Transcript
Speaker: Welcome to Critical Matters, a sound critical care podcast covering a broad range of topics related to the practice of intensive care medicine.
Speaker: Sound Critical Care provides comprehensive critical care programs to hospitals across the country.
Speaker: To learn more about our programs and career opportunities, visit www.soundphysicians.com.
Speaker: And now your host, Dr. Sergio Zanotti.
Speaker: During the last six months,
Speaker: The words, I can't breathe, have been a call for help by millions of patients with COVID-19.
Speaker: These words have also been a call for help by numerous black men, victims of police brutality.
Speaker: Men such as George Floyd, who uttered these words as he was being murdered by a Minneapolis police officer.
Speaker: COVID-19 and police brutality have once again shined the light on an old and deep rooted problem, systemic racism.
Speaker: Race is not a biological category that naturally produces health disparities because of genetic differences.
Speaker: Race is a political category that has staggering biological consequences because of the impact of social inequality on people's health.
Speaker: Dorothy E. Roberts.
Speaker: Today's episode of the podcast will focus on racism in healthcare.
Speaker: We will approach a difficult conversation, yet one that as clinicians we must have.
Speaker: Black Lives Matter, and we all should be doing a lot more to help save them.
Speaker: Our guest today is Dr. Gregory R. Johnson.
Speaker: Dr. Johnson is Chief Medical Officer of Hospital Medicine for Sound Physicians.
Speaker: Sound is a national multi-specialty practice with a focus on the acute care space.
Speaker: In his role as CMO for Hospital Medicine, he has clinical leadership responsibility for over 200 hospital medicine programs and thousands of clinicians that care for millions of patients every year.
Speaker: Dr. Johnson is a graduate of Dartmouth College and the McGovern School of Medicine at the University of Texas Health Science Center in Houston.
Speaker: He completed a dual residency program in internal medicine and family practice at the Ochsner Clinic in New Orleans.
Speaker: He has practiced hospital medicine his entire career.
Speaker: Dr. Johnson has had multiple leadership roles throughout his career at the local, state, and national level.
Speaker: He has served as president of the Houston chapters of the Society of Hospital Medicine
Speaker: and Harris County Academy of Family Physicians, chair of the Texas Medical Association's Young Physicians section and a member of the Society of Hospital Medicine's Public Policy Committee.
Speaker: He has served as clinical faculty for the Texas Tech University School of Medicine, as well as his alma mater.
Speaker: He currently serves as treasurer of the Texas Medical Association Foundation.
Speaker: Dr. Johnson is a thought leader within his field and a champion for diversity, inclusion, and belonging within medicine.
Speaker: and a phenomenal pandemic battle buddy.
Speaker: Greg, welcome to Critical Matters.
Speaker: Thanks for having me, Sergio.
Speaker: I'm happy to be here.
Speaker: So I think today we take a little bit of a departure from our usual topics in Critical Matters, although a lot of what we're going to talk is tremendously relevant clinically to our patients, but it's also a difficult conversation that I think that we must be having on a much more frequent basis.
Speaker: So I really appreciate the fact that you're willing to sit with me and help us with this conversation.
Speaker: And I asked the audience, I mean, to listen attentively because I think there's a lot of things that obviously are very important for us to discuss today in light of not only what's been happening over the last couple of weeks with police brutality, with COVID-19, but in reality for what's been happening for decades and centuries in our country.
Speaker: And as clinicians, I think we have a responsibility to do the best we can to impact our patients' lives and the lives of people that we work with.
Speaker: So Greg, maybe we should start with a very simple question, which I think is one that sometimes people struggle with answering, which is, what is race?
Speaker: Yeah, I think it's a fantastic question and a tremendous challenge, particularly when we're discussing not only racism, but racial disparities.
Speaker: And I think it's the identification
Speaker: either by us as clinicians or certainly by our patients of belonging to a very specific ethnic group.
Speaker: Now, I know most people say that we all belong to the human race and that's absolutely the case, but I think that we have historically in this country spent a lot of time making definitions of race based on skin color or a country of background.
Speaker: And so I think that's been a significant issue
Speaker: that absolutely contributes to the discussion and is really where things began.
Speaker: And I think it's very interesting because from a medical perspective, I think this bias that we have, like you said, in terms of basing things on skin color or country of origin, has really led people to confuse genotypes with phenotypes.
Speaker: And when we talk of human race, 99.9 of our genes are the same, no matter how you look externally.
Speaker: Yet a lot of our medical reasoning and medical decision-making might be biased by things that are based on the phenotype.
Speaker: No, that's absolutely the case.
Speaker: And I think that a lot of the evidence that goes, that's been produced in reports like the Institute of Medicine's unequal care really helps to underscore that,
Speaker: that there is a difference and ultimately a difference in terms of how our patients receive care.
Speaker: And it's simply based on that, again, that phenotype that's primarily based on skin color.
Speaker: So you mentioned two terms that I also wanted to dive a little bit deeper in terms of definition.
Speaker: You mentioned racism and you mentioned systemic racism.
Speaker: Could you tell us what we understand by racism?
Speaker: Well, I think racism just from a basic definition is just discrimination, prejudice, antagonism that's directed against a person or people based on their membership in terms of a specific ethnic group.
Speaker: And it's typically for those who are from marginalized groups or certainly those groups that are in the minority.
