57390 • Structural Racism and Bias: Impact on Patients and Care

Table of Contents

57390 • Structural Racism and Bias: Impact on Patients and Care

How to Receive Credit

Course Overview

Audience

Accreditations & Approvals

Designations of Credit

Course Objective

Learning Objectives

Faculty

Faculty Disclosure

Division Planner

Division Planner Disclosure

Director of Development and Academic Affairs

Director Disclosure Statement

About the Sponsor

Disclosure Statement

Implicit Bias in Health Care

1. INTRODUCTION

2. FOUNDATIONS: UNDERSTANDING STRUCTURAL RACISM

DEFINITIONS

HOW STRUCTURAL RACISM BECOMES EMBEDDED IN SYSTEMS

3. HISTORICAL CONTEXT AND PRESENT-DAY IMPACT

HISTORICAL FOUNDATIONS OF INEQUITY IN U.S. HEALTH CARE

STRUCTURAL POLICIES THAT SHAPE HEALTH TODAY

4. STRUCTURAL RACISM AND HEALTH OUTCOMES

SOCIAL DETERMINANTS OF HEALTH

HEALTH OUTCOME DISPARITIES: THE EVIDENCE

TRUST AND PATIENT ENGAGEMENT

CASE STUDY: PATIENT J'S JOURNEY THROUGH THE HEALTHCARE SYSTEM

5. STRUCTURAL RACISM IN HEALTHCARE SYSTEMS AND CLINICAL PRACTICE

OVERVIEW

CLINICAL ALGORITHMS AND EQUITY CONCERNS

WORKFORCE DIVERSITY AND PATIENT OUTCOMES

EFFECTS ON COMMUNICATION AND PATIENT TRUST

6. STRATEGIES FOR PROMOTING EQUITY

EVIDENCE-BASED APPROACHES TO REDUCING INEQUITIES

CASE STUDY

7. CONCLUSION

8. RESOURCES

9. GLOSSARY OF KEY TERMS

Works Cited

57390 • Structural Racism and Bias: Impact on Patients and Care

Mary Franks, MSN, APRN, FNP-C

www.netce.com

Copyright © 2026 NetCE, All rights reserved.

Racial and ethnic health disparities are not the result of chance or individual patient behavior; they are the predictable product of structural forces that have shaped American healthcare over generations. This course provides learners with a foundational framework for understanding structural racism as a system-level phenomenon distinct from individual prejudice or implicit bias. Drawing on established public health and clinical evidence, the course examines how historical policies, including redlining, medical segregation, and nonconsensual experimentation, continue to drive present-day inequities in chronic disease, maternal health, mental health, and access to care.

57390 • Structural Racism and Bias: Impact on Patients and Care

Education Category. Ethics - Human Rights

Release Date. 09/01/2026

Expiration Date. 08/31/2029

How to Receive Credit

To complete this course for continuing education credit please go to http://www.netce.com/course/3642 in your browser.

For assistance with receiving continuing education credit, please contact us at help@netce.com.

Course Overview

Racial and ethnic health disparities are not the result of chance or individual patient behavior; they are the predictable product of structural forces that have shaped American healthcare over generations. This course provides learners with a foundational framework for understanding structural racism as a system-level phenomenon distinct from individual prejudice or implicit bias. Drawing on established public health and clinical evidence, the course examines how historical policies, including redlining, medical segregation, and nonconsensual experimentation, continue to drive present-day inequities in chronic disease, maternal health, mental health, and access to care.

Audience

This course is designed for all dental professionals.

Accreditations & Approvals

NetCE Nationally Approved PACE Program Provider for FAGD/MAGD credit. Approval does not imply acceptance by any regulatory authority or AGD endorsement. 10/1/2021 to 9/30/2027 Provider ID #217994. NetCE is an ADA CERP Recognized Provider. ADA CERP is a service of the American Dental Association to assist dental professionals in identifying quality providers of continuing dental education. ADA CERP does not approve or endorse individual courses or instructors, nor does it imply acceptance of credit hours by boards of dentistry. Concerns or complaints about a CE provider may be directed to the provider or to ADA CERP at www.ada.org/cerp. NetCE is approved as a provider of continuing education by the Florida Board of Dentistry, Provider #50-2405. NetCE is a Registered Provider with the Dental Board of California. Provider Number RP3841. Completion of this course does not constitute authorization for the attendee to perform any services that he or she is not legally authorized to perform based on his or her license or permit type.

Designations of Credit

NetCE designates this activity for 1 continuing education credits. AGD Subject Code 558. This course meets the Dental Board of California's requirements for 1 unit(s) of continuing education. Dental Board of California course #01-3841-26575.

