Part 5 - This End Is Just The Beginning

Resilient remediation of inequities will require us to deconstruct the social fabric that perpetuates pervasive prejudice and bias.

Resilient remediation of inequities will require us to deconstruct the social fabric that perpetuates pervasive prejudice and bias. Difficult conversations will have to be had among colleagues. Uncomfortable moments of learning will be inevitable in order to break down barriers between providers and patients. Those in leadership positions with the authority to change systemic factors (e.g., policy), will need to be continuously held accountable and asked to consider the most marginalized over profit, if they are to truly live in alignment with the Hippocratic Oath to do no harm. Those not in leadership positions will need psychological strategies to have difficult conversations with their superiors -- in service of patient safety. 

This series was developed to empower change at all levels of the power structure through easily accessible & actionable frameworks. We aim to address both what the individual can do in the moment as well as long-term institutional strategies. 

The below are definitions and terms to empower your voice and your advocacy. Continue to follow this blog to hear the voice of others experiences, the sharing of successes and struggles, and the research related to institutional change.

Terms and Definitions: 

  • Institutionalized “isms” are implicit forms of oppression that persist throughout our healthcare system. These entrenched “-isms” are foundational to hostile work and educational environments. “-isms” directly and indirectly impact patient care. Directly “-isms” cause inequitable care. Indirectly they compromise patient care by means of hostile work environments interfering with the healthcare team’s ability to care for patients. 

    • It is important to note that each of us have our own unique history with respect to each of these “-isms”. Additionally, these “-isms” manifest in an intersectional manner, which is what makes them a complex repertoire to remediate in context and requires the topic of isms to be more openly discussed. 

    • Classism: “a belief that a person's social or economic station in society determines their value in that society. Behavior that reflects this belief : prejudice or discrimination based on class”.

    • Racism: “a belief that race is a fundamental determinant of human traits and capacities and that racial differences produce an inherent superiority of a particular race”

      • Race is a social construct, not a biological trait.

    • Sexism: “prejudice or discrimination based on sex or gender, especially against women and girls.”

      • Is feminism a “-ism”? No. Although it ends in “-ism” it is inherently different because it is a term that is not anti-male. “Feminism: the belief in social, economic, and political equality of the sexes. Although largely originating in the West, feminism is manifested worldwide and is represented by various institutions committed to activity on behalf of women’s rights and interests.”

    • Ageism: “is the stereotyping and discrimination against individuals or groups on the basis of their age. Ageism can take many forms, including prejudicial attitudes, discriminatory practices, or institutional policies and practices that perpetuate stereotypical beliefs.”

    • Ableism: “is the discrimination of and social prejudice against people with disabilities based on the belief that typical abilities are superior. At its heart, ableism is rooted in the assumption that disabled people require ‘fixing’ and defines people by their disability.”

    • Heterosexism (homophobia): “an ideological system that denies, denigrates, and stigmatizes any non-heterosexual form of behavior, identity, relationship, or community”

    • Sizeism: “discrimination or prejudice directed against people because of their size and especially because of their weight.”

    • Antisemitism: “is a certain perception of Jewish individuals, which may be expressed as hatred toward Jewish individuals. Rhetorical and physical manifestations of antisemitism are directed toward Jewish or non-Jewish individuals and/or their property, toward Jewish community institutions and religious facilities.”

  • Intersectionality--a term first introduced by social justice scholar, Kimberle W. Crenshaw in 1989--notes the ways in which isms intersect and lead to the compounding impact of oppression. 

 

The Invisible reinforcers: Gaslighting, Stereotype threat, Microaggressions, and Zero-sum game. These are the numerous patterned socially reinforced defense mechanisms that perpetuate “-isms”. 

  • Gaslighting: a term used that came out of Gas Light, a 1938 film, subsequently adopted into colloquial language in the 1960’s, and formally used in psychology literature since 1970. 

    • Gaslighting is a form of psychological abuse that undermines an individual’s self-confidence, self-trust, and sense of security. 

    • Gaslighting takes many forms but can be simplified into the subtle ways we invalidate and undermine someone else. This has become a pervasive tool to exhibit prejudice while appearing professional.

  • Stereotype Threat: A psychological threat causing someone to fear doing something or being in a situation which could be viewed as conforming to a negative stereotype associated with their presumed social group (1995 Claude Steele and Joshua Aronson). 

  • Microaggressions overlap with gaslighting but are themselves a different entity. Microaggressions are forms of communication (verbal and/or behavioral) that are hostile, derogatory, and perpetuate negative attitudes. Microaggressions can be intentional or unintentional (Freeman, & Stewart, 2018).

  • Zero-sum game is “a situation in which one person or group can win something only by causing another person or group to lose it.” 

  • Toxic Individualism: “A lack of empathy, an indifference to human vulnerability and suffering, to misfortune and lack of opportunity and circumstances, to exploit and ignore these realities can harm everyone”

Author: Shay Strauss, MD is a third year emergency medicine resident at Brown Emergency Medicine.

Faculty Reviewer: Taneisha Wilson, MD is an attending physician and educator at Brown Emergency Medicine.

Health EquityShay StraussInstitutional Isms, Health EquityComment