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Making Progress in Health Equity: In My Clinical P ...
Making Progress in Health Equity: In My Clinical P ...
Making Progress in Health Equity: In My Clinical Practice, Today
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All right. I think we'll get started here. We're close to 1230 here. So welcome. I'm Rob Roswell. I am the Associate Dean for Diversity, Equity, and Inclusion at the Zucker School of Medicine at Hofstra Northwell. And we're going to be talking about making progress in health equity in your clinical practice. So giving you tools and tips for achieving health equity through your particular clinical practice. And so I'll introduce my esteemed panel, but I think first we're going to talk about health equity in the setting of this patient case. And this is Dr. Biro, who's sitting next to me, I'll introduce you just now, published this in Jack Case Report. And this is a 35-year-old African-American man with a past medical history and coming to seek medical attention for recurrent syncope and admitted for further management for aortic stenosis with a mean gradient of 100 millimeters of mercury. He has no medical insurance, is unemployed, and has a history of recreational drug abuse. And so I'm going to introduce Dr. Biro, who's Assistant Professor at Mayo and Center for Health Equity and Community Engagement, to talk a little bit about definitions and what does this mean about health equity and health inequity, health disparities. And just a quick question too, I did think that that was a peak gradient, not a mean gradient, and that's a pretty high gradient there. And so just tell us a little bit and lay the foundation about health equity and the definitions and disparities. Well, thank you, Dr. Roswell, for the opportunity to be here today. And again, this is a topic that is near and dear to my heart. So let's start out with some definitions, and I always say definitions matter. I just want to be clear on what these are. So health inequities in cardiology are systemic, avoidable, and often unjust societal factors, structural practices, and racism that create barriers to opportunity and result in avoidable, adverse health status and outcomes. And health inequities then lead to health disparities, and these are adverse cardiovascular outcomes and or health status that is attributable to systemic, avoidable, and unjust societal factors, structural practices, including racism. And again, health inequities cause disparities. And health inequities and disparities hinder us from achieving health equity. And health equity is a human right that allows everyone to achieve the best attainable cardiovascular health and outcomes by overcoming all avoidable barriers. Thank you. And I really love this slide because it highlights the point that equality does not necessarily mean equity. So you can see in the equality slide, we'll figure here on the left, you're giving everyone pretty much the same thing to reach a goal of optimized health. And in equity, you're actually trying to tailor the interventions so that individuals can then meet that outcome. So it's really from the outset trying to make sure that everyone can achieve that attainable goal. And in this case, it's the getting that fruit or the optimized health outcome. And then justice is really just eliminating all of those barriers. So how do we make sure that we meet the needs of all of our patients so that they can achieve optimal health? Great. And we're going to talk about these cases and talk about this case in health equity. So and at the end, we will have opportunity for discussions. So start thinking about any questions you have about health inequity, health disparities. And before I move on to Dr. Burlacher, who's an assistant professor and associate chief of education at Pittsburgh, I always think about health disparities and health differences are something that people think about. And they're like, well, those are different outcomes. Is it really a disparity or is it just really a difference? And we'll get back to that a little bit because it gets confusing if there's differences, but disparities really are that there's an underlying systemic avoidable reason for the difference. And so, Dr. Burlacher, let's talk a little bit about this case, this aortic stenosis case and why was he coming to seek medical attention and having recurrent syncope with a mean gradient and not getting any treatment? What's implicit bias and how could that have impacted this person's trajectory? Yeah, thanks, Dr. Roswell. That is a wonderful lead into the things that I like talking about, which is exactly the case. The case makes and should make us think about all of the things the way that we would initially potentially unconsciously or sometimes consciously judge, right? So maybe we can even go back to that case. We'll come back to implicit and implicit bias. But just to flash that case, because I think it really it's great. Thank you for writing it. You guys could should the case is actually much longer and has a bunch of stuff in it. So you should really go back and review it. But the things here at the end, this last sentence, he has no medical insurance. He is unemployed and he has a history of recreational drug abuse, right? So many, many times in the medical chart, somebody would say he's noncompliant, right? And we label somebody that way. And then it gets furthered. And the reason