Course Objective

The purpose of this course is to provide dental professionals with foundational knowledge of structural racism, its impact on healthcare access and outcomes, and practical strategies to promote equity in clinical practice and healthcare systems.

Learning Objectives

Upon completion of this course, you should be able to:

1. Define structural racism and distinguish it from individual prejudice, discrimination, and implicit bias.

2. Describe how historical and contemporary policies contribute to healthcare inequities.

3. Recognize the effects of structural racism on health outcomes, healthcare delivery, and patient experiences.

4. Identify ways structural racism may influence clinical decision-making, organizational practices, and healthcare access.

5. Apply evidence-informed strategies to promote equitable care and reduce health disparities within their professional roles.

Faculty

Mary Franks, MSN, APRN, FNP-C, is a board-certified Family Nurse Practitioner and NetCE Nurse Planner. She works as a Nurse Division Planner for NetCE and a per diem nurse practitioner in urgent care in Central Illinois. Mary graduated with her Associate’s degree in nursing from Carl Sandburg College, her BSN from OSF Saint Francis Medical Center College of Nursing in 2013, and her MSN with a focus on nursing education from Chamberlain University in 2017. She received a second master's degree in nursing as a Family Nurse Practitioner from Chamberlain University in 2019. She is an adjunct faculty member for a local university in Central Illinois in the MSN FNP program. Her previous nursing experience includes emergency/trauma nursing, critical care nursing, surgery, pediatrics, and urgent care. As a nurse practitioner, she has practiced as a primary care provider for long-term care facilities and school-based health services. She enjoys caring for minor illnesses and injuries, prevention of disease processes, health, and wellness. In her spare time, she stays busy with her two children and husband, coaching baseball, staying active with her own personal fitness journey, and cooking. She is a member of the American Association of Nurse Practitioners and the Illinois Society of Advanced Practice Nursing, for which she is a member of the bylaws committee.

Faculty Disclosure

Contributing faculty, Mary Franks, MSN, APRN, FNP-C, has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Division Planner

Mark J. Szarejko, DDS, FAGD

Division Planner Disclosure

The division planner has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

Director of Development and Academic Affairs

Sarah Campbell

Director Disclosure Statement

The Director of Development and Academic Affairs has disclosed no relevant financial relationship with any product manufacturer or service provider mentioned.

About the Sponsor

The purpose of NetCE is to provide challenging curricula to assist healthcare professionals to raise their levels of expertise while fulfilling their continuing education requirements, thereby improving the quality of healthcare.

Our contributing faculty members have taken care to ensure that the information and recommendations are accurate and compatible with the standards generally accepted at the time of publication. The publisher disclaims any liability, loss or damage incurred as a consequence, directly or indirectly, of the use and application of any of the contents. Participants are cautioned about the potential risk of using limited knowledge when integrating new techniques into practice.

Disclosure Statement

It is the policy of NetCE not to accept commercial support. Furthermore, commercial interests are prohibited from distributing or providing access to this activity to learners.

Implicit Bias in Health Care

The role of implicit biases on healthcare outcomes has become a concern, as there is some evidence that implicit biases contribute to health disparities, professionals' attitudes toward and interactions with patients, quality of care, diagnoses, and treatment decisions. This may produce differences in help-seeking, diagnoses, and ultimately treatments and interventions. Implicit biases may also unwittingly produce professional behaviors, attitudes, and interactions that reduce patients' trust and comfort with their provider, leading to earlier termination of visits and/or reduced adherence and follow-up. Disadvantaged groups are marginalized in the healthcare system and vulnerable on multiple levels; health professionals' implicit biases can further exacerbate these existing disadvantages.

Interventions or strategies designed to reduce implicit bias may be categorized as change-based or control-based. Change-based interventions focus on reducing or changing cognitive associations underlying implicit biases. These interventions might include challenging stereotypes. Conversely, control-based interventions involve reducing the effects of the implicit bias on the individual's behaviors. These strategies include increasing awareness of biased thoughts and responses. The two types of interventions are not mutually exclusive and may be used synergistically.

1. INTRODUCTION

This is not a course about blame or individual fault. It is a course about systems—how they were built, how they function today, and what healthcare professionals can do within their roles to create more equitable care. Health inequities, defined as systematic differences in health outcomes between groups, are not random. They are the predictable result of policies, practices, and resource allocation decisions that have advantaged some groups while disadvantaging others over generations [1]. For healthcare professionals, understanding structural racism is not peripheral to quality care but is central to it. Research consistently demonstrates that racial and ethnic minorities experience higher rates of chronic disease, receive less aggressive treatment for the same conditions, and have lower rates of preventive service utilization compared to White patients, even after controlling for individual factors such as income or education [2].

