EDITORIAL: Diversity and equity in the health care system
Johny Van Aerde, MD, PhD
Without pretending to cover every aspect of diversity, this issue of CJPL builds on the previous one by expanding the scope of equity and diversity in the health care system and medical leadership. Despite the wide variety in topics — gender, generations, races, roles in academic and health care organizations — the following five integrated items offer commonality and can help us with the changes needed to increase diversity and equity.
Be aware of and manage fear
A recent opinion paper in the New England Journal of Medicine1 stated that, “We fear things that we perceive as unfamiliar, unexpected and uncontrollable.” Any effort to change has always been met with resistance, because change brings uncertainty and anxiety and it disturbs the comfort of the status quo.2 We often anticipate the worst possible outcome and perceive greater diversity and equity as a risk or a threat. For the groups that have been dominant for a long time — men over women, white over other races, doctors over patients, heterosexual over other gender orientations, trainers over trainees — change can trigger negative reactions including fear, when the advantaged position is threatened by redistribution of power.
For all parties “threatened” by increasing diversity and equity, it is paramount to be aware of the feelings and emotions triggered by those changes and to reflect on where they might be coming from and why. Only after that reflection will we be able to move on to the following steps.
Remain vigilant regarding mental models, assumptions, and beliefs
Both dominant and non-dominant groups are likely to carry biases, consciously and subconsciously. Diversity and equity for all can only be achieved when we fight all stereotypes that hold us back. Self-awareness, reflection, and self-management will help us identify mental models, beliefs, and assumptions that might cloud our thinking and prevent us from reaching our common goal.
Practise the skills of real dialogue
David Bohm, a quantum physicist wrote, “As with electrons, we must look on thought as a systemic phenomenon arising from how we interact and discourse with one another.”3 Dialogue is about exploring possibilities, gaining insight, and reordering our knowledge.4 In a world of aggressive debate and attention-seeking shouts on social media, our society has lost the art of true dialogue.
The six rules for real dialogue were detailed in one of our previous issues,5 and some of these are important here: be open and curious about others’ perspectives and willing to change your thinking; be respectful and supportive by suspending judgement and preconceived beliefs; share the reasons behind your questions and statements; listen to understand and be alert for what else is possible.
Create psychological safety
Dialogue cannot occur without psychological safety, which relates to a person’s perspective on how threatening or rewarding it is to take personal risks. Will new ideas be welcomed and built on, or will they be criticized and ridiculed? Is it safe to admit that you do not understand something, or will this lead to embarrassment?
Psychologically safe environments help create a setting conducive to learning. Positive feelings, such as trust, curiosity, and confidence, broaden the mind to help us build psychological, social, and physical resources. We also become more open-minded, resilient, motivated, and persistent when we feel safe. Humour and joy in work increase, as does solution-finding and divergent thinking — the cognitive process underlying creativity.6,7
Seeing a problem as a learning opportunity, showing curiosity, and having the courage to acknowledge fallibility and vulnerability contribute to building psychological safety. Speak human-to-human, asking yourself why a reasonable person would say or do certain things, while remaining aware of your own biases. Promote the practice of gratitude, which contributes to psychological safety and joy in work.7 Take an interest in other people and ask, “How are you, really?”
Make interactions relationship-centred
Many of our interactions, including clinical interactions, can be seen as complex adaptive systems.8 In the case of the clinical encounter, the focus has shifted from doctor to patient-centred care. Although the purpose of health care is to respond to the needs of the patient, the process toward equity can be understood neither from a doctor- nor a patient-centred perspective,9 but rather the explicit focus should be on the relationship between partners.
Regardless of whether we are in a clinical setting, when we aim to reach equity within diversity, the same principles of relationship-centred interaction apply: the relationship ought to include the personhood of each participant with her/his values, experiences, and perspectives; empathy and kindness are fundamental pillars of those relationships; parties influence each other reciprocally, even though one partner’s goal may take priority; there is a moral foundation to develop interest in the other and invest what is needed to serve others.8,9
Equity and diversity, inside and outside the health care system, are about true partnership. To paraphrase the LEADS framework, it is about distributed leadership to achieve common constructive goals in a caring environment.10 Top
Clearly, we have a lot of work to do.
1.Soklaridis S, Zahn C, Kuper A, Gillis D, Taylor V, Whitehead C. Men’s fear of mentoring in the #MeToo era – what’s at stake for academic medicine? N Engl J Med 2018;3 Oct. doi: 10.1056/NEJMms1805743
2.Bridges W. Managing transitions: making the most of change (2nd ed.). Cambridge, Mass.: Da Capo Press; 2003.
3.Bohm D, Edwards M. Changing consciousness: exploring the hidden source of the social, political and environmental crises facing our world. San Francisco: Harper; 1991.
4.Isaacs W. Dialogue and the art of thinking together. New York: Currency Doubleday; 1999.
5.Van Aerde J. Real dialogue: six conditions, six ground rules, three barriers. Can J Physician Leadersh 2017;4(1):3-7.
6.Delizonna L. High-performing teams need psychological safety. Here’s how to create it. Harv Bus Rev 2017. Available: https://bit.ly/2wCdOt9 (accessed 20 Nov. 2018).
7.Perlo J, Balik B, Swensen S, Kabcenell A, Landsman J, Feeley D. IHI framework for improving joy in work. Cambridge, Mass.: Institute for Healthcare Improvement; 2017. Available: https://tinyurl.com/jdkc999 (accessed 19 Nov. 2018).
8.Tresolini C, Pew-Fetzer Task Force. Health professions education and relationship centered care. San Francisco: Pew Health Professions Commission; 1994.
9.Van Aerde J. Relationship-centred care toward real health system reform. Can J Physician Leadersh 2015;1(3):3-8.
10.Dickson G, Tholl B. Bringing leadership to life in health: LEADS in a caring environment. London: Springer; 2014.
Johny Van Aerde, MD, MA, PhD, FRCPC, is editor-in-chief of the Canadian Journal of Physician Leadership and a former president of the Canadian Society of Physician Leaders.
This article has been peer reviewed.