Case Studies: Fostering an Antiracist and Equitable Telehealth Environment

Case Study #1: Lisa (13-year-old girl)

A 13-year-old Black/African American adolescent named Lisa, accompanied by her mother, has scheduled a visit with you via telehealth. This is the second time that you will be meeting with Lisa and her mother – they recently had their first visit at your practice and were seen in-person for a health supervision visit. During the first visit, a depression screening identified some mild depressive symptoms, and you suggested they schedule a follow-up in a few weeks to continue discussing these issues.

After taking a medical and developmental history, you ask whether Lisa’s health or everyday life has ever been impacted by seeing or experiencing racism. Lisa’s mom, who has accompanied Lisa to the appointment, seems surprised by your question and you reassure them that you are routinely asking your patients about any concerns or experiences of racism as it relates to their health. They seem reassured and even pleased that you asked. Lisa’s mom comments that she had wanted to see a pediatrician of color, but none were available. She goes on to discuss ways in which her previous clinician didn’t take some of Lisa’s concerns seriously, and their interactions did not seem authentic or genuine. This led them to look for someone else to care for Lisa. You encourage Lisa and her mom to bring up any concerns they may have about their care with you and your office staff and assure them that you will do your best to make them feel safe, affirmed, and comfortable in your practice.

1. Why is it important for clinicians to address racism with pediatric patients and their families?

According to the AAP policy statement The Impact of Racism on Child and Adolescent Health:

• “Racism is a social determinant of health that has a profound impact on the health status of children, adolescents, emerging adults and their families. Although progress has been made toward racial equality and equity, the evidence to support the continued negative impact of racism on health and well-being through implicit and explicit biases, institutional structures and interpersonal relationships is clear.”

It is important for pediatric clinicians to take a sufficient medical and social history so that they can provide patient/family-centered care. Discussing any experiences with racism may be an important part of this process.

2. How can clinicians know that this is something their patients want to discuss, or feel safe or comfortable discussing, especially in a telehealth environment?

Bidirectional trust in the clinician-patient relationship is a foundational element to creating safe spaces for dialogue. The only way to really know if this is something your patients are comfortable discussing is by asking and observing verbal and nonverbal cues from patients and families. It is important to become comfortable with your discomfort and to normalize the conversation by explaining that this has become a standard part of your evaluations and talking about the ways racism can negatively impact health.

3. What preparation, if any, do you think clinicians who care for children and adolescents should undergo before beginning to talk with their patients/families about racial identity and racism?

Reviewing the AAP policy statement The Impact of Racism on Child and Adolescent Health is a great place to start. One suggestion in the policy statement is that pediatric clinicians can:

• “…implement systems in their practices that ensure that all patients and families know that they are welcome, that they will be treated with mutual respect, and that high-quality care will be delivered regardless of background using the tenets of family- and patient-centered care. To do this, it is critical for pediatricians to examine their own biases.”

Resources to help clinicians examine their own biases:

• AAP PediaLink course: Fighting Racism to Advance Child Health Equity
• Implicit Bias Association Tests – “Project Implicit”

Additional resources:

• Considerations for Fostering an Antiracist and Equitable Telehealth Environment Panel Discussion

4. What are steps a clinician can take to create a safe space for these conversations?

• Create a culturally safe medical home, where clinicians take steps to acknowledge and understand their own biases and are sensitive to racism that children and families experience.
• Consider anti-racism and trauma-informed care training for all staff, not just medical providers.
• Prioritize hiring diverse staff and leadership.
• Integrate patient- and family-centered communication strategies and evidence-based screening tools that incorporate valid measures of perceived and experienced racism into clinical practice.
• Use strategies such as the Raising Resisters approach, supporting youth and families to:
  • Recognize racism in all forms
  • Differentiate racism from other forms of unfair treatment and/or routine developmental stressors
  • Safely oppose the negative messages and/or behaviors of others
  • Counter or replace those messages and experiences with something positive
• Train clinical and office staff in culturally competent care according to national standards for culturally and linguistically appropriate services.

Additional tips include:

• Practice empathy and cultural humility.
• Demonstrate authenticity in your interactions.
• Communicate to the families that you are understanding and supportive of their experiences.
• Avoid assumptions – remember that the patient and family are the experts in their own lived experiences, and honor this.

Additionally, clinicians should make it clear why they are asking these questions, and that it directly relates to the child/adolescent’s health and wellbeing.

5. What are some specific considerations for having these conversations during a telehealth visit?

There are a few strategies that clinicians can use to create a telehealth environment that is welcoming and equitable, including:

• Practicing active listening with all patients and their families
• Maintaining eye contact – avoid any distractions that may cause you to look away from the patient/family during the visit, and explain why you may need to look away (take notes, etc.)
• Ensure that the patient/family feels comfortable with the technology
• Send follow-up emails and/or resources after the visit
• Ask families/caregivers and patients about how they identify themselves, respect and acknowledge these identities. This could include intersecting identities related to race, ethnicity, disability, gender identity, among others. Avoid making assumptions about patient/family identities, and be mindful that not all aspects of identity are visible.
• Acknowledging that racism, and other forms of discrimination are real and the experiences of families and patients are valid.

To download a PDF of this case study, click here. 

Case Study #2: Jordan (16-year-old boy)

Jordan, a 16-year-old adolescent patient whom you’ve seen since childhood, is meeting with you for a telehealth visit. When you ask how school is going, Jordan’s demeanor changes and he states that school isn’t going well, and he thinks that it is pointless. As you ask probing questions, you find out that the students organized some peaceful protests last month in response to racism in their communities and at school. In response to the peaceful protests, the school increased the amount of police and security guards that were at the school during those periods.

