weinstein
J
.
Implicit bias in healthcare: clinical practice, research and decision making
.
Future Healthc J
.
2021
;
8
(
1
):
40
48

Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Spinks-Franklin was appointed to an American Board of Pediatrics task force to update entrustable professional activity 14, is a member of the American Board of Pediatrics Developmental Behavioral Pediatrics Subboard, and is an expert consultant for Understood.org; and Dr Walton has indicated she has no potential conflicts of interest to disclose.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.