The Institute of Medicine's landmark report Unequal Treatment documented that racial and ethnic disparities in health care are pervasive and extend across virtually every disease category and care setting [3]. Addressing these disparities requires healthcare professionals to look beyond individual patient behavior and examine the systems within which care is delivered.

Reflection

Before proceeding, take a moment to consider the following question:

“What factors outside individual patient choices influence health outcomes in your daily practice?”

Think about the patients you saw last week. What circumstances shaped their ability to arrive on time, follow up on referrals, afford medications, or trust your recommendations? Write down two to three factors that come to mind.

You may have identified things like transportation challenges, insurance coverage, language access, neighborhood resources, or prior healthcare experiences. These are not incidental. They are the terrain through which structural racism operates.

2. FOUNDATIONS: UNDERSTANDING STRUCTURAL RACISM

DEFINITIONS

Precision in language matters when discussing racism and equity. The following definitions draw from established scholarly and public health frameworks.

Race

Today, it is acknowledged that race is not a biological category but is a social and political construct. In fact, there is more genetic variation within so-called racial groups than between them [4]. Race was invented as a hierarchy to justify the economic exploitation of enslaved people and the colonization of indigenous communities. Yet while race is not biologically meaningful, racism (and its health consequences) are very real [5]. The health differences we observe between racial groups are the product of racialized systems, not of race itself.

Racism

Racism is a system of structuring opportunity and assigning value based on the social interpretation of how a person looks (what we call "race") that unfairly disadvantages some individuals and communities, unfairly advantages other individuals and communities, and saps the strength of the whole society through the waste of human resources [6]. This definition, developed by Dr. Camara Phyllis Jones, emphasizes that racism is a system, not merely an attitude.

Structural Racism

Structural racism refers to the totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, media, healthcare, and criminal justice [7]. It describes cumulative and compounding effects of an array of factors that systematically privilege White people and disadvantage people of color. Structural racism does not require individual racist actors. It functions through the policies, laws, and institutional practices that have become normalized over time (Table 1) [8].

Table 1: DIFFERENCES BETWEEN INTERPERSONAL AND STRUCTURAL RACISM

Level

Description

Healthcare Examples

Interpersonal

Racist acts between individuals

Can be intentional or unintentional

A provider using a dismissive tone with Black patients

Making assumptions about medication adherence based on race

Institutional

Discriminatory policies and practices within organizations

Hospital discharge planning that systematically refers patients of color to lower-quality skilled nursing facilities

Structural

The cumulative and compounding effect of multiple institutions operating in concert

Communities with majority-minority populations receiving fewer health resources, fewer specialists, less funding across generations

Source: [8]

Bailey and colleagues define structural racism as the macro-level systems, social forces, institutions, ideologies, and processes that interact with one another to generate and reinforce inequities among racial and ethnic groups [1].

Institutional Racism

Institutional racism refers to the policies and practices within institutions (e.g., hospitals, schools, banks, government agencies) that result in differential outcomes by race, whether or not those differential outcomes were intended [6]. Examples in health care include hospital siting decisions that locate full-service facilities away from communities of color, credentialing processes that create barriers for minority applicants, and clinical algorithms that embed race-based corrections that alter treatment recommendations [9].

Implicit Bias

Implicit bias refers to the attitudes or stereotypes that affect our understanding, actions, and decisions in an unconscious manner [10]. Unlike explicit bias, which is conscious and deliberate, implicit bias operates outside of awareness and can influence clinical decision-making even among well-intentioned providers. Importantly, implicit bias alone does not explain health disparities; it functions within a broader structural context.

Jones describes these as the "gardener's tale," or the soil in which seeds are planted that matters as much as the seeds themselves [6]. Two patients with identical clinical presentations may have vastly different outcomes based on the conditions of their social environments.

HOW STRUCTURAL RACISM BECOMES EMBEDDED IN SYSTEMS

Structural racism does not require active malice. It is maintained through [1]:

- Policies that appear race-neutral on their surface but produce racially disparate outcomes (e.g., policies tying Medicaid reimbursement rates to regional wage averages in historically underfunded areas)

- Laws, including those that have been repealed, whose downstream effects persist for generations (e.g., redlining, racially restrictive covenants)

- Institutional practices (e.g., resource allocation formulas, staffing models, data collection systems) that do not capture race and ethnicity in a way that reveals disparities

- Opportunity structures, defined as unequal access to quality education, stable employment, and safe housing, all of which shape health before a patient ever reaches a clinical setting

Consider hypertension management as an example. At the individual clinician bias, a provider may underestimate pain or underestimate the health literacy of a Black patient and fail to adequately explain lifestyle modifications. At the organizational policy level, the health system may not have designated sufficient interpretation services for patients with limited English proficiency, limiting therapeutic relationships. At the community level, the patient's neighborhood may have no full-service grocery stores, no safe places to exercise, and high levels of environmental stress, all of which directly impact blood pressure and chronic disease management. All three levels interact, and effective solutions must engage all three.

