Parking might not strike you as an integral part of modern healthcare infrastructure, but it regularly affects care for countless patients in the United States. This seemingly simple issue routinely wreaked havoc on my operating room schedule. It also starkly highlights the subtle bias that pervades the healthcare system.
Every few weeks my operating staff and I, prepped and ready in the OR, would watch the clock as a scheduled surgery start time came and went, with no idea as to where our patient was. As each person in the room felt their tightly scheduled day crumble, the murmurs of frustration would grow louder.
Late or no-show patients are always a source of frustration, because a postponed surgery can throw an entire day into chaos. Some surgeries are up to six hours long. Crafting the schedule that governs an operating room is nearly as delicate an undertaking as the surgery itself.
And each moment is enormously expensive: Thousands of dollars go to equipment, supplies, medications, and the staff needed to perform the procedure. And if that procedure doesn’t occur, the patient’s insurance provider doesn’t pay for any of it, forcing the hospital and surgeon to eat the cost for everything. Every minute that passed cost $45.
No matter how thoroughly we felt we’d informed and reminded our patients and their caretakers, the problem persisted. More and more, I noticed how some of my especially incensed colleagues would talk about late patients: “Those people are always late!” It was subtle, but their frustration increasingly came with a certain disregard.
It was an othering I recognized.
I came to America during a tumultuous time. My parents left our homeland of Iran so they could pursue their education, and it seemed like as soon as they left home, the country behind them ignited. Suddenly there was a revolution — family members and friends were being imprisoned, persecuted and executed, and my parents and I were stranded an ocean away. We were helpless, powerless, stuck in a foreign land. And then I became desperately ill. My parents, who spoke very little English, rushed me to the hospital.
I spent months as an inpatient with bacterial meningitis. My future was unclear: both the illness and the medications used to treat it have the potential for life-altering effects ranging from hearing loss to permanent brain damage. The language barrier meant my parents had to push for the most basic details, and were still left confused. They had to navigate a massive healthcare institution, with scant experience and means.
We were “those people.”
Decades later I was proud to be a surgeon at that same hospital. Throughout my training and work in other hospitals, I had begun to notice the subtle divisive language within the healthcare system. Now as an attending surgeon, I had learned of an internal study that confirmed what everyone privately already knew — what was meant when doctors said “those people.” Late and no-show patients are almost always on public insurance like MassHealth (CHIP and other Medicare Programs), just as my family had been. I also began to understand that under these programs, hospitals and doctors are paid just half as much for services rendered to these patients as they are when treating patients with private insurance.
For the first time I began to understand the friction that exists in our healthcare system between revenue and equity. And as such, even if “those people” were always on time, they aren’t the patients doctors or hospitals prefer to treat. In 2017, Mayo Clinic CEO Dr. John Noseworthy faced criticism for announcing that Mayo would be prioritizing privately insured patients over public ones. I was disgusted by his comments — but also surprised by the backlash. After all, he’d merely said aloud the quiet rule that secretly governs hospital scheduling practices all over the country: double book “high risk, low reward patients,” (“those people”) and don’t take on too many at once.
Data bears this out. Research shows that patients on public insurance face particular stigma and bias in the U.S. healthcare system. This is despite the higher-than-average likelihood that they’ll need to call upon it. Insurance-based discrimination is one of U.S. healthcare’s dirtiest open secrets.
So when publicly insured patients at our hospital showed up late or not at all, it reinforced stereotypes already formed in many minds. They located the patients’ tardiness within a web of other negative associations related to the patient’s class — they were lazy, they were unserious, they had no respect for institutions, and so on. As a result, patients received worse care from doctors biased against them, a combination known to produce worse health outcomes.
But at the same time, I knew the people I worked with were good people. They had dedicated their lives to helping sick and injured children. How could these educated and loving individuals buy into a narrative that was so hurtful and dangerous? I believe this bias has its roots in a lack of curiosity, shared experience and true human connection—the kind that fosters empathy. Without that foundation of empathy, there’s nothing to shore you up against the slow, incremental, unconscious drift toward prejudice that happens each time you face frustration that seems compounded by facts.
It may seem small, but lack of curiosity and empathy for another person leads to dehumanizing that person because of a misunderstanding of an entire population. Otherism is like a tide that rises slowly, surrounding you when you’re distracted by other things. It takes away an individual’s humanity and replaces it with the patterns and behaviors of “those people.”
This kind of passivity when it comes to thought and reflection is common across industries. But it’s especially glaring when it comes to the patterns that emerge at the intersection of financial systems and healthcare, where it can lead to collective thought that breeds bias without further examination. This bias is detrimental to both the people these systems were designed to help and heal, and the helpers and healers themselves.
Logic and experience get us part of the way: when it comes to healthcare for children, it’s hard to argue that anything is more powerful than a parent’s desire to care for their child. That’s how I knew that when my Medicaid patients arrived late or didn’t show up for surgery at all, there had to be more going on than neglect, laziness, or lack of interest in addressing serious health issues. These were caring parents to vulnerable kids. So I got curious: I asked my patients, in a kind, patient, and empathic way, “Why are you late for surgery?”
Almost every family had the same answer: parking.
So I got curious: I asked my patients, in a kind, patient, and empathic way, “Why are you late for surgery?”
Almost every family had the same answer: parking.
What does hospital parking have to do with bias in healthcare? And what does solving for parking have to do with making healthcare more financially sustainable, and improving outcomes overall?
