Us and Them: A Pain Researcher Discusses Why Diversity in Health Care Matters

Jun 5, 2013, 10:00 AM, Posted by Martin Schiavenato

Martin Schiavenato, PhD, RN, is an assistant professor at the University of Miami School of Nursing and Health Studies, and a Robert Wood Johnson Foundation Nurse Faculty Scholar. This is part of a series of posts looking at diversity in the health care workforce.

It is human nature.  The old adage “opposites attract” is a myth; in fact, the contrary is true.  We feel more comfortable with and welcome those who share in our definition of “us” than not.  Accordingly, this also forms the basis to how we define “them.”  It is intuitive that we feel connected to and prefer those who share in what we believe to be our experience, and that we are suspicious and even spurn those who we feel do not.  This phenomenon is referred to by psychologists as “in-group bias.”

"When it comes to providing best clinical care, race and culture matter."

In my field of pain research, there is ample documentation of how clinician preferences impact the care of patients.  Clinicians better address pain management in patients who “match” their reference group or their preferences more closely. For example, better pain care is given to patients who speak the same language, are of similar socioeconomic status, or even those considered more attractive to the clinician. Subtle cues from the patient—their physical appearance, the circumstances that brought them to seek care, their behaviors and expressions—all will have a consequence on the nature of the care that they will receive.  Thus, the race and culture of the clinician have the potential to be significant contributors in the quality of care that a patient will receive.  This inherent tension between “us” and “them” may be particularly relevant in a country with a history of institutionalized racism.

Patients with sickle cell disease (SCD) suffer from an incapacitating symptom called a vaso-occlusive crisis (VOC).  The VOC is caused by abnormal sickled or crescent-shaped red blood cells (normally round or doughnut-shaped) which do not circulate well, occlude blood vessels, and subsequently starve body tissue of life-sustaining oxygen.  This experience is characterized by excruciating pain. Unfortunately, and due to multiple factors, the pain in patients with SCD is consistently reported to be poorly treated.  A significant contributing factor to poor pain treatment in these patients is thought to be a mismatch between the race and culture of the patient and clinician. The overwhelming majority of patients with SCD in the United States are African American, while African Americans are underrepresented above and beyond their expected minority numbers in the ranks of health care providers.  Significantly, poor pain treatment translates beyond personal suffering and into prolonged hospitalizations and unnecessary costs.    

Let me clarify.  I am not saying that clinicians are inherently racist, or that a mismatch between patient and clinician race inevitably leads to poor clinical outcomes.  Nor am I advocating that clinicians should only care for those patients they match by race or culture. I am stating that in-group bias marks boundaries of distinction (us and them, familiar and foreign) that must be recognized as limits to our understanding and to our ability to provide best care. When it comes to providing best clinical care, race and culture matter.

Diversity is generally and rightfully celebrated for its differences; it adds flavor, color, and spice to what would be an otherwise homogenous landscape.  The objective of this entry is to highlight the other side of that coin; the importance that similarities play; the relevance and impact that a common background has on improving health care.  Diversity in health care matters because improved health outcomes will be achieved when the pool of health care providers better reflects the society that it serves.  


This commentary originally appeared on the RWJF Human Capital Blog. The views and opinions expressed here are those of the authors.