3. HISTORICAL CONTEXT AND PRESENT-DAY IMPACT

Understanding where we are requires understanding of how we got here. Current health inequities did not arise spontaneously. They are the predictable product of deliberate historical policies (Table 2).

Table 2: HEALTHCARE-SPECIFIC DISPARITIES: CONNECTING HISTORY TO TODAY

Domain

Historical Policy

Present-Day Impact

Primary care access

Hospital segregation, unequal facility distribution

Black and Hispanic communities more likely to rely on emergency departments for primary care needs.

Maternal health

Historical dismissal of Black women's pain, exclusion from nurse-midwifery training

Black women are two to three times more likely to die from pregnancy-related causes than White women.

Behavioral health

Criminalization of addiction and mental illness, disproportionately affecting communities of color

Lower utilization of mental health services

Higher rates of untreated depression and anxiety

Preventive services

Lack of community-based providers, insurance gaps

Lower rates of cancer screening, vaccination, and chronic disease monitoring in minority communities

Source: [11,12,13,14,15]

HISTORICAL FOUNDATIONS OF INEQUITY IN U.S. HEALTH CARE

Medical Experimentation Without Consent

The history of American medicine includes documented cases of nonconsensual medical experimentation on Black Americans, including the infamous Tuskegee Syphilis Study (1932–1972), in which Black men with syphilis were deliberately denied treatment so researchers could observe disease progression [11]. In another, more recent example, members of the Havasupai Tribe in Arizona provided blood samples to Arizona State University researchers for research into type 2 diabetes in the 1990s and 2000s. Tribe members understood the research to concern diabetes, but the samples were subsequently used for studies involving schizophrenia, population migration, and inbreeding, without obtaining consent for those uses [36]. This history, and its contemporary echoes, shapes the distrust that many patients of color bring to healthcare encounters today.

Segregated Healthcare

Until the passage of the Civil Rights Act of 1964 and the implementation of Medicare and Medicaid in 1965 (which required participating hospitals to desegregate), most hospitals in the South (and many in the North) were explicitly racially segregated. Black physicians were excluded from medical school training programs, hospital staff privileges, and professional associations for much of the 20th century [12].

The American Medical Association's Role

The American Medical Association (AMA) formally excluded Black physicians from membership for decades and opposed the inclusion of Black hospitals in accreditation systems. In 2021, the AMA acknowledged this history and committed to embedding racial justice across its strategic priorities [13].

STRUCTURAL POLICIES THAT SHAPE HEALTH TODAY

Housing Segregation and Redlining

Beginning in the 1930s, the federal Home Owners' Loan Corporation (HOLC) systematically graded neighborhoods by perceived investment risk, with Black and immigrant communities almost universally marked in red ("hazardous") for mortgage lending. This practice, known as redlining, denied generations of Black and immigrant families the opportunity to build wealth through homeownership [14].

Neighborhoods redlined in the 1930s and 1940s continue to show significantly higher rates of poverty, lower life expectancy, higher rates of chronic disease, and reduced access to health care compared to previously "green-graded" neighborhoods [15]. In a very real sense, a map from 1940 can predict health outcomes today. A patient's zip code remains one of the strongest predictors of health outcomes, stronger, in many cases, than genetics or individual behavior. This is not a coincidence; it is the direct consequence of decades of policy decisions that concentrated disadvantage in specific communities [8]. Healthcare professionals who understand this history are better equipped to recognize when a patient's challenges are systemic rather than personal and to respond with appropriate advocacy and support rather than judgment.

Educational Inequities

School funding systems tied to local property tax bases mean that communities with lower property values (often communities that were redlined) receive less funding per pupil. This creates compounding educational disadvantages that affect health literacy, employment prospects, and lifetime earning potential [16].

Employment and Wealth Disparities

The racial wealth gap in the United States is dramatic and persistent. In 2019, the median White family held approximately eight times the wealth of the median Black family and five times the wealth of the median Hispanic family [17]. Wealth determines health in many direct ways: access to health insurance, ability to afford medications, capacity to take time off work for medical appointments, and the ability to live in resource-rich neighborhoods.

Healthcare System Exclusion

Discriminatory credentialing, hospital segregation, and exclusion from medical training programs meant that communities of color were left with fewer providers who shared their cultural backgrounds or linguistic identities, and with healthcare facilities that were structurally under-resourced. These conditions were not corrected overnight with civil rights legislation, and they set in motion resource gaps that persist today.