Speaker: Systemic racism is really, or I think,
Speaker: in many instances also described as institutional racism is really the structure, the processes, the laws, and any other systems that help to reinforce that prejudice and that antagonism.
Speaker: And so I think those are the differentiation points between just global racism and then systemic or institutional racism.
Speaker: And I think it's also important to point out, Greg, which I think is part of the discussion that we're having today and part of the discussions that we've had offline multiple times in the last several weeks is that many, many of our colleagues don't consider themselves racist because they obviously do not exhibit hatred towards people of other races, yet complicitly, maybe in silent, we participate in the system
Speaker: that is systematically treating people in a racist way, or we might have behaviors that might be racist based on implicit bias that have been given down to us by society and by generations of education or lack of education.
Speaker: Can you comment a little bit on that?
Speaker: No, I think certainly from my personal perspective, what you stated is I hope the dominant case, which is that in many instances there have been
Speaker: either societal reinforcement or educational reinforcement that creates bias that ends up being a longstanding issue for all of us, whether it's black individuals to black individuals or non-black individuals to black individuals.
Speaker: And again, I'm highlighting black versus non-black, but I think it can apply certainly to
Speaker: any other ethnic group.
Speaker: And that's the challenge for us to accept is that there's been a lot of reinforcement that's gone on through the years that leads into bias and that bias leads to beliefs and those beliefs end up in, ultimately result in how people are treated.
Speaker: And we're talking certainly about treatment from a medical standpoint, but we're also just talking about treatment in terms of non-medical, in terms of just how people are treated in general society.
Speaker: Absolutely.
Speaker: And I think we're going to dive into different topics.
Speaker: And hopefully what I intend would be the result of this is that the listeners can reflect at the end of this podcast and really recognize how their actions or lack of actions contribute
Speaker: to the perpetuation of racism in healthcare and what are the steps that we need to take at the end to really change this trajectory.
Speaker: So maybe we can talk a lot of what we've been talking for the last several weeks, I mean, at a professional level at our calls, Greg has related to COVID-19 and I think it might be a great place to start exploring racial disparities.
Speaker: When this whole pandemic started, I noticed two very different interesting
Speaker: On one hand, from a clinician standpoint, we were very interested in identifying risk factors for people developing COVID, developing severe forms of COVID, and very quickly, people started talking about age, people started talking about comorbid conditions such as heart disease, hypertension, diabetes, immunosuppression.
Speaker: From a public perspective, also it seemed that they were very interested in identifying these risk factors
Speaker: But what I found was talking with friends and people in the public is it's almost like there was a need because of fear to make sure that the people who get really bad COVID are not like me.
Speaker: They have problems.
Speaker: They have other issues that put them at a higher risk.
Speaker: And that seems to be a very interesting narrative.
Speaker: But we definitely worked on identifying these risk factors.
Speaker: And there's a big risk factor that I didn't mention, which is race.
Speaker: And I think as the pandemic progressed, we recognize that it's
Speaker: around the world, but specifically in the United States, being a black male or female or being Hispanic were very, very high risk factors.
Speaker: And we started talking about racial disparities in COVID-19 and the risk factor of race.
Speaker: Could you tell us a little bit more about that, Greg, in a general context?
Speaker: Well, yes, Sergio.
Speaker: I think when we were fairly early in the pandemic, you're right, everybody was listing
Speaker: the number of risk factors, we were discussing older age, male sex, hypertension, diabetes, obesity, any concomitant cardiovascular issues.
Speaker: But then when you started looking at the reports that were coming out from different locations, so Illinois, African-Americans are 14% of the population and certainly early on in the pandemic, what was noted was that African-Americans were 40% of the overall fatalities related to COVID.
Speaker: For Native Americans in Arizona, reports were coming out that Native Americans were only about just short of 5% of the overall population, but in excess of 16% of the fatalities.
Speaker: And if you look at the most recent MMWRs now, we're talking about the Latinx population, which the overall mortality associated with that is 24.4%.
Speaker: And yet,
Speaker: in terms of the overall share of the population, it's closer to around 13% based on some of the reports.
Speaker: And so, there have been a number of articles that have really highlighted that as a particular concern, because again, it's really talking, speaking to the fact that there is increased amount of, in fact, I'll quote this article from James Henry and David Lighton that really,
Speaker: underscored it's the distribution of suffering during the pandemic.
Speaker: And I think that's something that as an independent risk factor and recognizing that there's a higher level of mortality, not just morbidity, but mortality related to it, it was certainly disturbing.
Speaker: And that has continued as additional reports have come out about patients that are not only being diagnosed with COVID,
Speaker: but also that are dying from it.
Speaker: Yeah.
Speaker: And I think that obviously begs the question, why is it that African-American and Hispanic patients are at higher risk, not only of having COVID, but of having the severe forms of COVID?
Speaker: And I think that as we explore this question, Greg, maybe we can start by some myth busting, which I think is very commonly present in the narrative of medicine in general, but also I think I've heard within COVID-19,
Speaker: And one of them that I think is very prevalent in our medical education is biology.
Speaker: Can you talk a little bit, I mean, are their lungs different?
Speaker: Is that why they get worse, COVID-19?
Speaker: No, I think, you know, when we're talking about myth busting, a lot of what's been done historically in this country has been about getting to the point that you said, us versus them, in terms of what is going on and why
Speaker: Black patients, Latinx patients would be treated differently.