that we react and that our brain categorizes things in a patient like this is because we have what's called implicit bias, right? And we're going to break those things down. We can move back to the slide. We're going to break those two words down or that phrase down into two different things. So implicit and bias, right? Implicit just means that you're not conscious about it. This is the way that my brain works. It's purposeful that our brain works like that so that we can be efficient and fast in our world. If it didn't work that way, we would be really slow and clunky, right? But then when you add it to bias, the word bias, which is a preference or aversion toward a person or a category as opposed to being neutral to it. So you're unconsciously biased towards something, right? And it can be a person, but when we, it's actually not that person. It's those things that make up that person that we assigned to that person. His drug use, his unemployment, and his lack of insurance. We have assigned meaning to those things and then that implicit bias occurs in our brain and it's the way that we see that patient, which then is what we're going to get to gets in the way of us taking care of that patient, right? These other things, stereotype and stereotype threat, very similar. Not exactly the same, but very similar. Stereotype is a specific trait or attribute that's associated with a category of person, right? So think in your head, what is a stereotype of something about a category of a person that you fit in, whether it's your age, whether it's your race, whether it's your gender, whether it's your sexuality. There is a stereotype for every single one of those things. There's a stereotype, I'm from Pittsburgh, and there is a stereotype about Jensers or Pittsburghers and that is that we all cheer for Steelers, right? That's a stereotype. Truth, right? Truth. I actually am a Steeler fan, actually a Steeler fan. But that doesn't mean that everybody from Pittsburgh is, right? So that's an example. And the stereotype threat, last but not least, is where we get into that sticky situation and where people feel themselves to be at risk to conform to stereotypes of their social group. So it might be that my medical student moves to Pittsburgh for residency and they feel threatened that maybe they're not a, they're not, God forbid, they're a Cleveland Browns fan, but they feel like they have to, right? So those are the things. So the stereotype versus the stereotype threat. And that's really, we want to talk about not those, I mean, they're fun examples, but we really want to talk about how they get in the way of us taking care of patients and how our brain fights us sometimes and it becomes that barrier to take care of patient in the best way possible to get to the equity and the justice that we really want to move forward to. All right. Now I'm done. I think that was great. And I think just thinking about the names that float around in charts, you know, difficult patient, non-compliant patient. And I think those are some, I think, key words and I think they flag to us and they sort of trigger our subconscious that this patient maybe is not deserving or doesn't need. And so we have to be very careful about these words that trigger implicit bias that carry over in the chart. I think Dr. Aguni, we were going to talk about social determinants of health and Dr. Aguni is a associate professor of medicine at Emory, associate medical director, Grady Heart Failure Program from the Grady Health System. So what, what social determinants of health, you know, we've been talking, we've been hearing a lot about this and Dr. Burlaka just, just mentioned some of them, but why are these social determinants of health? What are they and why are they important and why do they impact cardiovascular health and health in general? Thank you so much for that invitation and thank you so much for leading the way. You know, I practice at Grady Memorial Hospital, which is a safety net hospital in Atlanta. It's actually the fifth largest public hospital in the country. So my day, my clinical practice is all about assessing and addressing social determinants of health. So what are social determinants of health? They are access to education and not only access to education, but what is the quality of education? And when we talk about health access, healthcare access, we're talking about access and quality. So people may have access and not quality, right? So if you remember the case that we just looked on, we talked about insurance status, we talked about the fact that he was unemployed. And can someone tell me what the third social determinant of health was in that case? Drug use, you know. So I always tell my fellows when they present, they will tell you, like she said, a 33-year-old African American male with history of drug use or cocaine use, that is not part of the history, right? You don't even have to include the race, right? And recently the American Heart Association actually has included racism and discrimination as a social determinant of health. So that's one thing we need to keep in our mind, that race really, as we talk about health disparities, is not the risk factor, but the risk factor that is driving disparities in heart disease is actually the impact of racism, be it institutional racism or structural racism or interpersonal racism and discrimination. And there have been studies that show that it increases your