Reprinted from the summer 2021 Issue of The Ohio Family Physician
By: Elizabeth G. Baxley, MD, Executive Vice President, American Board of Family Medicine (ABFM); and Ashley Webb, ABFM Director of Outreach
As our nation finds itself in a period of renewed focus on social justice and equity, the role of family physicians, in both their practices and communities, could not be more critical in helping to address inequities in direct care delivery, patient outcomes, and the need for all people—no matter their zip code—to have similar opportunities to access resources to help achieve health and wellness. The evidence clearly documents disparities in health based on race, ethnicity, religion, sexual orientation and gender identity, and disability. The Institute of Medicine’s 2003 report entitled Unequal Treatment1 demonstrated the degree to which these disparities were not just the result of social policy, but also of intrinsic bias in the health system. What we now know is that systemic racism contributes to poorer health outcomes and increased mortality – a fact that was dramatically illustrated for all of us during the COVID-19 pandemic. Mindful of the many individuals and organizations who are already working to contribute necessary solutions to this problem, the question for the American Board of Family Medicine (ABFM) is: What is the role of a certifying board in addressing health disparities and their underlying causes?
In 2019, the ABFM created a six year strategic plan in which it committed to support efforts addressing “the social contract, advocacy, health equity, and social drivers of health at all levels of education.” As with many professional organizations, as well as private companies, the ABFM has re-doubled its work in these areas, beginning with an introspection of the ABFM’s current efforts and an analysis of the myriad ways in which specific initiatives might contribute meaningful improvements in diversity, equity, and inclusion, both within the organization and in support of family physicians across the nation who are on the front lines of this important work. In this article, we wish to highlight some of the current efforts and preview additional ones to come:
- After the death of George Floyd, Brianna Taylor, Ahmaud Arbery, and countless others, we heard from Diplomates who were impacted by the unrest directly in their practices and communities, and others who simply wanted to be doing more to address inequities in care delivery or disparate outcomes among various populations of patients – often seeking help with how to begin the process of doing so. In response, the ABFM developed and deployed a unique, self-directed Performance Improvement (PI) activity on health disparities/equity. This activity provides a mechanism for physicians to meet their PI requirement by selecting an approach to improving the way their practice addresses social determinants of health; health equity (broadly defined); and/or systemic ways in which they assure that patient access, experience, and care are equitable. Any dimension of care that supports the goals can be utilized, including addressing disparate clinical outcomes by race/ethnicity, socioeconomic status, sexual orientation/gender identity, disability, rurality, and other vulnerable, underserved populations. Additionally, they can choose to work on understanding implicit bias or systemic barriers to care within their practice or system that impact access to culturally conscious care delivery, or to contribute to community interventions focused on broader populations than those served by their own practice. In this activity, the ABFM also provides a list of potential resources that a Diplomate can access in support of a PI activity in this area.
- Another common theme the ABFM heard among Diplomates and colleagues was “I need to better understand the issues involved in social inequities and systemic racism in order to improve how I care for patients.” To this end, the ABFM has begun working with the American Academy of Family Physicians (AAFP) to develop a Knowledge Self-Assessment activity that leads to ABFM certification credit. The AAFP has a robust set of resources within its Center for Diversity and Health Equity that can help bridge gaps in knowledge and understanding, with a goal of actualizing new approaches to care, while also earning certification points and continuing medical education credit. The ABFM anticipates that these will be available for all Diplomates before the end of this year.
- Understanding any potential differential impact on certification in relation to participation, learning, and assessment outcomes has been part of the ABFM’s work for nearly eight years. During this time, it has collected data on Diplomate race and ethnicity in order to assess whether any bias exists in the ABFM’s examination questions using a panel of experts representing a diverse group of family physicians. When items that are believed to be differentially bias responses by racial or ethnic background, based on both item performance and expert opinion, they are removed from the item bank. Additionally, the ABFM is researching overall examination performance to see if any differences exist across different demographics of family physicians, and will address those findings if differences are found.
- ABFM researchers have been able to include this information on race and ethnicity, along with gender, age, practice type, location, and scope, to better understand the ecology of the specialty over time. Knowing the importance of cultural concordance on patients’ experiences and outcomes, it is imperative that the ABFM contributes to supporting and measuring the impact of recruiting and training a more diverse family physician workforce that aligns with the population of our nation and of their local communities.
- Finally, the ABFM, like many organizations, is looking inward to identify and address opportunities to improve its own personnel composition and experience within the workplace. This includes not only the core ABFM staff, but the many family physician volunteers who contribute much to the quality of certification programs and activities, as well as its governing Board of Directors. The ABFM, also, needs to learn and grow in the space of diversity, equity, and inclusion; and it is the ABFM’s commitment to do so.
The business literature is clear that the more diverse the organization, the better its overall performance. Diversity of ideas, across many dimensions, supports greater understanding and equitable opportunity for all. There is no better time for the house of medicine to embrace this knowledge and focus it on improving health outcomes, equitably, for all we serve.
References available on the Ohio Academy of Family Physicians website.