Speaker: And the answer, obviously, to your question is no, we're not seeing any differences with respect to what's going on with lungs or heart disease.
Speaker: Obviously, there is an increased prevalence of heart disease, of diabetes in the Black and Latinx communities that have been highlighted.
Speaker: And the question I think that's related to COVID is which comes first, the chicken or the egg?
Speaker: And have historic inequities in terms of addressing those conditions contributed to the increased prevalence of COVID-19 and the increased effects of COVID-19 in these populations?
Speaker: But if you look at throughout everything that has gone on historically,
Speaker: We're not seeing this.
Speaker: There may be some issues that are related to socioeconomics, but again, looking at a variety of different reports and we don't have enough with respect to COVID, socioeconomic differences don't seem to bear out why there are such pronounced differences in the black and Hispanic communities specifically with COVID-19.
Speaker: And I think that taking a leap at congencially, this is something that has also been explored in
Speaker: in maternal fetal deaths and black women, regardless of socioeconomic status, have a higher risk of having maternal fetal complications at delivery.
Speaker: And again, that's not explained just by socioeconomics, which is something that I think also, like you said, is being explored in COVID.
Speaker: Well, and I'm sorry, Sergio, I really want to underscore that particular point because even, and I'll refer frequently back to the Institute of Medicine's unequal
Speaker: care report that's actually a book, but there is a very specific citation in there, and this is from 20 years ago, and if you go back 40 years, it's the same information, is that when you look at the majority of studies and they control for socioeconomic status, there's still disparities with respect to care.
Speaker: And so that's gotta be in the back of, that's gotta be addressed up front
Speaker: for all the listeners in terms of saying, if we're making that assumption, it's not a correct assumption.
Speaker: We already have a confirmation that, you know, that that's not, that doesn't explain everything.
Speaker: And I think it's important because two things that I think are very irrelevant that I think a lot of clinicians sometimes overlook is that biology does not explain the difference in outcomes and socioeconomics does not explain all the difference in outcomes either.
Speaker: And I think it's the result, and we'll talk more about specific examples of basically a system that has systematically over time been biased against people of certain races causing a lot of these problems.
Speaker: And I think like you said, we have to recognize that as clinicians because it is a risk factor that's no different than hypertension, than diabetes and the ones that we mentioned earlier.
Speaker: The other thing that I've also read on a lot of the COVID papers in terms of another incorrect assumption is the fact of racial stereotypes about behavioral patterns, where people think that because certain groups or certain ethnic groups behave differently, they might be at a higher risk for COVID.
Speaker: But I think that that fails to maybe link that social distancing might be a privilege, working from home might be a privilege.
Speaker: And I think especially in some of our
Speaker: here in Texas and some of our Hispanic communities, our Latino communities, we've seen that.
Speaker: Can you comment on that a little bit, Greg?
Speaker: Well, I think you're right.
Speaker: Like when you're thinking about things that are related to healthcare, but are other social determinants of health, whether we're talking about housing and housing distribution, well, you look at the data that
Speaker: like you discussed social distancing and the ability to have access to masks.
Speaker: Well, that's a tremendous issue when you're thinking, considering like the homeless and the fact that there is a significant portion of the population that's certainly black or African-American that is homeless and therefore doesn't have access to that information, the ability to isolate from others, have masks or to shelter in place because
Speaker: there is no place to shelter.
Speaker: When you're considering issues about interfacing with schools and understanding that there is a tremendous documented difference in terms of access to things like Wi-Fi and the internet for many Black populations, and therefore that's going to have material effect on people's ability to access schools.
Speaker: I think when we're considering what you're discussing, and maybe it's a tangential point or direct, but these are all, again, additional factors in terms of social determinants of health that include ethnicity and race that have to be considered in terms of how we're addressing our patients.
Speaker: And I think that you mentioned that what comes before the chicken or the egg, when we look at some of the risk factors in terms of diabetes, hypertension, heart disease, clearly more common
Speaker: in black males, more prevalent, I should say, in black males.
Speaker: And the assumption, I think, has always been that there might be some genetic predispositions, but the reality is that the reason why they're probably more prevalent has to do with access to care, and that is independent a lot of times because of things that have been embedded in the system for decades now of socioeconomic status and really talks to basically racism in healthcare at a systemic level in a much broader context.
Speaker: So maybe we can kind of explore that
Speaker: by looking at some of the issues that I think are very relevant and that I think have an historical context also in terms of impact of racism on access to healthcare beyond socioeconomics.
Speaker: And I would like to start with trust.
Speaker: Could you talk a little bit to that in terms of how that impacts access to care for black communities?
Speaker: Well, I think that
Speaker: There's interesting that there's a recent Pew study that came out that actually discussed that very specific issue and very specifically that Black Americans in general are skeptical of medical misconduct.
Speaker: And there is a lot of historical basis with respect to that.
Speaker: If you look at
Speaker: Anybody who wants to look this up can certainly go to the CDC's website or other known resources, but you look at experiments like the Tuskegee syphilis experiments where black patients were enrolled in a study to look at latent syphilis, and then once penicillin became available as a treatment, the patients weren't given that treatment.
Speaker: you know, basic things that you would say, hey, look, what medicine and healthcare is supposed to be doing is, you know, helping to treat and relieve people from disease and looking at instances such as that, the instances such as what's happened with Henrietta Lacks and what occurred in terms of herb cells being taken, cultured, and, you know, essentially rolled out as
Speaker: part of additional medical research without her individual consent.
