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Since their inception in the early 1960’s, addressing disparities in healthcare has been at the core of the mission of FQHCs.  Through the ensuing decades, much of the approach has been aimed at access, as we have provided healthcare to all members of our communities, including the most needy and those with no health insurance coverage.  FQHCs have also addressed disparities in other, more dramatic ways.  The first FQHCs were employment centers, engaged in voter registration in the deep south, and provided care to entire populations who had previously been denied access due to their race or standing in society.

In Maine, we also have a tradition of addressing disparities.  Drs. Dan Hanley and Jack Wennberg undertook pioneering work to identify and address geographic disparities in health outcomes in Maine in the 1970s (arguably the first explicit attempt at population health).  The Hanley Center has built on that foundation, and organizations like Maine Quality Counts and Maine Health Access Foundation are national leaders in fundamentally addressing disparities in care and improving the infrastructure of health care delivery in order to create a more consistent baseline of quality.  And certainly here at PCHC a number of important initiatives have been undertaken which are largely aimed at supporting a high standard of quality and service (Patient Centered Medical Home accreditation, NCQA Quality recognition, Meaningful Use in some regards, etc.).

There is, however, some initial evidence that another contributor to disparities in health resides not in our systems or work processes, but in each of us.  Implicit Bias describes our individual, innate, sub-conscious tendencies to react to (and therefore to evaluate and treat) people differently based on their race, sexuality, appearance, gender, or financial standing.  Blair, et al published an important article outlining the challenges of this phenomenon in Permanente Journal in 2011. Whereas explicit bias involves a conscious decision to regard a group of people more negatively simply based on a characteristic (for example racism, homophobia, anti-Semitism), implicit bias is unintentional and unconscious.  It is the result of a life of exposure to certain attitudes or stereotypes, or cultural “norms” and it is activated quickly and unknowingly by cues such as skin color, accent, or appearance, and can impact our perception, behavior and even memory.  It follows that Implicit Bias may impact health care delivery and outcomes, and some initial studies indicate that it is likely the case.  Whereas explicit bias has been on a steep decline in the last 50 years, Blair and his colleagues state that Implicit Bias persists.  Since it is not part of conscious thought, Implicit Bias cannot be measured through standard questionnaires.  Harvard has developed an on line tool which measures response times to paired associations of positive and negative traits paired with contrasting characteristics (white and black, young and old, wealthy and poor, etc.) which helps to identify Implicit Bias.  You can try it here:  https://implicit.harvard.edu/implicit/ .

All of this raises important questions.  Can we quantify the effect of Implicit Bias on healthcare outcomes?  Can we accurately measure Implicit Bias and develop processes to counter its negative effect?  What can each of us do as an individual who cares about providing consistently good care?  I’ll try to address some of these questions in next month’s newsletter.  In the meantime, I welcome your feedback.

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Noah Nesin, MD

Dr. Nesin, Vice President of Medical Affairs for PCHC, is a family doctor with 30 years of experience.

One Response to “Federally Qualified Health Centers”

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    Eric Buch

    Very interesting. I appreciated the brief FQHC history lesson and the opportunity to try one of the implicit bias tests. It seems to me that it’s challenging enough to address all of the explicit issues we face, now you want us to go after implict ones as well? Again, thanks for sharing. Eric

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