As I discussed in my last piece, uncovering and addressing unconscious bias is a complicated undertaking. It’s one thing to have understanding and compassion for those who are like you, but expanding beyond that viewpoint to give everyone the benefit of the doubt is a powerful step. It comes from engaging with people and seeking to comprehend their circumstances out of genuine curiosity and empathy. It’s especially important for those of us in positions of relative privilege and influence, who hold the keys to desperately needed resources — like medical treatment — to foster our own curiosity and empathy.
Almost all hospitals have garages where people can park their cars while they or a loved one are being treated. Say the cost of parking is $12 for two hours, and $40 for eight. That’s before validation, which knocks it down to $10 for an entire day. This probably sounds reasonable, but for those already struggling to pay for healthcare, it can present a significant barrier. The validation process can be unclear — prohibitively so for those learning English — and the amount shelled out for parking may represent a substantial chunk of a person’s discretionary income.
When I finally asked why so many of my patients had been late for surgery, I learned that their parents had been circling the hospital in ever-widening loops for minutes or hours in search of street parking — in a neighborhood, I’ll add, that also included the notoriously packed Fenway Park. Add to that the time it takes to walk from whatever parking they did find to the hospital, with a child who’s already tired, under duress, and in need of a surgical intervention, and you can see how our fine-tuned schedules were impossible for parents and patients.
Far from being lazy or disinterested, as some of my colleagues had seemed to assume, these caretakers were doing just about everything they could to get their kids the care they needed. They took time off work, took their kids out of school, and sometimes walked a mile or more. These people weren’t indolent. They just couldn’t afford to add parking costs to that list.
In Massachusetts where nearly 16% of households face food insecurity, paying for parking is not a priority.
Once I knew what the problem was, it was easy enough to solve: I asked my patients if parking was a challenge for them and offered those who wanted help free vouchers for the garage on the day of the operation. Just like that, they stopped missing or showing up late to their procedures. All it took to uncover the root issue behind late patients and delayed surgeries was the simple curiosity and compassion to ask my patients about their experiences. All it took to address the problem was a basic fix that cost us $10 per patient — far less than a rescheduled surgery.
I was elated. I had solved a problem that had been plaguing the hospital, and made it possible for the patients I was dedicated to serving to get the help they needed, without the potentially disastrous delays. Excited by the development, I shared it with hospital management. We could put an end to the wasted time and unused resources that had been throwing our operating rooms into chaos. We could make more care more accessible to more patients.
The hospital’s response stunned me: I was ordered to stop. Legal counsel had explained to management that paying for a patient’s parking could be seen as a monetary incentive coercing them into care. While the concrete, positive effects were clear, the potential liability placed the hospital in legal jeopardy. I would have to stop covering patient parking, lest I put the hospital at risk for a lawsuit or federal fines.
And it’s not that the hospital was especially cautious or overreacting. The truth is this problem is built into our legal system and affects every hospital at every level.
I have deep respect and admiration for every hospital where I’ve worked, including the institution that saved my life when I was a small boy, and the one I am proud to be part of as a surgeon today. From the top down, we are doing the hard work of reflecting, consulting and taking action against bias. This story is not meant to denigrate this institution, or any other hospital. Rather, I want to show that even at the best hospital, hypothetical legal risk and cultural bias can block attempts to alleviate structural issues.
Fortunately, there has been a trend within healthcare toward cultivating and prioritizing empathy. Healthcare institutions and organizations beyond are waking up to the idea that living up to the promise of addressing wellness in patients goes beyond prescriptions and blood work.
But it’s not clear who will pay for these programs. Is it the onus of doctors or hospitals to help children get enough to eat? Is it an administrative issue? And once programs have been set up, how does the healthcare system connect people to those resources? How do we make it an efficient, sustainable program that can be adopted at scale? This is an area where public-private partnerships, a mix of philanthropy, institutional, technological and venture support, may be able to pave the way. In addition to vital organizations and nonprofits doing this work, I predict that companies will begin to emerge that will work with hospitals to address food insecurity, and offer options like microfinancing to pay for healthcare expenditures.
The startup community is already making crucial efforts. Companies like Violet are working to benchmark and publicly recognize medical professionals around cultural competence, and offering training to help them increase their knowledge and skills. I am eagerly waiting to see the emergence of startups addressing other social needs that so often fall through the cracks — things like food insecurity.
The reality is that our healthcare and insurance systems as they are now are broken. Research has shown that even people with private insurance through their employers are dissatisfied with their coverage, skip routine preventative care due to cost, and are more likely to experience medical debt. And yet it’s “those people” — the ones without private insurance — who face negative bias and deliberate deprioritization within the healthcare system.
Of course, I don’t have a simple answer for how to fix the healthcare system’s current problems. No one does. There are no simple answers to questions like these. The hospital parking garage is one example of how small-scale, individual intervention — as small as asking a simple question — can have a major impact along the entire care and revenue chain of a much larger health system.
It also showed me that small-scale intervention is not nearly enough. We must combine the compassionate urge to address problems on an individual basis with the big-picture reckoning it takes to face the greater problem. Those who measure legal risk must remember what that liability is, at its core, meant to represent: human safety and wellbeing. Meaningful change must begin with empathy, and the firm belief that everyone is from the same human family. Through this lens, we can start to deconstruct, and forge a new path forward.
We have to keep asking patients, “Why?” with love and kindness when we seek to understand a problem. And when the obvious solution is deemed too risky, we also have to keep asking ourselves, and the institutions we work within, “Why not?”
Author: Salim Afshar
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