Speaker: These are part of the historical context.
Speaker: And even if people don't know the details, people hear the stories that are associated with those and then have a fundamental concern about what's going on in terms of whether or not they're going to receive healthcare.
Speaker: Another instance that I know when I read it, I was...
Speaker: my mind was blown, but again, it comes from the Institute of Medicine report.
Speaker: And again, the case of bilateral orchiectomy and amputation, and noting that again, controlling for their same peers, black patients undergo rates of 2.4 to 3.6 times greater bilateral orchiectomy and amputation than their white peers.
Speaker: of, you know, do people know these studies?
Speaker: No, but you start hearing things on a very consistent basis and then yes, there's going to be concerns about whether or not the system, the healthcare system is specifically interested in treating you or using you for treatments for other individuals.
Speaker: And so that's a fundamental component of people's trust of the healthcare system in general.
Speaker: And I think the examples that you've mentioned
Speaker: I think for our listeners, I mean, we'll put links to all of these, but these are not like far and few between.
Speaker: There is a consistent thread of similar abuses to Black Americans over time.
Speaker: There's also a lot written about Dr. J. Miriam Sims, who was considered the father of gynecology in the 1800s, and the amount of experimentation without consent that he did on Black females.
Speaker: And there's, I mean, multiple stories and examples that I think, like Greg said, I mean, I think would predispose any community to mistrust of a medical system that historically has not had their best interest at hand.
Speaker: Now, the other side of the ad equation, I think you have the mistrust from the black patient.
Speaker: But I think that another thing that's worth talking about, Greg, is the implicit biases
Speaker: that many non-black clinicians and maybe even some black clinicians carry as a basically, this is a result of decades of systematic racism.
Speaker: And I don't know if you, it was just a very recent Twitter post from a doctor that went viral and I caught it because Neil deGrasse Tyson,
Speaker: put it in his feed and start commenting on it.
Speaker: I don't know if you're aware of what I'm talking about, I'll share with you where the surgeon had to perform during COVID, a non-COVID patient, but a major surgery on a black patient.
Speaker: And with limited access to families, obviously, and all the restrictions, this surgeon was taken aback by the fact that the time that the family had to discuss the surgery with the surgeon was
Speaker: the family chose to make sure that they spent enough time or all the time detailing how high functional, how accomplished, and basically dignifying the patient as a real contributor to society, as opposed to asking the questions that most people would be asking regarding the surgery.
Speaker: And now DeGrasse Tyson immediately shared that when his 88 year old father had a stroke, when he took a picture of him giving it as a professor,
Speaker: giving a lecture and people identified who it was, the treatment immediately changed.
Speaker: Can you talk a little bit about this, Greg?
Speaker: I'm not familiar with what you described, but I do think that what you're highlighting is the, and you'll have to forgive me, I'm going to take my own particular view of this,
Speaker: But I think this is really underscoring what people are attempting to express in stating Black Lives Matter, is to underscore that to a lot of African Americans, there has to be a justification to a healthcare professional and to the healthcare institution that this individual, despite the color of his or her skin,
Speaker: requires the best of your care, and in many instances, they are taking extra time to make sure that it is justified so that that way it's either humanizing the patient and underscoring that this person has value and contributes to society.
Speaker: And it's a painful aspect in terms of thinking
Speaker: that individuals have to go forward and make that explanation and justify it.
Speaker: But in so many instances, there are conversations of, oh, the patient's gonna refuse care, I don't wanna be able to give this.
Speaker: And again, what so many reports have documented is that patients aren't receiving care.
Speaker: In oncology patients, they're not receiving access to treatment
Speaker: And the only disparity that we can identify is how the healthcare provider sees the patient.
Speaker: And so it's a tremendous problem.
Speaker: It's tremendously painful and difficult to address, but it is a component of things that we need to consider in terms of how we're, again, in terms of how we're treating all of our patients, but particularly our patients of color.
Speaker: And I think that the fact that as
Speaker: as a community or as a group, they feel the need to justify that illustrates how deep-rooted these problems really are.
Speaker: And I think that you mentioned it, Greg, and I think it's a great place to tell people this is why when people say all lives matter, they're missing the point.
Speaker: The point here is that there has been a systematic bias against certain races in healthcare
Speaker: and that we as clinicians must first recognize that, and second, do what we can as well as our hands to change that.
Speaker: And I think that even though you didn't know the specific case I was sharing, I think that that's exactly what I was trying to get to.
Speaker: And it's obviously, again, these are not a far and apart incidences or exceptions.
Speaker: These are things that happen on a recurrent basis, correct?
Speaker: Correct.
Speaker: And we have it documented.
Speaker: repeatedly over the last 40 to 60 years.
Speaker: And that's only because that's when we started documenting it.
Speaker: The other thing that I think we talked about trust and implicit biases, but obviously a lot of people have talked about the ideal situation is to have a race concordant or even language concordant or belief concordant.
Speaker: clinicians taking care of you because you're much more likely to connect with that person or that person might be able to understand a lot of your background and what's going through your mind.
Speaker: Can you talk a little bit about, again, how that is almost impossible for most Black patients and why?