4. STRUCTURAL RACISM AND HEALTH OUTCOMES

SOCIAL DETERMINANTS OF HEALTH

The social determinants of health (SDOH) are the conditions in the environments where people are born, live, learn, work, play, worship, and age that affect a wide range of health, functioning, and quality-of-life outcomes [18]. These include:

- Economic stability (e.g., income, employment, food security, housing stability)

- Education access and quality

- Healthcare access and quality

- Neighborhood and built environment

- Social and community context

Structural racism operates through the social determinants of health. It is the mechanism by which communities of color are disproportionately exposed to the adverse conditions that drive poor health outcomes—not because of cultural practices or individual choices, but because of deliberate policy decisions and institutional practices [19].

HEALTH OUTCOME DISPARITIES: THE EVIDENCE

Chronic Disease Burden

Black Americans have significantly higher age-adjusted death rates from heart disease, stroke, diabetes, and cancer than White Americans [2]. Non-Hispanic Black adults are 60% more likely to be diagnosed with diabetes and twice as likely to die from the disease compared to non-Hispanic White adults [20]. Asian and Pacific Islander men are twice as likely as their non-Hispanic White counterparts to have stomach cancer and are 1.7 times more likely than White men to die from liver cancer [37]. These differences are not explained by genetic differences; they are explained by the differential exposure to social risk factors that structural racism produces.

Maternal and Infant Outcomes

The Black maternal mortality crisis is one of the most striking examples of structural racism's health impact. Black women in the United States are approximately two to three times more likely to die from pregnancy-related complications than White women, regardless of income or education level [21]. Dr. Shalon Irving, a CDC epidemiologist with expertise in social determinants of health, died in 2017, six weeks after giving birth, from complications of hypertensive crisis. Her death illustrated that even professional status and advanced education do not fully protect Black women from the effects of cumulative racial stress and inadequate postpartum care [38].

Contributing structural factors include inadequate access to prenatal care, higher rates of uninsurance, lower rates of continuity of care, and the biological effects of chronic racial stress (known as weathering), which accelerates physiological aging in Black women [22].

Mental Health

Communities of color face unique barriers to mental health care, including provider shortages, lack of culturally competent services, stigma within communities where mental health services have been historically unavailable, and the psychological burden of experiencing racism itself [23]. Chronic exposure to discrimination is associated with elevated rates of depression, anxiety, post-traumatic stress, and cardiovascular disease [24].

Life Expectancy

The life expectancy gap between American Indian/Alaska Native and Black Americans compared with White Americans, driven by higher rates of preventable death, has been documented for decades. LaVeist and colleagues estimated that racial health inequalities cost the United States $229 billion in direct medical care expenditures and economic losses over a three-year period [25]. This is not only a moral problem; it is an economic one.

Preventive Care Access

Structural barriers, including lack of insurance, provider shortages in underserved areas, transportation challenges, and lack of time off work, all contribute to lower rates of preventive service utilization in minority communities. These are not preferences; they are consequences of systems that allocate resources inequitably.

TRUST AND PATIENT ENGAGEMENT

Research consistently demonstrates that patients of color report lower levels of trust in the healthcare system, lower satisfaction with care, and less confidence that providers take their concerns seriously [26]. This is not irrational; it is a learned, evidence-based response to a documented history of mistreatment and neglect. Patient distrust is itself a downstream effect of structural racism, and addressing it requires more than communication skills training for individual providers. It requires system-level investment in building trustworthy institutions.

CASE STUDY: PATIENT J'S JOURNEY THROUGH THE HEALTHCARE SYSTEM

We will use the following case throughout the remainder of this course. As you read, note the barriers Patient J encounters and consider which are structural versus individual.

Patient J is a 52-year-old Black man living in a mid-sized urban neighborhood. He works as a security guard, a job that requires him to be on his feet for 10-hour shifts. He has a history of hypertension, type 2 diabetes, and depression. His primary care physician recently identified worsening blood pressure control and requested a nephrology referral.

Patient J has experienced the following over the past six months:

- His nephrology referral has been pending for four months. He is not sure why.

- The nearest nephrology office is 18 miles away, and he does not own a car. The bus route requires two transfers and takes 90 minutes each way.

- His insurance plan has a high deductible, and he has not filled his new antihypertensive prescription because he cannot afford it until after his next paycheck.

- He stopped going to his previous primary care provider after he felt his pain complaints were dismissed on three separate occasions.

- He has not disclosed his depression to his current provider because a friend told him that disclosing mental health conditions could affect his employment status.

Reflection

Which of Patient J’s barriers are individual? Which are structural? Make a list before reading further.

