Join us in learning from our wonderful guests, Dr. Denise Connor (hospitalist and groundbreaking leader in curriculum development for diagnostic reasoning and anti-oppression) and Dr. Cristina Gonzalez (hospitalist and internationally renowned expert in the development of skills-based curricular interventions in implicit bias recognition and management). Dr. Connor and Dr. Gonzalez teach us how to define, identify, and mitigate disparities in diagnostic decision-making and reasoning in order to attain greater diagnostic equity for all patients.

This podcast episode is funded in part by the Gordon and Betty Moore Foundation through a grant program administered by the Council of Medical Specialties Societies. Additional resources on this topic are available through the ACP Online Learning Center.

​Click here to earn CME/MOC credits for listening to the episode ​

Learning Objectives
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1. Define disparities in diagnosis and diagnostic reasoning.
2. Review contributing factors to disparities in clinical diagnosis.
3. Outline steps individuals can take to reduce disparities in diagnostic reasoning.
4. Discuss organizational strategies to mitigate diagnostic disparities to achieve diagnostic equity.

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Show Notes
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[00:00] Introduction
  • Co-hosts Dr. Ricardo Correa and Dr. Elisa Choi introduce the topic and expert guests Dr. Denise Connor and Dr. Cristina Gonzalez. 

[06:16] Defining Disparities in Diagnostic Decision-Making and Reasoning
  • Dr. Connor discusses inequitable differences in the processes or outcomes of diagnostic care that are experienced by patients based on their social identities, economic, environmental, or structural factors.
  • Dr. Gonzalez discusses eliminating the current disparities in timeliness and accuracy of diagnosis, and communicating the diagnostic decision process. Also, achieving diagnostic excellence equitably across populations.

[10:37] Working to Reduce Diagnostic Disparities
  • Dr. Connor describes her work in educating students and trainees about being intentional in the diagnostic process, awareness of context, and potential communication barriers that get in the way of equitable diagnoses. 
  • Dr. Gonzalez shares that it is important to recognize implicit bias in clinical encounters and manage contextual factors. Successfully managing bias and demonstrating respect can lead to restoration of a relationship and reconnection with patients. 
  • Simulated patient encounters help demonstrate that outcomes are worse for black standardized patients when compared with white standardized patients. Medical decision making is also worse by physicians.
  • Empathy and intentional communication allows patients to share additional information and leads to better outcomes during the diagnostic process. 
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[22:38] Different Approaches to Decreasing Inequities in Diagnostic Decision-Making
  • Dr. Choi inquires about the potential effect of language barriers and other factors on diagnostic decision-making. Dr. Gonzalez shares that the Implicit Association Test (IAT) has limitations. A skills-based behavioral approach is a method to intentionally check in if a patient interaction has changed. It can be used to reset and reconnect regardless of the underlying reason for perceived bias.
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[26:30] Contributing Factors to Disparities in the Diagnostic Process
  • Dr. Connor shares that the quality of communication directly impacts history-taking and diagnosis and even a first question is significant (Harris and Robinson, 2006).
  • The background, identity, and social identities of the clinician and the patient affect an interaction. Recognizing that basic communication strategies may not be applied equitably all the time is important as are mitigating barriers before a dialogue begins to elicit a more full illness story from a patient.
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[31:40] Health-Related Stereotype Threats
  • Dr. Connor describes health-related stereotype threats that interfere with communication and access to excellent care, especially when patients adjust their behavior to mitigate these threats.
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[34:03] Discussion of Implementing Strategies into Practice 
  • Dr. Correa inquires about the challenges of implementing these strategies for practicing clinicians. 
  • Dr. Connor emphasizes that additional clarity is needed for incredibly busy clinicians and who may be burned out on why different communication approaches are needed to decrease disparities, one of the most significant healthcare issues of our time. Both individual efforts and institutional support are required.
  • Dr. Connor shares some potential strategies to help patients that have experienced healthcare discrimination or had negative experiences with the healthcare system in the past. 
  • Dr. Gonzalez describes the importance of building clinicians’ skill sets in ways that can be integrated into usual clinical workflows with minimal disruption. Simulated settings can streamline the transition to actual patient care settings and decrease any unintended consequences.
  • Hopefully future cost-effectiveness analysis will demonstrate that skill-building results in more equitable care of patients and better outcomes for additional system buy-in. 
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[41:22] Individual and Organizational Strategies to Decreasing Diagnostic Inequities 
  • Dr. Connor shares that more research and funding is needed in this area. She also stresses the importance of strategies and mitigation solutions, including the use of community-based, community-led research, and community participatory research allowing patients to become partners in this work.
  • For clinicians, Dr. Connor discusses intrapersonal (what can I do to work on myself to get better?); personal (what can I do in my communication, in my interactions with my patients, their families, and with my colleagues?); and then the systems institutional and societal level strategies. All will needed to move towards diagnostic equity.
  • The development of communication skills at the interpersonal level is of vital importance for patients to get an accurate diagnosis and the care and treatment they need. Advanced communication training builds new skills for even experienced clinicians. 
  • Ensuring that your individual institution is actually collecting data to identify diagnostic disparities and diagnostic outcomes with disaggregated data is also essential as many different social identities are linked with disparities including gender and patients with disabilities.
  • Dr. Gonzalez describes the potential for implicit bias recognition and management, as well as skill-building to be a team sport in achieving diagnostic excellence. Training and expansion of the clinical toolbox can occur in the team setting.
  • In addition to more skill-based interventions being deployed, Dr. Gonzalez also discusses normalizing discussions about providing inequitable care or witnessing potentially inequitable care being delivered within a collaborative, safe, and respectful environment.
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[52:19] Closing Remarks
  • Dr. Correa and Dr. Choi share closing thoughts. Starting with yourself and then expanding your circle of influence will make a difference in achieving diagnostic excellence and decreasing diagnostic disparities together. More resources are available in the references to continue the discussion and learning process.
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[55:14] Outro
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Email: thedeishift@gmail.com
Website: www.thedeishift.com