Speaker: Well, I mean, I think, so first off, to confirm your original point is that, again, there have been studies to document that racial concordance
Speaker: between patient and provider has better patient participation in healthcare, higher satisfaction, and better adherence to treatment.
Speaker: Now, why is that impossible?
Speaker: Well, if you look at what is in place in terms of, and I'll speak because I know the information specifically about Black and African-American, Black and African-Americans is, again,
Speaker: certain percentage of the population, but there's only 5% of all physicians that are African American.
Speaker: And the spread of African Americans across the country is tremendous.
Speaker: So it is, I mean, based on how we are admitting folks, based on institutional biases,
Speaker: with respect to the advancement of African Americans and other ethnic minorities into healthcare, it's incredibly difficult.
Speaker: I won't say it's impossible, but as it stands today, it's not possible for us to achieve racial concordance despite the fact that the data shows that we can get better patient outcomes and certainly improvements in terms of patients' overall adherence to their care.
Speaker: And I think it also speaks, I mean, as you were mentioning, the discordance that we have in terms of the percent of the population who is Black and the percent of the population in our country who are physicians.
Speaker: It also goes, I mean, to historical systematic issues that have made it much more difficult for Black young men and women to get to medical school historically.
Speaker: And those are also part of this whole
Speaker: systemic racism.
Speaker: And I think it really is just shows that at all levels of society, there are hurdles that are much higher for a for black people to overcome.
Speaker: And that is something that has been like that for many years, despite I mean, the effort of the civil rights movement, and that is still pervasive and prevalent, right?
Speaker: No, it's absolutely the case.
Speaker: Again, looking at my I'll speak about my own experience in medical school, that
Speaker: you know, watching the number of Black and African American students, quite honestly, ethnic minority students who were involved and accepted into the medical school, and then the Hopwood decision came through that specifically excluded the consideration of one's ethnic background.
Speaker: And for years afterwards, there was a dramatic reduction in terms of the
Speaker: the number of ethnic minority students that were led into my medical school.
Speaker: As one example, that it's a barrier and again, while people can look at this from a variety of different angles, the simple fact of the matter is that there are a lot of studies that indicate that not only diversity in the medical school class helps to lead to greater cultural competence in the aggregate,
Speaker: but it also means that there's going to be improvements in terms of patient care and the commitment to make sure that particularly ethnic communities that are higher risk, meaning ethnic communities that are not only underrepresented but also socioeconomically disadvantaged, that it is ethnic minority physicians who are much more likely to enter those communities
Speaker: and help to address the healthcare concerns of that patient population.
Speaker: Absolutely.
Speaker: And I think that we talked about the value of having race concordant physicians, but obviously there's a lot that we have to do to keep pushing that.
Speaker: But I think that it's something that as clinicians, we should be aware.
Speaker: But I've also heard that some clinicians will say, well, I'm colorblind when I treat patients.
Speaker: But if race is a healthcare risk factor,
Speaker: for worse outcomes, whether it be COVID or just care in general, maybe as a clinician, I shouldn't be colorblind and I should really try to integrate into my decision-making into what I'm trying to ask and trying to support and trying to guide all these issues as well.
Speaker: Can you comment to that, Greg, please?
Speaker: Well, absolutely.
Speaker: I think, first from just the humanity perspective, I think most patients know that it's very obvious
Speaker: I certainly say as being a black man, I don't think it's not, it's difficult for people to identify me as that.
Speaker: And I quite frankly, I'm proud of it and I'm proud to be identified in that particular way.
Speaker: I think we state in many instances that we're being colorblind, but if you look at the typical history and physical of our patients, almost everybody
Speaker: makes a comment about a patient's ethnic background in the initial portion as how they identify patients.
Speaker: And I think that if we are being true to our patients and doing the best we can in terms of treating them to understand that there are cultural competency issues that we want to address, there are risk factors that make potential patients higher risk, and that we want to make sure that we are addressing those particular concerns.
Speaker: All of those are incredibly important, but then again, just addressing somebody as a human being and saying, yes, I see you for who you are is as important and as important in terms of helping patients to relax and understand that we as caregivers are interested in them holistically eliminates the
Speaker: For me, it eliminates the perspective of discussing people as being colorblind.
Speaker: It's a false reality.
Speaker: And I think that at the end of the day, obviously, what we always try to do with any patient is to foster a connection and find things in common, and there's plenty.
Speaker: And I think that understanding also some of the things that patients suffer that we don't suffer, and having that true empathy and compassion definitely, I mean, can make us better clinicians and serve our patients better.
Speaker: One of the things that I wanted to talk a little bit about it also in terms of the impact on healthcare access is algorithms.
Speaker: And I know that we talked about this offline not too long ago.
Speaker: And I read, I mean, as prep for this podcast, was reading a very interesting article that talked about how a biased algorithm would actually require a black patient to be significantly sicker
Speaker: than a white patient in order to receive a certain care because a lot of the algorithm was based on how much they spend on care.
Speaker: And the reality is that on average, regardless of socioeconomic status, the black patients have less access or get less treatments for many reasons.
Speaker: So that particular algorithm was extremely biased against black patients, but you've also,
Speaker: taught me that algorithms can be a solution.
Speaker: Can we talk a little bit more about that?
Speaker: Well, yes.
Speaker: I think you could absolutely cite some of the issues that are also related to the algorithms and calculating GFR.
Speaker: And they certainly have impact in terms of caring for patients.