risk for cardiovascular disease. So rather than saying your patient is non-adherent or your patient is non-compliant, it could be that the reason they're not eating healthy is because they don't have access to these resources, or it is a coping mechanism, right? They're not eating right, they're not sleeping right, because they've developed this coping mechanism to deal with the racism and discrimination they face on a day-to-day basis. So the other social determinants of health include economic stability, the context of their social and community environment, and also their neighborhood characteristics, and we're going to have a lot of discussions about it. So my background is in public health, so my clinical practice is always looking at the big picture. And if we want to talk about health equity or reducing disparities, we have to go beyond the individual patient and go to the global picture and attack this at a population level so that we can bring that back to our clinical practice. So when we talk about social determinants of health, they have a tremendous effect on individuals, irrespective of age, race, and ethnicity, and they're actually responsible for 80% of whatever cardiovascular disease you're thinking about. You know, as clinicians, we think about, oh, this patient has hypertension, it's on this medication, we've got to put them on GDMT, whether they have access or not. We have all our notes written out. But we've got to look at the big picture. 80% of whether that patient is compliant or has their blood pressure controlled depends on this social determinants of health. And guess what? In this era of electronic medical records, there are tools to help you assess this. And you don't have to do it. Your MA can do it. They can assess all these things. At least we use Epic, and we have to do, the MAs have to do that before we see the patient. So I hope that one thing you take away today is the impact of social determinants of health, and to achieve health equity for all, we have to address social determinants of health. Thank you. Thank you. Can we get applause? Yes. Applause. I think it's really important, I think, to stress that figure, I think, because most don't know that 80% of health outcomes come from the social determinants of health. And the 20% is what we do in clinics and in sort of the medical care. But the most, about 80%, really, are social determinants of health. And so as we wrap up the last section, we'll talk with Dr. Martinez, who's Assistant Dean for Community Engagement at Northwell, is also Associate Professor of Medicine and Assistant Vice President at Northwell for Health Equity. And I think that we're going to wrap up before we take some questions from the audience. Just talking about, how do you do this? How do you think about social determinants of health? What do you do? How can you enhance your everyday practice? What are some tips that people can do? And we talk about structural competence, that's a big word, but it just really means, who's in front of you in sort of addressing them? So why don't you tell us a little bit about, and give us some tips about, and maybe tips including what we're doing with Mr. Jordan. Yeah, perfect. Thank you. So again, thanks you guys for joining us on this afternoon. So I think we went from the macro, from definitions, large scale, institutional policy, advocacy. We sort of put that in the context of, you know, a little bit of health services research or from the population health standpoint. And I'm hoping that everyone in the room or sitting in front of us are advocates and champions. And many of you guys do influence policy and procedures or institutions, but most of us are clinicians and we're seeing patients at the bedside. So perhaps we can go from the macro to the micro. We talk about population studies and how we apply that at the bedside. We talk about thousands in, you know, RCT trials and others. But when we're at the bedside, we're talking about the N of one, right? The patient that is sitting right in front of us. So how can I, as a clinician, take all of the things that we know that are evidence based that are in practices and in trials and that are made in recommendations for best practices and really apply it to the patient that is sitting in the bed right next to me as I'm seeing him or her inpatient, outpatient in our practices. So I'll list for you just a couple of the things that do in the literature show that there are best practices around how we can advance what we're doing as clinicians at the bedside to bring out more equitable, high quality results for the patients that we are taking care of. So as we just mentioned, if your MOA does not have the opportunity or if your health system does not have a universal social determinants of health screening program, currently because you don't have EPIC or whatever the reason may be, make it a point to actually do it, right? So the social history goes beyond, specifically for cardiologists, drug use, smoking history, but should also include the social determinants of health or for patients specifically, because we're talking about the NO1 is their social needs. So again, in this case, we talked about unemployment, we talked about drug misuse, we talked about the race as a social determinant of health and being sort of cognizant, are those things going in our one-liner or are they going under your social history where they probably ought to be wherever