Additional Resources:
1)  ACP Online Learning Center - Diagnostic Reasoning, Tools, Techniques​
​2)  Ark, T., et al. Gonzalez, C. Heartache or Bellyache? Epigastric Pain, Communication Skills, and Implicit Bias: Can We Uncover an Association in the Simulation Lab? Academic Medicine 97(11S):p S118, November 2022.
https://journals.lww.com/academicmedicine/fulltext/2022/11001/heartache_or_bellyache__epigastric_pain,.20.aspx

3)  Connor D, Dhaliwal G. Moving upstream to address diagnostic disparities. BMJ Quality & Safety Published Online First: 06 July 2023. https://qualitysafety.bmj.com/content/early/2023/07/05/bmjqs-2023-016130.long

4)  Burgess, et al., Stereotype Threat and Health Disparities: What Medical Educators and Future Physicians Need to Know. J Gen Intern Med. 2010 May; 25(Suppl 2): 169–177. Published online 2010 Mar 30. doi: 10.1007/s11606-009-1221-4. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2847106/

5)  Heritage, J., Robinson, J., The Structure of Patients’ Presenting Concerns: Physicians’ Opening Questions. HEALTH COMMUNICATION, 19(2), 89–102. https://www.sscnet.ucla.edu/soc/faculty/heritage/Site/Publications_files/OPENING_QUESTIONS.pdf

6)  Balogh, EP, Miller, BT, Ball  J, eds. Improving diagnosis in health care. National Academies Press, 2015.

7)  Singh  H, Schiff  GD, Graber  ML, Onakpoya  I, Thompson  MJ. The global burden of diagnostic errors in primary care. BMJ Qual Saf 2017;26:484-94. https://qualitysafety.bmj.com/content/26/6/484

8)  Cheraghi-Sohi, S., Holland, F., Singh, H., et al. Incidence, origins and avoidable harm of missed opportunities in diagnosis: longitudinal patient record review in 21 English general practices. BMJ Qual Saf 2021;30:977-85. https://qualitysafety.bmj.com/content/30/12/977

9)  Gunderson  CG, Bilan  VP, Holleck  JL, et al. Prevalence of harmful diagnostic errors in hospitalised adults: a systematic review and meta-analysis. BMJ Qual Saf 2020;29:1008-18. https://qualitysafety.bmj.com/content/29/12/1008

Organizations: 
National Academy of Medicine Scholars and Diagnostic Excellence Program: https://dxexscholars.nam.edu/
Academy of Communication in Healthcare (ACH): https://www.achonline.org/
Gordon and Betty Moore Foundation: https://www.moore.org/
Council of Medical Specialty Societies: https://cmss.org/

Credits:
Course Directors/Co-Hosts: Dr. Ricardo Correa, Dr. Elisa Choi                                                                  
Guests: Dr. Denise Connor, Dr. Cristina M. Gonzalez                                                              
Executive Producer: Dr. Tammy Lin                                                                                                                 
Co-Executive Producers: Dr. Pooja Jaeel, Dr. Maggie Kozman                                                                
Senior Producer: Dr. DJ Gaines                                                                                                                 
Associate Producer: Dr. Candace Sprott                                                                                                   
Production Assistants: Erynn Beeson, Nikhil Thope                                                                           
Website/Art Design: Ann Truong                                                                                                                  
Music: Chris Dingman

Disclaimer: 
The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with. 
The DEI Shift podcast is proudly sponsored by the American College of Physicians, Southern California Region III Chapter. Our theme music is brought to you by Chris Dingman. Learn more at www.chrisdingman.com.
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Contact us: thedeishift@gmail.com, @thedeishift, thedeishift.com

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Disclaimer

.The DEI Shift podcast and its guests provide general information and entertainment, but not medical advice. Before making any changes to your medical treatment or execution of your treatment plan, please consult with your doctor or personal medical team. Reference to any specific product or entity does not constitute an endorsement or recommendation by The DEI Shift. The views expressed by guests are their own, and their appearance on the podcast does not imply an endorsement of them or any entity they represent. Views and opinions expressed by The DEI Shift team are those of each individual, and do not necessarily reflect the views or opinions of The DEI Shift team and its guests, employers, sponsors, or organizations we are affiliated with.