Speaker: But one of the interesting things that, again, the Institute of Medicine report highlighted was that looking at other systems, for instance, the VA system, that where
Speaker: patient care is highly protocolized and understanding that certainly from the IOM's perspective and after the research that they've conducted, that actually instituting care protocols that ensure that patients do get consistent access and evaluation is potentially a way to address disparities.
Speaker: And I know that as a clinician, I know I've
Speaker: been as guilty of saying, oh, well, you know, these, you know, I don't want to practice cookbook medicine.
Speaker: And I certainly would never advocate for eliminating clinical judgment.
Speaker: But I think that we also have to acknowledge that whether it's for sepsis or for VTE prophylaxis or anything else that where there are commonly identified and consistently identified
Speaker: treatments that benefit patient care, those protocols are an important step in terms of helping to make sure that we as clinicians can mitigate potential disparities in care.
Speaker: It doesn't eliminate them, but I think the IOM has very clearly said that this would be a step in the right direction.
Speaker: The next thing I wanted to touch on, which is I think a recent, not a recent development, I think it's an old development, but that has obviously been in our minds
Speaker: a lot more recently because of the events that we described at the introduction relates to police brutality on black males.
Speaker: And you had shared with me in a conversation prior to the podcast that obviously a black male who stopped by the police is significantly higher chance of dying than a non-black male stopped by the police, even for a regular traffic stop.
Speaker: So clearly it is a
Speaker: healthcare risk factor for death, especially in young males.
Speaker: And I think as such, it's definitely something that we as clinicians have to absolutely be involved with and changing.
Speaker: And I just wanted to get your thoughts as we talk about this and maybe start by sharing, I mean, conversations that I've had with you and other friends in terms of our sons who are
Speaker: teenagers who are driving.
Speaker: And obviously, all parents worry about the car being wrecked at the minimum or the kid getting in an accident.
Speaker: But you have other worries that a lot of people of white color like myself don't worry as much.
Speaker: Can we start there, Greg?
Speaker: Yeah, I mean, I think I always try and ground things in facts.
Speaker: And I think if you, you know, strictly looking at
Speaker: what's been documented out there, the morbidity and mortality weekly report that comes from the CDC identifies something very specific around legal intervention deaths, meaning death involving a police officer of any form.
Speaker: And if you look at this, non-Hispanic white males accounted not,
Speaker: sorry, non-Hispanic black males had the highest rate, 2.8 times the rate of non-Hispanic white males.
Speaker: Almost three times the rate of black males versus white males, almost three times the rate in terms of deaths involving a police officer.
Speaker: And of those, a quarter of those were unarmed.
Speaker: And I think it, go ahead, sorry.
Speaker: No, it's okay.
Speaker: And I think when you and I are discussing this and I think of areas that are a public health emergency, anytime I can hear that, you know, something that should be as simple as a traffic stop or another legal intervention where somebody is three times increased likelihood of, not injury, of death,
Speaker: is gotta be something, you know, it's gotta be a klaxon for us as a profession to say, these are our patients.
Speaker: Irrespective of anything else that's going on, these are patients and three times more likely to die from a specific intervention.
Speaker: Something's gotta be done.
Speaker: And, you know, when I think what you and I were talking about was, you know,
Speaker: Before I even knew this data, my conversations with my teenage sons was really focused on how do you do your best to mitigate the risk of death from a legal intervention?
Speaker: And I know that when you and I talked about it, you're like, this isn't a conversation I've ever had with my kids when they got a driver's license.
Speaker: But I believe that's what you're talking about.
Speaker: And I know that it's not a conversation that's comfortable for certainly me and having it with my kids and making them any less scared about driving even when they're new drivers.
Speaker: But also understanding that this is something, and I get back to the point that you were making before, this is a public health issue.
Speaker: emergency that, and I don't think that's an overstatement that I think that we've got to be able to address.
Speaker: Absolutely.
Speaker: And I think that it's important for us also to recognize in the same way how it impacts our colleagues in healthcare.
Speaker: And I think one of the things that I wanted to talk with you about was what is the racism that is still prevalent towards physicians and clinicians
Speaker: in our practices today.
Speaker: And this is something that we've talked a little bit offline, but I think it speaks to what it means to be privileged, what it means to have white privilege.
Speaker: Like people say, apologists will say, well, I worked hard.
Speaker: And we always talk about this.
Speaker: We both have similar roles within our organization.
Speaker: We both worked very hard to become good doctors.
Speaker: We both worked very hard to keep learning, to keep making a difference.
Speaker: yet I've never had to work hard because of the color of my skin or work harder because of the color of my skin.
Speaker: Yet I know that a lot of my black colleagues have suffered indignities and difficulties just because of that.
Speaker: Could you speak to that a little bit, Greg?
Speaker: Yeah, I think it's, again, if you look at the history of medicine and the fact that there have been, there's clear documentation that specialty societies
Speaker: geared to make sure that ethnic minorities were excluded from medical staff.
Speaker: There are obviously other issues that really created concerns about the number of whether or not an ethnic minority, particularly Black individuals, were ever even let into medical schools.
Speaker: And I think, you know, when we discuss privilege, I think, you know,
Speaker: as a component of the societal issues that we've discussed, there is a constant, and I know some people have concerns about the word constant, but there is a constant issue that many of us feel that we have to address in terms of our belonging at the table, because people question whether or not you were let into medical school
Speaker: and whether or not you were qualified to be there.
