Addressing clinician well-being has reached a new level of urgency during the COVID-19 pandemic. Record numbers of clinicians are experiencing moral distress from critical resource shortages, emotional distress from delivering care to profoundly ill patients while being socially isolated, and role stress from the loss of child care or other supports. These stressors have been compounded by the deaths of Breonna Taylor, George Floyd, and others, heightening awareness of long-standing, unaddressed structural racism that impacts both clinicians and patients.
Work culture heavily influences clinician well-being, and changes that improve organizational work culture and create seamless workflows have been successfully implemented to reduce burnout and increase well-being. Similar arguments can and must be made for healthcare organizations to adopt antiracist practices that result in sustained meaningful change, because for too many clinicians, racism is a defining component of work culture.
Why, in the midst of a pandemic, must we immediately prioritize antiracism and inclusion? There are numerous benefits for patients and clinicians. Studies have demonstrated that race-concordant patient-clinician dyads have better outcomes and that inclusive, diverse teams provide better patient care and are more innovative. Given that the increasingly diverse U.S. population needs a similarly diversified clinician workforce to adequately meet its health care needs, barriers to recruitment, retention, advancement, and career fulfillment of clinicians of color must be removed.
These barriers are manifold. Some are ostensibly subtle, such as disparaging remarks by peers, supervisors, or patients, but they are frequent, disrespectful, and rarely unaddressed by witnesses or leaders. More insidious barriers are products of our system. For example, qualitative evaluations of medical students have been found to differ by race, even when controlling for performance on standardized tests. This can negatively affect matching into competitive residency programs and lead to imposter syndrome. Additionally, descriptive evaluations of residents differ by race; for people of color, an increased focus is often placed on personal attributes rather than competence. Reliance on these purportedly objective measures that may be racially biased can have lifelong consequences, since evaluations affect selection for career-accelerating leadership positions, such as chief resident or fellow. These inequities and injustices have long-lasting effects on learners' well-being and professional fulfillment and underscore the interdependence of racial equity and professional well-being.
This linkage continues after training. Health care workplaces often undervalue the importance of mentorship, committee membership, and efforts in diversity and equity, and this can hold back prospective leaders of color from career advancement. Performance metrics that help determine physician pay are affected by race and gender, such that clinicians of color may be underpaid, or, worse, falsely identified as inferior clinicians.
Recognition of the intersectionality of these issues is important as well, with women physicians of color reporting that they are mistaken for nonphysicians and need additional specific skills to be recognized as clinical team leaders. They also describe being demonized; or labeled as angry, aggressive, or intimidating when they take positions that support change or suggest needed improvements.
Another problem is clinical settings with policies and procedures resulting in reduced access to advanced care for some patients, including people of color. This signals to clinicians that patients who look like them are not valued. Clinicians of color then carry yet more invisible weight; they must act as ambassadors to patients that look like them, reassuring these patients that health care systems will protect their interests, while sometimes witnessing the opposite. This is paired with the psychological burden resulting from the implication that being a clinician of color comes innately with the skills of how to garner the trust of patients of color, while offering little support to those clinicians when they are unable to shield their vulnerable patients from systems flaws they are not responsible for.
These very brief highlights demonstrate that racism-based threats to professional well-being are pervasive and ingrained. Focusing on creating a diverse health care workforce without prioritizing antiracism results in professional disparities paralleling the health disparities experienced by patients. These constructed systems can be deliberately addressed and corrected. A key will be greater transparency in evaluation, promotion, and compensation criteria, as well as in racial differences in professional advancement, and in outcomes following a commitment to undo these systems. Robust antiharassment and antidiscrimination policies with accountability for addressing harassment, discrimination, and bias are also critical to both signal and ensure a supportive work and learning environment.
In addition to realizing the potential of a more diverse, equitably treated workforce to improve the care of patients and our learning environments, it is also morally right to remove barriers to success that stem from structural inequities. For too long, we have allowed these to persist, and we all have a duty to challenge, remove, revise, and recreate processes, policies, and procedures that hold back peers, learners, and ourselves.
Burnout is an entrenched problem with insidious impact on antiracism efforts even among clinicians who may not overtly face racism and inequities. Clinicians in environments where they struggle to handle their workloads or meet productivity metrics aren't likely to have the capacity to also address structural racism. Organizations and individuals working on clinician well-being or antiracism in health care must ally with each other to have the best chance of success. Some models for doing so exist, including the Center for Human and Organizational Potential at Southern Illinois University in Springfield, the Center for Professional Health at Vanderbilt University in Nashville, Tenn., and the Physicians Foundation's Women's Wellness through Equity and Leadership Project. Additional models and true road maps are urgently needed in both high- and low-resource settings.
Racism and well-being in the health care workforce are linked, and efforts to address clinician well-being should not be isolated from antiracism efforts. A longitudinal commitment is needed by organizations, acknowledging their duty to act as a partner in antiracism and well-being efforts and codifying that duty to peers, education and training, the health care workforce, patients, and payers. Bias, discrimination, and other threats to clinician well-being are the product of our system and will only be resolved through comprehensive and sustained system-level improvement efforts. The profession and patients deserve it.