Cleveland pre-med students learn about bias to combat health disparities

Ideastream Public Media’s health team is connecting the dots on how racism contributes to poor health outcomes in the Cleveland area. Cleveland State University officials tell us about a program geared to help students recognize their implicit bias and understand how systemic racism affects health in urban areas before they enter medical school.

On a recent autumn afternoon at Cleveland State University, sunlight streamed through the windows of a classroom where Tatiana Pascol, a second-year student in CSU’s urban health certification program, was listening to a lecture about redlining.

Redlining is a policy where banks in the 1930s declared majority Black neighborhoods undesirable to live in, resulting in decades of low investment in those communities. 

Pascol is a recent graduate of Bowling Green State University, and she wants to become a physician.

But before she heads off to medical school and puts on her white coat, she’s spending two years in CSU’s Pathways To Practice program learning about historical policies like redlining that have contributed to racial health disparities for decades. She is also learning to recognize her own implicit biases, she said.

“We always say, ‘Oh, I'm going to go in there and not have any implicit biases,’ and so on and so forth, but there are so many underlying things that we don't realize within ourselves and consider that we end up projecting onto others,” Pascol said.

Pascol, who is biracial and was raised by a single mom in Painesville, said even she is surprised by how much she has learned about her own implicit bias.

“I'm getting a perspective that I thought I had, until I realized I didn't have [it] at all,” Pascol said.

Every semester, students are required to take the Urban Health course, which is geared to get students thinking about all of the factors that influence a person’s health, such as where they live and what resources they have access to, said Lena Grafton, professor and coordinator of the course.

Neighborhoods that were formerly redlined in Cleveland are now some of the most impoverished, and report poor health outcomes like infant mortality and low life expectancy, she said. 

The students learn empathy by spending a day in the life of a poor single parent

To demonstrate this, students recently completed an assignment called “A Day In The Life,” where they had to envision themselves as a single parent from a poor neighborhood seeking treatment, or a physician who lives in the suburbs but practices in inner-city Cleveland.

“They had to identify and process all the nuances that's related to that individual based on their role,” Grafton said. “So for the single mom, they had to develop what would happen throughout the day, and I would give them different scenarios that they would have to fine tune.”

A PowerPoint slide shows the two different options students could choose for their Day In The Life assignment: a physician in an outer-ring suburb or patient in an urban neighborhood in Cleveland. [Anna Huntsman / Ideastream Public Media]

Scenarios like childcare falling through, or the patient not being able to secure transportation - making it harder to make their doctor’s appointment, Grafton said.

Pascol, who picked the role of the physician, said students in some cases had to go out in the community and research how much these resources cost and where they are located.

“It started off with just little information. I was like, ‘why do I have to explain what I'm eating? Or like, what time I will get up? The route I'm taking? I don't get it,’” Pascol said.

Pascol said she eventually realized the point of the assignment was to show that a physician in a wealthier suburb, such as Solon, may have skewed perceptions of how challenging it is for patients in urban neighborhoods to access resources like healthy food and transportation.

“When you talk to students who chose the single head of household, many of them felt very restricted about some of the choices that they had. And when you talk to the students who chose the role of the physician, they felt empowered. They felt like there were limitless options that were available to them as a physician,” Grafton added. “That was one of the ‘aha’ moments - that even when … patients might have had the understanding of how to have access to health care, there were still some limitations for them.”

CSU student Sam Perry (second from right) discusses takeaways from the Day In The Life assignment. [Anna Huntsman / Ideastream Public Media]

Educating students before they enter medical school about their biases and the obstacles patients in underserved areas face will help them treat patients more holistically, Grafton said, with a better understanding of all the factors that influence health.

“I want to make sure by the time the students leave the program that they understand … that everyone deserves the right to health care and it is their role to meet people where they are,” she said.

For example, a doctor might assume a patient who misses appointments doesn’t care about their health – looking past the fact that they couldn’t afford to take off work or get transportation, Grafton said. Research about provider bias shows these assumptions may cause doctors to treat patients unfairly, she said.

For Grafton, this is personal.

“That single mom, that single head of household, that was me,” she said. “Many times, I was not given the respect because I was a young mom from an urban community, and possibly not even given all the options that they would have given another person with the same condition.”

Research shows provider bias leads to health disparities

Studies have confirmed that Black and brown patients are often viewed differently and not given the same level of medical care as white patients, and provider bias is one of the biggest issues perpetuating health disparities today, said Dr. Gregory Hall, director of the National Institute for African American Health.

“This is not about American history, this is about last week at the doctor. You know, this is like … they're having these experiences right now and are frustrated about it right now are vowing to not go back to the doctor again,” Hall said. “And then, they wait until it becomes, whatever is wrong with them, is a complete disaster.”

For instance, Hall said physicians may assume a Black patient will not have good health insurance, so they will decide not to prescribe them a certain medication – which can further exacerbate poor health outcomes.

It is crucial for providers to take the time to ask the right questions and listen to their patients to avoid these potentially harmful assumptions and biases, he added.

While most Cleveland-area hospitals are now offering bias training to their staff, having trainings and classes for students before or during medical school is the key to making systemic-level change, Hall said.

But, many pre-med and medical schools claim to not have the capacity for implicit bias training or classes on top of the already rigorous clinical curriculum, he said.

"I taught pre-med students and med students … some of them still come with a lot of bias,” Hall said. “They come from families that have a lot of bias and it's ingrained in them. And in trying to displace that, it almost seems like we become this, you know, “left-wing” teacher … and all of a sudden it becomes this bigger political thing, which I'm always trying to stay above.”

Lena Grafton, professor and coordinator of the Urban Health course, writes some of the discussion points on the board that students learned during their assignment. [Anna Huntsman / Ideastream Public Media]

Pascol’s biggest takeaway from the Day in the Life assignment, she said, is the importance of listening to patients without judgement and meeting them where they are. Throughout the course, she has also learned to recognize and overcome her own biases, which will help her immensely when she goes to medical school and starts focusing on the clinical side of the profession, she said.

“As much as you only get one side of somebody, there's so much more going on within them, and just to simply just be patient and build that relationship with them,” Pascol said. “You should give them the care that they deserve, no matter what the attitude, feeling, what their reasoning is, why they do what they do. That doesn't matter - you are there to serve them and help them.”

Hall said another way to help reduce racial health disparities is for more people of color to become doctors.

Pascol is guaranteed a spot at Northeast Ohio Medical University (NEOMED) when she completes the CSU program, and plans to focus on emergency or surgery.

Like Pascol, some of the students in the program are just out of undergrad, while others are switching careers. The program is for students who have not yet started medical school and want to eventually practice in an urban community.

The program began in 2013, so some of Grafton's earliest students are now completing residencies.

“When they got to medical school, they saw that many of their counterparts had no background in social determinants of health and health equity. And so they were ahead of the game," she said.

The CSU program is in partnership with Northeast Ohio Medical University (NEOMED). In addition to Pascol, about half of the 35 students in each cohort have received a guaranteed spot at NEOMED after they complete the program, Grafton said.