We discuss healthcare equity in medical education the same way we discuss systemic racism in society.
Both are perceived to be problems that originate subtly and manifest later as disparate outcomes. Both often dissolve into heated arguments. But the two are fundamentally distinct.
At its core, systemic racism alludes to implicit biases affecting the implementation of rules and policies in society. These subtle tendencies lead to different decisions and behaviors. These subtle actions, often transpiring subconsciously, lead to disparities in society across racial lines.
One of the hallmarks of our modern society is the ability to address and rectify these subtle patterns of discrimination.
But when we apply the same ability to healthcare equity, we create more problems than solutions.
Recently, the American Association of Medical Colleges (AAMC) unveiled the AAMC Center for Health Justice, an organization that addresses healthcare inequities in society by educating medical students to recognize and actively address these inequities as they appear in society.
This is the latest and largest effort to integrate the study of healthcare equity into medical education. The AAMC should be applauded for their efforts. Healthcare is changing and medical education should change accordingly.
But a critical pattern found in societal change is the tendency to change too much.
When we apply principles of equity to healthcare, we often conflate equity with equality. And when we discuss equality in healthcare, we often impose standardizations upon people.
When taken to an extreme, healthcare equity is perceived to vary inversely with many patients’ sense of autonomy. Patients value the right to healthcare and value equal access to healthcare resources. But when those same rights become standards, patients perceive the original value as an infringement upon individual autonomy.
Much of the healthcare disparity we find in society is a complex blend of systemic problems in society and personal decisions made among similar groups of individuals. In our efforts to integrate the study of healthcare equity into medical education we should not conflate broad societal inequities with individual liberties.
Patients have a right to choose. They have a right to be noncompliant, to make unhealthy decisions, and to forego medical treatment against the advice of their physician. This is a part of healthcare.
The study of healthcare equity should recognize that not all people make medical decisions similarly. That true equity in healthcare recognizes certain amounts of variability in patient outcomes – a function of aggregated individual patient decisions.
When studying healthcare equity, we must be keen to differentiate disparities in outcomes based upon addressable societal problems from disparities based upon patients’ rights to make individualized healthcare decisions. Balance the tendency to standardize healthcare with the variability emanating from patient decisions.
Equity is not equality. True healthcare equity recognizes that patients have a right to make decisions that may not adhere to established standards of care, leading to inevitable disparities in clinical outcomes.
We will never have absolutely equal patient outcomes across all genders, races, and socioeconomic statuses. Nor should we try to pursue it. That is not the goal of healthcare equity.
The goal is to optimize access to care and to offer healthcare resources, relative to each individual’s right to choose to utilize that access and those resources.
That is true healthcare equity – a balance of clinically sensible policy and individual liberty.