you're documenting? Cultural preferences, so as you read the case or will read the case in more length, the one-liner was really a one-liner that the intern did to present the case as opposed to how we should be thinking about this patient. And as we sort of mentioned briefly, should race really be in the one-liner or should be in your social history because we know that it is not race or the biological genetic things that are influencing this patient's care, it is the racism that he or she is experiencing. So it is a social factor and probably fits more in your social history. We talked a little bit about implicit bias, so check your assumptions. Again, I think everyone in this room can acknowledge that we have biases, so raise your hand if you don't. Okay, trick question, you're paying attention. So right, everyone in this room is aware, we're aware of our biases, we're aware of our assumptions, we're aware of the judgments that we make. And I think as the world has changed after the murder of George Floyd, after the COVID pandemic, I think we were all very comfortable in saying and acknowledging our biases. But today we're also acknowledging that every one of us have racist behaviors, right? So we ourselves may not be racist, but we have racist behaviors that we do every single day. Any behavior that we do can be either racist or anti-racist. So check those things too when you're doing something. What am I doing? Is the medical decision that I'm making actually advocating for this patient or not advocating for this patient along my assumptions? Clearly he was African American, was he Caribbean American, was he Haitian American, was he from Nigerian descent, not sure. Did he speak another language? So being mindful of language and really understanding that bringing in an interpreter to every single session if a patient is limited English proficient is probably the best thing you can do to provide him or her good care. Incorporates the social needs into the treatment plan. So it is not important to only acknowledge that a patient has social needs, but to actually include that in your diagnosis in your treatment plan, right? So for instance, if someone has comorbid conditions, we will do goal-directed medical therapy to get to where we are. And that may be the theoretical thing, but if you can't actually execute on that treatment plan, then your plan is not as successful as it could be. So being mindful of making sure everything that you know about the patient is incorporated in a holistic fashion in your treatment plan. So all of you guys in medical school, those of us who teach medical students and medical residents have been taught about teach-back as an effective communication strategy and what that actually means for patient's adherence and ability to actually carry out the plan. So again, you know, these complex, we talk about congestive heart failure, we talk about aortic disease, people leave with four to five to eight medications at a time. And the question isn't, did we know as clinicians what were the right medication classes? Are they on ACE inhibitors and diuretics? But it is, can the patient actually take the regimen that we just prescribed? So again, think about your last clinical practice. How many of you guys asked, do you have insurance? Can you afford these medications? Do you have out of cost care, you know, or payments that you're gonna have to pay for because these medicines are expensive even with insurance? So being mindful to ask about that, a very simple thing to do before the patient actually leaves. And then I think, you know, we're at a national meeting, understanding that every single one of you guys in this room is a champion and an advocate. And because you're cardiologists and because we're physicians, and because we are at a national meeting, each of you have privilege and power and understanding how that privilege and power affects the patient and not only understanding it, but bringing it into action. Again, making sure the patient in this story actually finally got health insurance. And even though we could have given him or her the surgery that saved his or her life, but in the end, if he left uninsured and couldn't afford any of his medications, it is very likely that he will just be rehospitalized. And the life-saving surgery that the patient just underwent probably would have been for naught. So again, just a couple of tips as we come back to Mr. Jordan, thinking about him and thinking about, again, why did he syncopize so many times and not come back? Was there fear of the system? Did he have mistrust? Was he labeled? Was he mislabeled many times and was hesitant to come back? Thinking about his unemployment and his uninsurance status, is this the reason that he isn't able to or never actually had the surgery? As we think about the recreational drug misuse, again, was this something that brought stigma to him that he didn't want to talk about? Is this a reason that maybe perhaps no one offered him this surgery that he needed early on in his care? So thinking about those just few simple tips on this case and the cases that you guys see again, over and over again, so as the scientists that we are, taking those population health studies and really applying them to the N of one that's sitting right in front of us every single day. Thank you. Back to Dr. Haslall. So now, if anybody has any questions about this case, we can just go to the mic and we'll