5. STRUCTURAL RACISM IN HEALTHCARE SYSTEMS AND CLINICAL PRACTICE

OVERVIEW

Structural racism shapes the clinical encounter in ways that are often invisible to providers but deeply felt by patients. The following domains are particularly affected.

Screening

Who gets screened and when is shaped by both guidelines and access. When guidelines are based on data that under-represents minority populations, they may fail to identify risk appropriately. Additionally, lack of access to primary care means that screening occurs less frequently in communities of color, resulting in later-stage disease diagnoses [27.

Diagnosis

Diagnostic tools and reference ranges developed primarily in White populations may perform differently across racial groups. More critically, research demonstrates that patients of color are more likely to have their symptoms attributed to non-organic causes, to be undertested, and to receive delayed diagnoses across multiple conditions [2,3].

Treatment Decisions

Multiple studies document that race influences treatment decisions. Black patients are less likely to be referred for cardiac catheterization after heart attacks, less likely to receive adequate pain management, less likely to be offered clinical trial participation, and less likely to receive guideline-concordant care for a range of conditions [3]. These patterns persist even after controlling for clinical severity.

Care Coordination

Fragmented care disproportionately affects patients with limited resources. When specialty referrals require transportation, time off work, and the navigation of complex insurance requirements, patients who lack these resources fall through the gaps. For example, Patient J's four-month pending nephrology referral reflects this systemic failure.

Resource Allocation

How health systems deploy their resources, including where they locate facilities, which services they fund, how they staff clinics, and which language access programs they invest in, directly reflects and reproduces structural inequities. Health systems that serve predominantly minority populations are consistently underfunded relative to those serving predominantly White populations [25].

CLINICAL ALGORITHMS AND EQUITY CONCERNS

In recent years, clinicians and researchers have raised significant concerns about race-based corrections embedded in clinical algorithms. These corrections, often built into electronic health records and clinical decision support tools, adjust clinical recommendations based on a patient's race, under the assumption that race represents a biological difference.

Vyas and colleagues examined several widely used algorithms, including [9]:

- Estimated glomerular filtration rate (eGFR): The race-adjusted eGFR formula historically calculated a higher kidney function score for Black patients than for White patients with the same creatinine level, potentially delaying referral for nephrology evaluation and kidney transplant listing.

- Vaginal birth after cesarean (VBAC) calculator: The algorithm assigned lower probability of successful vaginal delivery to Black and Hispanic women, influencing clinical recommendations without a sound biological basis.

- Cardiac risk calculators: Race is embedded in several tools in ways that may alter risk stratification.

These race-based corrections conflate race (a social category) with biology and may reinforce rather than reduce health disparities. Many professional organizations, including the National Kidney Foundation, have since recommended removing race from eGFR equations [28]. This example illustrates how structural racism can be embedded in the very tools clinicians rely on, requiring ongoing critical evaluation.

WORKFORCE DIVERSITY AND PATIENT OUTCOMES

A diverse healthcare workforce is not simply a matter of representation; it has documented clinical consequences. Research demonstrates that [29]:

- Black patients are more likely to accept preventive services from Black physicians.

- Patient-provider racial concordance is associated with improved communication, greater patient satisfaction, and better adherence to treatment recommendations.

- Communities with greater physician workforce diversity have better population health outcomes across multiple indicators.

Yet structural barriers in medical education, from the cost of medical school to the composition of admissions committees to the climate within training programs, continue to limit the diversity of the healthcare workforce. Addressing workforce diversity is therefore an equity intervention, not merely an aspirational goal.

EFFECTS ON COMMUNICATION AND PATIENT TRUST

When patients have experienced discrimination from healthcare institutions or from society at large they bring that history into every clinical encounter. This manifests as:

- Reluctance to disclose symptoms, particularly mental health symptoms

- Skepticism about recommended treatments

- Reduced willingness to participate in clinical trials

- Avoidance of care until conditions are severe

Providers who are unaware of this dynamic may interpret patient hesitancy as noncompliance or disinterest. Providers who understand structural racism can recognize these responses as adaptive and respond with transparency, patience, and advocacy [26].

6. STRATEGIES FOR PROMOTING EQUITY

Understanding structural racism is a beginning, not an end. This section focuses on what healthcare professionals can do to promote equitable care at the individual, team, organizational, and system levels (Table 3).