On one of the days, Jordan was running across campus to make it to class. One of the campus police officers stopped him and insisted on searching his bag even though he had done nothing wrong. He thinks the only reason he was stopped and searched was because he is a Black student. Jordan describes being afraid in that moment and since then he has seen that same campus police officer many times on his route to class. A couple of times since then, Jordan has skipped that class all together to avoid running into the officer. Jordan also states that he overheard some of the staff at school debating whether they should have to teach critical race theory or not, which he has also heard debate of on the news and at home.

1. How can you respectfully explore the impacts of racism on Jordan’s mental health?

As stated in the AAP policy statement The Impact of Racism on Child and Adolescent Health, “assess patients who report experiencing racism for mental health conditions, including signs of posttraumatic stress, anxiety, grief, and depressive symptoms, using validated screening tools and a trauma-informed approach to make referrals to mental health services as needed.”

After learning more about what Jordan has been experiencing at school, consider sharing with Jordan that the racism he is experiencing may be impacting his mental wellness. Let Jordan know that you'd like to ask him a few questions to understand how best to support him and his mental health in this challenging situation.

If mental health concerns are identified through the screening process, and the concerns are mild/moderate, consider scheduling follow-up appointments with Jordan via telehealth to further explore and manage these concerns. If the concerns are more severe, telehealth could be leveraged to facilitate referral to a mental health professional, and care coordination within the medical home. Let Jordan know that you'd like to connect him to additional professionals and how they might address some of the concerns.

2. How will you assess Jordan’s network to seek support around these circumstances?

It will be important to discuss this with Jordan and his family/caregivers. Often parents will want to take the lead on discussions with their child’s school, but you can offer your support and be sure to follow-up regarding what specific actions the school is taking to address Jordan’s experience. The AAP Council on School Health provides resources to help pediatric clinicians engage and interact with their school system and provides guidelines around the role of school physicians and school health personnel.

3. How else can you support Jordan in following up on these incidents?

According to The Impact of Racism on Child and Adolescent Health, some suggestions include integrating positive youth development approaches, including racial socialization, to identify strengths and assess youth and families for protective factors, such as a supportive extended family network, that can help mitigate exposure to racist behaviors.

Let Jordan know that you'd like to continue this dialogue in future appointments. Encourage role playing scenarios with Jordan and family members to build healthy reflexes on racialized encounters.

To download a PDF of this case study, click here.

Case Study #3: Sandy (Grandmother of a 6-year-old boy)

Sandy, who is African American, has a 6-year-old grandson who has a hearing loss. She provides support to her daughter and son-in-law by taking her grandson to medical appointments. She has already had difficulty in the past with clinicians who appeared racially biased in their interactions with her and her grandson, so she was leery of seeing a new specialist. She found a pediatrician who she has developed a supportive, trusting relationship with after several false starts with other clinicians.

Her grandson’s pediatrician made a referral to new audiologist. However, when she scheduled the telehealth visit with the audiologist, she found him dismissive and demeaning in the video visit – the clinician frequently broke eye contact with the family and seemed distracted. He would not address her questions and concerns and seemed put out that she was a smart, informed consumer who wasn’t going to simply accept his recommendations without having her concerns addressed. She abruptly ended the visit with the audiologist and sought a new referral with someone a friend recommended to her. As a result of this failed telehealth visit, Sandy’s grandson is now hesitant to use telehealth again.

1. After the visit, how can the clinician reflect on the interaction with the family to identify opportunities for improvement?

It is important for pediatric clinicians to reflect on their interactions with patients/families to ensure they are providing patient-centered care. In doing this, the clinician should first consider their own implicit biases, and if these biases may have impacted interactions with the family. The clinician can also reflect on their communication style and actions taken during the telehealth visit.

Clinicians should always make sure families understand the options presented to them and allow time to answer any questions that may arise. It is important to ask questions about patient/family experiences, barriers and past experiences with services and clinicians. If a pattern emerges where a pediatric clinician is experiencing families of color leaving their practice, it should raise a concern and possible need for further education, training and supervision about how to be more welcoming and affirming in their work for non-White families.

2. What are some things that the audiologist could have done differently to create a more welcoming telehealth visit experience for Sandy and her grandson?

There are a few ways in which the audiologist could have created a more welcoming environment for this visit, including:

• Asking about Sandy’s previous experiences with her grandson’s pediatricians and specialists.
• Using strategies for effective telehealth visits, like making eye contact with the camera, actively listening to the family and their concerns, and avoiding distractions in the room.
• Leveraging the family’s strengths and applauding Sandy’s questions – instead of making Sandy feel like her questions were unwelcome or burdensome.
• Finding ways to engage directly with the grandson during the visit, in addition to Sandy

3. Experiences of racism and ageism in the health care system has caused this family to feel disrespected and unheard. How can this be avoided in future interactions with other families?

It is important for clinicians to practice cultural humility and awareness, especially with families from diverse backgrounds. Some questions to consider include:

• Does the practice have welcoming signs, photos and indicators of their inclusiveness and diversity?
• Is the clinic staff representative of the population that the clinic serves?
• Has the staff been provided training on creating a welcoming environment, especially for minoritized populations?
• Do clinicians prioritize establishing relationships with families, including those who may require additional time to have their questions and concerns addressed?
• Is there a post-visit satisfaction survey available so families/caregivers can share their experiences for continuous quality improvement?
• During telehealth visits, do clinicians maintain eye contact and engagement with the family throughout, or do they look away, take notes, or get distracted frequently?

Encourage clinicians within the practice prioritize authenticity and empathy when communicating with all families. Ask questions about previous experiences within the health care system. Creating a welcoming environment for all families is where the work begins and will ensure that the experience is a positive and successful one for all.

To download a PDF of this case study, click here.