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November 30, 2020

An Interview with Sean Phelan, PhD, MPH, on Stigma in Primary Care

Type: Recognition Tags: Covid 19, Stigma, Education, Interview, Primary Care

This month's featured interview focuses on addressing stigma in primary care settings. This month the team spoke with Sean M. Phelan, PhD, MPH, Associate Professor of Health Services Research at Mayo Clinic in Rochester, MN in the Department of Health Sciences Research, Division of Health Care Policy and Research. Dr. Phelan is currently developing a curriculum for primary care trainees on overcoming stigma as a barrier to integrated behavioral health utilization.

What would you say are the key challenges to addressing stigma in primary care settings? 

Mental illness and substance use disorder stigma are both relevant to integrated behavioral health (IBH) care because they serve as barriers to patients disclosing behaviors or mental health concerns. These stigmas can be challenging to address because oftentimes patients attribute these conditions as a sign of weaknesses. It can be very difficult for many people to accept that they need resources and patients can often internalize negative stereotypes of behavioral health conditions. Add to that the public stigma about mental health and reactions they may anticipate from loved ones, and it makes sense that some would rather avoid the label that comes with it. One thing primary care providers can do is help patients understand the influence of external factors. That includes understanding and communicating to patients that mental illnesses and substance abuse disorders are diseases with complex causes: social, genetic, environmental; and are not signs of weakness or personal failure. And, that like other diseases, they may require treatment from health care professionals.   

Do you see any current opportunity to combat stigma in primary care? Do you have additional recommendations on how to do so?

I think the integrated behavioral health model can be an important tool for combatting the effects of stigma in primary care settings. For example, obesity stigma is a phenomenon I have studied extensively. Clinical recommendations state that primary care providers (PCPs) should screen for obesity and offer patients access to an intensive multicomponent behavioral weight loss program. Often, PCPs don’t have access to this resource so they feel they need to offer weight loss advice, which can result in patients feeling stigmatized.

I am working on a study now where we are finding that people who feel stigmatized in primary care are more likely to delay subsequent needed care and more likely to “doctor shop” for a new provider. Incorporating behavioral health into primary care presents an opportunity to address important mental health factors. This also allows the behavioral health conversation to shift to the specialist, which helps to preserve the trust that is important to a patient-primary care provider relationship.

Can you outline some strategies for teaching primary care learners about the impact of stigma on their patient care? Additionally, how can providers work to recognize their own biases?  

It varies depending on the type of bias. If the stigma is related to explicit biases and attitudes, then education about the complex causes of the condition can help reduce those explicit biases. This is because attribution is one important factor in determining how strongly a condition or characteristic is stigmatized. Primary care educators should focus on strategies that learners can use to overcome the influence of automatic biases on their behavior and the quality of care that they provide. For example, implicit biases are most likely to affect behavior when we are stressed or overwhelmed, so training learners in self-care strategies can help them focus on the individual rather than making assumptions. Additionally, having learners work in diverse communities can improve empathy and reduce anxiety about providing care to different populations. 

Additionally, medical educators should help learners confront their implicit biases by having them complete an Implicit Association Test focused on the specific stigmatized group of interest. I suggest doing this as part of an education program about what implicit bias is (the automatic associations that are created in our brains based on a lifetime of exposure to stereotypes and societal stigma) and what it is not (what someone REALLY thinks!) as well as strategies to overcome the effects of those biases on behavior. Leaving a trainee with the knowledge that they hold an implicit bias without a way to understand what that means will not allow them to develop away from these biases.

One thing that I and my collaborators find consistently in studies is that role modeling is strongly associated with learner biases and behaviors. The notion that the “hidden curriculum” of medical school has a powerful influence on students is not new, but the consistency with which we find that faculty role-modeling of discrimination in the form of derogatory comments or humor is associated with more negative implicit bias and explicit learner attitudes. This is one area that medical schools, residencies and other training programs should work to address.  

sean bio

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