be happy. There are two mics. Can I ask one question? I just need to show a hands of the crowd. Who's taken the IAT, the implicit association test? Who has taken an IAT? Okay, so that's less than 50% in the crowd. I just want you to right now on your phones to Google IAT. You can go to that site and take an IAT test. Just take one. You can take the gender one or the race one. There's a bunch of them. They only take 10, five minutes for some of them, but do that so that you know your implicit bias. The second thing, this is just my curiosity. Who has what you were talking about, the calculation of the social determinants of health? I'm just wondering how common that is. Who has that in their EMR at their home institution? Who has something that calculates their social determinant of health? So four people. Okay, things for us to work on. Okay, I'm just planning for next year. Absolutely. Question? So thank you all, first of all, for that amazing talk. So my question is, in your experience, what are some practical ways that we can incorporate into our practice to overcome these biases in order to improve patient care? I can do this. There's a number of different ways that we can do implicit bias mitigation. Okay. First is to know what your implicit bias is. So I already blew that tip. Go to the, one more time. Go to the IAT, take an IAT test, know what your implicit bias is. Because once you make it less implicit, meaning you know about it, you can then apply things that get rid of it, which are learning about, consider the other. So learning about somebody of, who is from the group that you have implicit bias towards. You can also do implicit bias training. And so if we're talking about individual versus large institutions and groups, and our hope is that all of you will go back to your home institution and put forth some plans to combat implicit bias. And really, that's gonna be some training programs so that everybody gets implicit bias training. Everybody is doing some testing. Those sorts of things. I'm curious. Yeah, I think there's one I like to rely on. It's technical, it's called metacognition, but it's thinking about the way you think. And I think once you get in touch with your biases, you understand it much, much better. And I'll give you a quick example. In the Cardiac ICU, I walk in doing rounds, and there were all male residents. And then I heard like, my internal voice was like, oh, it's gonna be a long month. I said, wait, why did I think it was gonna be a long month without even knowing any of the people here? And I think once you start catching yourself and catching the implicit biases, when they come up, you can start to prevent them from having some impact. A lot of that also happens with recreational drug use when people, they're having ACS and they have cocaine use, and people are like, well, they're gonna use cocaine all the time. I don't think they deserve to get a stent. This should be a conservative management patient. And it's, wait a minute, why don't we talk to the patient? And understand what's going on before we flip that switch very quickly. So I think it's really important to realize when these things are going to impact. And I think, I usually think about it when you're not gonna offer something to someone, just check your biases to see if there was any demographic or any reason that you were withholding treatment to a patient is some of the quick tips. And I just wanted to say also, really check your assumptions at the door. So this was presented to me, first patient of the day on a long list that we had to get through on morning rounds. And I said, so did you explore, to the intern, did you explore the recreational drug abuse? What was that about? And the answer was, oh, I didn't really ask many questions about that. I don't really know what was going on there. So really, when we built more rapport with this patient, it uncovered that he had underlying mental health issues that stem from adverse childhood events. And this was his coping mechanism, if you will. And even when we walked in the room, and I really hope you all read the case, he had a very guarded demeanor with us. And for me going in as an African-American physician, I felt that I could potentially build that rapport quicker, but that was not the case. So I actually had to go back into the room without the entire team, because I felt that you could clearly tell that it wasn't very intimidating to him to have an entire team of physicians towering over him and telling him what to do, and also giving him this really scary diagnosis of aortic stenosis, which was underlying bicuspid aortic valve. And he actually thought that it was something that he did to get this. He was like, oh my gosh, what did I do? I hate, I didn't, I should have got my insurance, I should have gone to see the doctor. And as I spoke with him more, the reason that he didn't go to the doctor is because of that medical mistrust. He felt that all of his concerns were dismissed and that he was being discriminated against, so he just didn't go. So really check your assumptions at the door that people, first of all, in his case, he had really low health literacy. Two, he had so many adverse, if you will, encounters with the medical system. And three, he really just didn't know what to do. He didn't have health insurance and he had adverse childhood events. And so I see you have another question. Let's get another question over here