Speaker: I know I had a debate with somebody that said, yeah, there were absolutely people that were in our medical school class that weren't qualified.
Speaker: And I know that my counter to that was these are individuals who are board certified, passed all three steps, and are board certified and highly successful in their choice.
Speaker: How would you determine whether or not they were qualified or not?
Speaker: You weren't on the admissions committee, you have no visibility to that, and obviously they were able to succeed.
Speaker: There is still active issues of whether or not, again, Institute of Medicine reports that black and Hispanic physicians have difficulty getting their patients access to subspecialists.
Speaker: There wasn't a why, but why that's the case,
Speaker: But it's a question that we should be asking ourselves is, why would that be the case?
Speaker: Why would people be questioning whether or not those, and I don't know if it's a question or not, there's more to be garnered from those studies, but those are still active portions of practicing medicine as a black person in this country that we still have to address even in 2020.
Speaker: And so,
Speaker: I think as we are considering our colleagues now, some of this is recognizing that the experience in terms of getting to the point of being able to deliver care is quite commonly very different irrespective of those individuals' backgrounds.
Speaker: And it does highlight the issue that privilege isn't just, you know,
Speaker: is also not necessarily socioeconomically derived.
Speaker: And I think another topic that I wanted to ask you about was that that relates to microaggressions in the workplace.
Speaker: And I know that this is a term that has been also used in other areas where there's discrimination, be it gender, be it sexual orientation, which I think are all super important, but obviously
Speaker: It's not what we're talking about today.
Speaker: But could you maybe explore or go down that rabbit hole a little bit more for us, Greg?
Speaker: Yeah, I think so again, defining microaggressions for some that wouldn't necessarily know it, but microaggressions are considered everyday verbal, nonverbal, environmental slights, snubs, or insults.
Speaker: They may be intentional, they may not be, but ultimately they communicate
Speaker: level of hostility.
Speaker: And that definition comes from the UCLA diversity and faculty development department about diversity in the classroom.
Speaker: But again, it's effectively messaging, negative messaging that is going to marginalize groups.
Speaker: And some are
Speaker: Some are conscious, some are unconscious, and then there's just a lot of invalidations.
Speaker: Things like, I don't see you as black.
Speaker: You are not like them.
Speaker: You're different.
Speaker: Are all types of microaggressions that absolutely convey issues that are
Speaker: certainly prevalent in terms of how we deal with each other as clinical colleagues, but also carry forward in terms of how we address our patients.
Speaker: Yeah, and I think it's very important because if you look at human psychology from a very basic perspective, we tend to think that things that happen to us happen to us if they're positive because
Speaker: of something we did or because we are gifted or we're very good at what we do.
Speaker: And if they're negative, it's the environment.
Speaker: If it happens to somebody else and it's negative, it's usually their fault.
Speaker: And then when we start expanding that to groups, right, we think that the group that is our group is much more diverse.
Speaker: We tend to humanize that group a lot more.
Speaker: But the group that is not our group, they're all the same.
Speaker: So those, I think, are our assumptions or biases when you tell somebody, I don't see you as Black,
Speaker: is because you're making an assumption that all black people are the same, right?
Speaker: And that is, I think, a remnant of decades and centuries of racist behavior, basically.
Speaker: It's absolutely true.
Speaker: And I think that part of our challenge in terms of addressing what's going on currently and what has been going on in our hospitals and our healthcare community is recognizing that
Speaker: yeah, there may be contradictions and areas of concern that when we're discussing racial concordance in one sense, and one could make an argument, oh, well, that's treating all black people as if they're the same versus the microaggression piece that we just discussed.
Speaker: And I think nobody's saying that any of these conversations, solutions, or topics are easy to address, but
Speaker: The fundamental piece that we have to focus on is there is a significant difference of what's going on with our patients.
Speaker: It's based on skin color and it is our obligation to do something about it.
Speaker: Yeah.
Speaker: And I think that one of our objectives was obviously to start this conversation, to shed light to something that is not new, but that we definitely, I mean, have to take care of as clinicians.
Speaker: And I think that the recent developments obviously have amplified the volume for the need for us as clinicians to work on this with COVID, but also with all the recent episodes of police brutality.
Speaker: But I would like to end, I mean, the conversation on racism in healthcare with a little bit of a positive note in terms of what can we do to move this forward?
Speaker: And I would like to start with a couple of maybe just a minute, you could give us like a couple of pointers or thoughts in terms of what can each one of our listeners do to move this forward, to make it better first for our patients?
Speaker: Well, I think in terms of what we can do for our patients, I think it's really spending some time considering what interventions we can make to standardize care.
Speaker: certainly where it makes sense and certainly where the evidence supports that.
Speaker: As I mentioned before, Institute of Medicine reports that maybe one of our initial approaches should be identifying protocols and making sure that we're consistently using them.
Speaker: I know for SAUND's hospital medicine practice, one of the things that we are going to start doing very specifically is addressing how consistently order sets that
Speaker: are evidence-based are being utilized in order to treat our patients.
Speaker: Because one of the things that we know that if we have a strong belief that that level of consistency is going to diminish disparity, then it's something that we know that we can do and quite honestly, we know we can track.
Speaker: What about things we can do, Greg, for our colleagues?