Table 3: APPROACHES TO ADDRESS THE IMPACT OF STRUCTURAL RACISM IN HEALTH CARE

Action

Description

Individual-Level Actions: What Clinicians Can Do

Screen for social needs

Use validated tools (e.g., PRAPARE, AHC-HRSN) to identify food insecurity, transportation barriers, housing instability, and other social needs at the point of care

Use person-centered communication

Elicit patient preferences, concerns, and social context before making recommendations

Avoid assumptions based on demographic characteristic

Recognize and interrupt implicit bias

Reflect on differential patterns in your own practice

Seek feedback

Use structured decision-making tools where appropriate

Address race-based clinical algorithms

Know which tools in your practice embed race-based corrections

Advocate for evidence-based alternatives

Document social needs

Record identified social needs in the patient record to support care coordination and continuity

Advocate for patients

Navigate system barriers on behalf of patients (e.g., expediting referrals, connecting with social work, escalating unmet needs)

Engage in ongoing learning

Commit to continuing education on structural racism, health equity, and culturally responsive care

Organizational-Level Actions: What Health Systems Can Do

Review policies for disparate impact

Regularly audit policies related to scheduling, discharge planning, referral processes, and resource allocation for unintended inequitable effects

Stratify quality metrics by race and ethnicity

Move beyond aggregate outcome reporting to identify disparities within the patient population

Invest in language access

Ensure robust interpreter services, translated materials, and multilingual staffing

Create accountability structures

Tie equity metrics to leadership performance goals and organizational dashboards

Diversify the workforce

Implement evidence-based strategies to recruit, retain, and advance providers and staff from under-represented groups

Partner with communities

Develop formal community advisory structures that give historically marginalized communities genuine influence over healthcare decisions

Assess the built environment

Evaluate service lines, facility locations, and hours of operation through an equity lens

Source: [31]

EVIDENCE-BASED APPROACHES TO REDUCING INEQUITIES

Equity-Focused Quality Improvement (EFQI)

Standard quality improvement approaches measure outcomes at the population level but may not stratify data by race, ethnicity, language, or other equity-relevant characteristics. Equity-focused quality improvement (EFQI) builds on established quality improvement methods by explicitly examining whether improvements are distributed equitably [31]. The Institute for Healthcare Improvement's framework for achieving health equity recommends that organizations [31]:

- Make a commitment to health equity as a strategic priority

- Build infrastructure to support equity work

- Address the multiple determinants of health

- Eliminate racism and other forms of oppression

- Partner with community

Data Collection and Disparity Monitoring

It is not possible to address what is not measured. Health systems should routinely collect, analyze, and act on data stratified by race, ethnicity, language, gender identity, and socioeconomic status [31]. This includes not only outcome data (e.g., mortality, readmissions, complications) but also process data (e.g., wait times, referral completion rates, prescription fill rates) and experience data (e.g., patient satisfaction, communication ratings).

Trauma-Informed Care

Trauma-informed care recognizes that many patients, particularly those who have experienced racism, poverty, violence, or historical institutional betrayal, carry trauma that affects their health behaviors, their healthcare interactions, and their physiologic stress responses [32]. A trauma-informed approach:

- Assumes that patients may have experienced trauma

- Prioritizes safety, trustworthiness, and patient empowerment

- Avoids re-traumatization

- Integrates knowledge of trauma into policies, procedures, and provider behaviors

For patients like Patient J, whose prior negative healthcare experiences contribute to avoidance of care, a trauma-informed framework is not optional—it is clinically essential.

Culturally Responsive Practice

Culturally responsive practice involves recognizing and incorporating patients' cultural values, health beliefs, and community contexts into care planning [33]. This is distinct from stereotyping, as it requires asking and listening rather than assuming. Key elements include:

- Eliciting patients' explanatory models for their illness

- Incorporating patients' preferences and values into shared decision-making

- Acknowledging cultural variation in health beliefs without pathologizing difference

- Providing language-appropriate care and materials

Community Partnerships

Health systems that partner with community organizations, including faith institutions, community health workers, neighborhood associations, food access programs, are better positioned to address the SDoH that drive outcomes between clinical encounters [34]. Community health workers in particular have demonstrated effectiveness in reducing disparities in chronic disease management, prenatal care, and cancer screening.

Workforce Development

Building a diverse, equity-competent workforce requires intentional investment across the educational pipeline. Health systems can support this through:

- Culturally responsive onboarding and training

- Mentorship programs for underrepresented trainees and early-career professionals

- Evaluation of hiring and promotion practices for disparate impact

- Compensation and recognition of equity-related work

CASE STUDY

Let's return to Patient J's case. If you were his provider, his care team, or a healthcare administrator, what would equity-promoting action look like?

Patient Level

- Conduct a social needs screening. Identify the transportation barrier and connect Patient J to Medicaid transportation benefits or community ride programs.

- Have a transparent conversation about medication costs. Explore generic alternatives, manufacturer assistance programs, or in-house pharmacy options.

- Create a psychologically safe environment to discuss mental health. Clarify confidentiality and address the patient's concern about employment consequences.