and then let me just take this one. No, I just wanted to say thank you. Oh, okay, got you. So go ahead, yes, it's on. So I guess, my name is Heba. I'm a third year resident at Wayne State University in Detroit, Michigan. And so I tried to incorporate social determinants of health screening in our clinic, but I wanted to apply for a grant to get extra funding so that we can have an extra maid to do all of this and surveys and things like that. When I applied for the grant, they said that this looks like a project that you can do without any funding. So there was no importance put on this project. So it was hard to add it onto a resident's plate because we couldn't even incorporate it into an EMR. The resident has like 15 minutes, the MAs are overwhelmed. And then trying to squeeze a two-page survey or questionnaire on social determinants of health was really hard without extra funding. So I don't know if you have any tips or advice for that. That's a great question, how do we do this? So I think it's beyond you as residents. I think that it's a healthcare system change. We have to change the culture. I think that professional organizations like the ACC, the AHA, they are realizing the impact of social determinants of health. So if you look at recent guidelines, even the blood pressure guidelines they talk about. So I think that we have to start at the top and come down. The other thing about addressing social determinants and you alluded to it is that it's, I think to address it, it's a multidisciplinary team effort. So it's not only, I think we should take away from this that it's not only addressing or identifying the social determinants of health, but we got to have interventions, right? So you address that someone has an adverse social determinant of health, like this patient, mental health issues. Do you consult psychiatry? Do you connect them to those resources? You find out that someone doesn't have insurance. Like in Atlanta where I live, actually for a heart failure program, we discovered that many of these patients qualify for some form of assistance. Our health system, so we're supported by DeKalb and Fulton County. So if you come to my hospital with an admission of heart failure, you actually go home with a 30 day supply of your medications. So it goes beyond the individual person as the health system, it's policy at the government level, the people in leadership seeing that this is, that for us to eliminate disparities and to achieve health equity for all, it's everybody's job, it's not just one person. Absolutely. But I do think that somebody on Monday, I mean, is there anything that we can give to her on Monday morning when she goes back to clinic? Is there something? And I would encourage you to take one piece of social, that circle that's a lot, maybe you don't have a calculator that's automatically included. This takes years, years and millions of dollars. This is not inexpensive and not short, but is there something that you could do? And I would say, start with one of those things and start documenting it and then educate your peers. If those above you are not ready for it or don't wanna fund it, you can do it. It's grassroots, just bite off less. Thanks. And I know that we're up at time right now. So let me just take one quick question and comments before we close out. Okay, I'll make this quick. I wanna thank all our presenters and take time to acknowledge Dr. Martinez, your comments about the African-American patient and assumptions that are made, right? So this patient could be Nigerian-American, they could be Haitian-American, they could be Guinean. So just acknowledging that when you have a patient that is considered black or African-American, it's not a homogenous group and there's greater appreciation that immigration itself is a social determinant of health. So this person may have challenges accessing healthcare, not be documented, right? There are different layers and I just wanna thank you for acknowledging that. Thanks. Thank you. So thank you all. We're gonna end right here and we'll stay around for more questions, but thank you so much.
Video Summary
In this video, a panel of experts discuss health equity and ways to overcome biases in clinical practice. They start by defining health inequities, which are avoidable societal factors that create barriers to health and lead to disparities. Health equity, on the other hand, allows everyone to achieve optimal health by overcoming these barriers. The panel emphasizes that achieving health equity requires addressing social determinants of health, such as access to education, economic stability, and neighborhood characteristics. They also discuss the impact of implicit bias and the need to be aware of it to provide equitable care. Practical tips for incorporating health equity into clinical practice include screening for social determinants of health, checking assumptions, incorporating social needs into treatment plans, using culturally sensitive communication, and using privilege and power to advocate for patients. The panel also emphasizes the importance of institutional changes to address health equity, such as implementing social determinants of health screening programs and providing implicit bias training.
Keywords
health equity
biases in clinical practice
health inequities
social determinants of health
implicit bias
equitable care
institutional changes
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