Speaker: I think one of the things that's probably important that we can do for our colleagues is, I'd say it's twofold.
Speaker: The first of which is, you know, being willing to have the conversations that you and I have, right?
Speaker: It's being open to hearing things that make you uncomfortable with the understanding that the goal is to get you to understand better.
Speaker: I think more formally,
Speaker: looking for opportunities where you can get into unconscious bias training and be able to address that very specifically is a way that you can very specifically learn how to better interact with your colleagues of color.
Speaker: And finally, what about what are things that we can do for society?
Speaker: And I think that this obviously is going to center more around
Speaker: decreasing police brutality?
Speaker: So I know that is a huge reach for everybody.
Speaker: I personally like to go where the evidence is.
Speaker: And the 8 Can't Wait campaign has been something where, again, it's evidence that shows that by police departments taking on these eight specific revisions of their interventions,
Speaker: has dramatically decreased the mortality associated with legal interventions.
Speaker: And there's a website, 8 Can't Wait, where people can read what the interventions are and how they can make changes in their local community.
Speaker: So we'll definitely link that website to the show notes so people can take a look and, like you said, be proponents in their own communities of this campaign that, like you said, is evidence-based.
Speaker: So this obviously is a conversation that I probably should have had many, many years ago with one of my colleagues, but they say that the best time to plant the tree was 20 years ago.
Speaker: The second best time is today.
Speaker: So I'm super thankful, Greg, that you're willing to take the time to talk with me about this and educate not only myself, but our audience about something that I think is extremely important for us as clinicians and as a society.
Speaker: But before I leave you off the hook,
Speaker: I wanted to ask you some closing questions that are unrelated to the topic or not necessarily related to the topic that we always ask our guests to try to tap into their wisdom and knowledge.
Speaker: Would that be okay?
Speaker: Sure.
Speaker: So the first question relates to books.
Speaker: And I wanted to know if there are any books that have influenced you the most or books that you have gifted most often to others.
Speaker: Well, in regard to this topic, absolutely.
Speaker: The, uh,
Speaker: The Institute of Medicine's Unequal Treatment Report, which is a book that has influenced me the most.
Speaker: The other book that I have certainly suggested is Just Medicine by Dana Matthew.
Speaker: It's another book that I'm actually in the midst of reading now, but I think it's really focused on not only identifying disparities, but helping to provide solutions on how to address them and improve healthcare.
Speaker: with respect to race and ethnicity in this country.
Speaker: Excellent.
Speaker: The second question relates to what do you believe to be true in medicine or life that most other people don't believe or at least behave like they don't believe?
Speaker: I think that certainly about this topic, I believe that most of us probably are racist and
Speaker: we either joke or accept it and we don't recognize that we've been taught to be that way either by society, our families, or both.
Speaker: And I think that acknowledging that and addressing it, and again, I'm speaking about myself as well, is an opportunity for us to connect better with each other as human beings and ultimately for us to
Speaker: in terms of acknowledging it, addressing it, and then learning our way out of it to become anti-racist is an incredibly important, at least personal belief of mine.
Speaker: Yeah, and I think that it speaks also to something that we have talked about before, which is it's not enough for people to say, I'm not racist, because like you said, if we really are honest to ourselves, we probably have all had racist attitudes towards
Speaker: different races or different people.
Speaker: But I think it's about as clinicians becoming anti-racist and really changing the trajectory of these healthcare disparities.
Speaker: And also, I mean, at a society level, just, I mean, doing what's right for people based on what we really believe.
Speaker: The last question, Greg, relates to what would you want every intensivist who's listening to us right now to know?
Speaker: Could be a quote, a fact, or just a comment.
Speaker: Oh, you know, you prepared me for this before, and it's a, I think it's a tremendously challenging question to be able to go out to this audience.
Speaker: But I think the biggest thing that I want to know is that, is that first and foremost, I'm aware that our, my intensivist colleagues, you included, have, are,
Speaker: the tip of the spear with respect to addressing what's going on with COVID and my thoughts, my prayers, and my hopes in terms of your own individual well-being.
Speaker: I can't express my own gratitude and just my own concern for everybody's well-being because I know that we're all, everybody who is seeing patients and delivering care is at risk.
Speaker: But I think that
Speaker: you know, the other component is to really underscore that, you know, medicine is complicated, medicine is difficult.
Speaker: None of these problems are new and none of these problems are gonna be solved overnight.
Speaker: But I think that everybody can take an individual step towards helping to address healthcare disparities because ultimately it is our commitment as a profession to make sure that all patients receive
Speaker: the best care, and to underscore that first we do no harm.
Speaker: And if we can find very specific ways, not only from police brutality, but in terms of addressing a lot of these disparities, then we will be materially reducing the harm that many of our patients are receiving from the healthcare system.
Speaker: And I think that's a perfect place to stop.
Speaker: Greg, once again, I really appreciate your time and your willingness to talk about this topic, but also share your expertise and
Speaker: and your thoughts and hope to have you back on the podcast to talk about maybe other topics or this topic again.
Speaker: Thank you very much.
Speaker: Thanks, Sergio.
Speaker: Thank you for listening to Critical Matters, a sound critical care podcast.
Speaker: Make sure to subscribe to Critical Matters on Apple or Google podcasts and share with your network.
Speaker: Sound Critical Care is transforming the way critical care is provided in hospitals across the country.
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