- Acknowledge prior negative healthcare experiences without defensiveness. Ask what he needs from you to rebuild trust.

Team Level

- Assign a care coordinator or community health worker to track the pending nephrology referral and remove barriers to completion.

- Conduct a warm handoff to behavioral health rather than providing only a referral number.

- Use the care team's huddle to flag patients with complex social needs and coordinate wrap-around support.

Organizational Level

- Review referral completion rates stratified by race and insurance type. Investigate whether there are patterns of differential delay.

- Assess transportation assistance programs and pharmacy affordability resources. Ensure that information about these programs reaches patients proactively.

- Examine whether the clinical algorithm used to calculate Patient J's kidney function incorporated race-based corrections, and review the process for updating clinical decision support tools.

7. CONCLUSION

Structural racism is a system, not a sentiment. It operates through policies, laws, institutional practices, and resource allocation decisions, not only through individual attitudes or prejudice. It produces racially inequitable outcomes whether or not individual actors intend to cause harm [1,7].

The health inequities we observe today are the direct and predictable results of historical policies—from redlining to medical segregation to non-consensual experimentation. Understanding this history is not an academic exercise; it is essential clinical knowledge [12,15].

Racial and ethnic minorities experience higher chronic disease burden, worse maternal outcomes, reduced access to preventive care, and lower life expectancy, and these differences are not explained by biology or individual behavior [2,21]. Screening practices, diagnostic tools, treatment decisions, clinical algorithms, and communication patterns can all embed and perpetuate structural inequities, requiring ongoing critical reflection and action [9,27].

Individual providers, care teams, health systems, and policymakers all have roles to play. No single intervention is sufficient. Sustained, multilevel commitment is required to achieve measurable and lasting change [31]. Before completing this course, take a few minutes to identify your personal commitments:

- What is one clinical practice change you will make? (Example: I will use a validated social needs screening tool with every new patient and document findings in the chart.)

- What is one organizational improvement opportunity you will raise? (Example: I will bring a proposal to our quality committee to stratify our readmission data by race and ethnicity.)

- What is one action I will implement within the next 30 days? (Example: I will schedule a meeting with our social work team to learn more about transportation resources available to patients.)

These commitments are most powerful when they are shared. Consider discussing your commitments with a colleague, supervisor, or quality improvement team to create accountability.

Equity work is not a one-time training; it is a practice. The discomfort that this content may produce is not a sign that something is wrong; it is a sign that learning is happening. Healthcare professionals who commit to ongoing reflection, education, and advocacy are the ones who will move the needle on health disparities.

As Churchwell and colleagues note in the American Heart Association's 2020 presidential advisory on structural racism, "Healthcare professionals are uniquely positioned to address structural racism, not only through clinical care, but through research, advocacy, and leadership within their institutions and communities" [35].

8. RESOURCES

American Medical Association Center for Health Equity

https://www.ama-assn.org/about/ama-center-optimal-health-outcomes

Institute for Healthcare Improvement

Achieving Health Equity: A Guide for Health Care Organizations

https://www.ihi.org/library/white-papers/achieving-health-equity-guide-health-care-organizations

Robert Wood Johnson Foundation

Structural Racism and Health

https://www.rwjf.org/en/our-vision/focus-areas/Features/structural-racism-and-health.html

Project Implicit

Implicit Association Test (IAT)

https://implicit.harvard.edu/implicit/takeatest.html

Institute of Medicine

Unequal Treatment

https://www.ncbi.nlm.nih.gov/books/NBK220358

9. GLOSSARY OF KEY TERMS

Structural racism: The totality of ways in which societies foster racial discrimination through mutually reinforcing systems of housing, education, employment, media, healthcare, and criminal justice

Institutional racism: Policies and practices within institutions that result in differential outcomes by race, regardless of intent

Implicit bias: Unconscious attitudes or stereotypes that affect understanding, actions, and decisions

Social determinants of health: Conditions in the environments where people live, learn, work, play, and worship that affect health outcomes

Health disparities: Preventable differences in the burden of disease, injury, violence, or opportunities to achieve optimal health experienced by socially disadvantaged groups

Weathering: The hypothesis that Black Americans experience accelerated physiological aging due to cumulative exposure to chronic racial stress

Redlining: The systematic denial of mortgage lending, insurance, and investment to communities of color by government agencies and private institutions beginning in the 1930s

Equity-focused quality improvement: Quality improvement that explicitly examines whether improvements are equitably distributed across patient subgroups

Cultural humility: A lifelong process of self-reflection and self-critique, distinct from cultural competence, emphasizing ongoing learning rather than achievement of expertise

Trauma-informed care: A framework that recognizes the widespread impact of trauma and integrates knowledge about trauma into policies, procedures, and practices

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