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    Transcript: Do No Harm: Racism in Patient Care

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    Narrator: Do no harm.

    The Hippocratic oath, which dates back to the fifth century B.C., is well known as the traditional — and sometimes required — pledge that medical students recite at the beginning of their professional careers. Though it exists in many different versions today, most iterations include a promise to commit to the equitable care of patients — and to do no harm.

    In fact, the original Hippocratic oath doesn’t include the words “do no harm,” but many medical schools and students have written their own versions that incorporate this concept along with a variety of other values deemed foundational to a career in medicine.

    But there’s evidence that the words have proved hollow for many in the profession. Examples of bias in the delivery of health care are rampant. Black and Indigenous communities and people of color across America face discrimination on a daily basis. This must change.

    How do we move toward more equitable care for all? How do we prepare and train the physicians of tomorrow to be allies for everyone?

    In this episode, Dr. Malika Fair, the AAMC’s senior director of health equity partnerships and programs, talks with Dr. Laura Guidry-Grimes, an assistant professor in the Department of Medical Humanities and Bioethics at the University of Arkansas; Dr. Brian Gittens, vice chancellor of diversity, equity, and inclusion at UAMS; Dr. Carol Major, co-founder of University of California, Irvine, School of Medicine’s Leadership Education to Advance Diversity–African, Black and Caribbean; and Dr. Charles Vega, professor of family medicine at the University of California, Irvine, School of Medicine and the director of the Program in Medical Education for the Latino Community.

    This is our conversation on “Beyond the White Coat.”

    Malika Fair, MD, MPH: Hello. I'm Dr. Malika Fair, and I'm here today with Dr. Brian Gittens and Dr. Laura Guidry-Grimes from the University of Arkansas for Medical Sciences and Dr. Carol Major and Dr. Charles Vega from the University of California, Irvine, School of Medicine. Thank you all for being here. This is a trying time in our nation and in the medical community, where we are confronting two pandemics: one of COVID-19 and then acknowledgement that systemic racism is alive and well, both in our society and in the medical community. This is an important conversation for us today to talk about racism and patient care. Let's jump right in.

    At the beginning of medical school for me, I remember putting on the white coat and stating the Hippocratic Oath — and that's still being done today. Dr. Guidry-Grimes, you were recently quoted in an NPR article about the University of Pittsburgh School of Medicine's new oath and said, "My fear is that too often, the oath-taking is a ritual for the sake of ritual. You have words washing over everything without meaning or impact." Can you talk a little bit more about what this oath means and how it can or should translate to how physicians provide care?

    Laura Guidry-Grimes, PhD: Yes. Thank you for having me. Edmund Pellegrino, who is a physician bioethicist — he talked about the explicit and implicit trust asked of patients in the oath and in everyday practice, as well as the significant moral burden of taking on that trust. I think this is right. The oath is a way for the newly-minted professional to commit themselves to taking that trust seriously with all of its implications. When you think about it, medical teams ask for an enormous, mind-boggling amount of trust, especially since they are usually complete strangers to patients and their families. The relationship is one of intense intimacy, and the nature of this trust from patients and the public, it changes over time because health care and its challenges are never static. What it means to heal and to serve evolves, and this should not be glossed over for the sake of ritual. Given the long history of racism, sexism, ableism, and other forms of bias and systemic discrimination in health care, professionals should be prompted to reflect on what medicine really means in this context — and the oath is an opportunity for this reflection.

    Malika Fair, MD, MPH: Thank you for that. Dr. Major, do you have anything to add about your experience for UC Irvine?

    Carol Major, MD: Yes. At UC Irvine, we do a student-driven oath. It was created back in — I think — 1977 and it's a variation of the normal Hippocratic oath. Just going back to the Hippocratic oath, I just remember myself saying — that I actually stood up there in front of my family and friends and recited the Hippocratic oath with pride, and so I think there is some importance and meaning to it because I'm here, I am pledging my allegiance to medicine and doing the right thing in front of an audience full of people — and I think that there is some benefit to that. The Hippocratic oath — it was written four or five B.C. — probably has very little meaning and pertinence to what we do today and to our students today.

    I really liked the one that the University of Pittsburgh, the students — their variation on the Hippocratic oath. It had more meaning and they created it themselves, and so there's more passion and meaning behind the oath and I think it — since it was crafted by the students, that definitely was more relevant. It made me think about maybe each year students should get together and write their own Hippocratic oath and — something that has meaning and it's coming from their hearts and they can be passionate about and really stand for and it just wouldn't be a ritual. It would be more of a declaration of their promise to do the right thing.

    Malika Fair, MD, MPH: Thanks for mentioning this passion and meaning that you had as a medical student and, as we see both in your institution and the University of Pittsburgh, that these students have when they're creating this new Hippocratic oath. Unfortunately, the enthusiasm that starts in the beginning of medical school sometimes can dissipate because of the experiences that you have when you're there. We know that many people of color, both working in medicine and receiving care as patients, experience racism in the health care sector. Are there any examples of times when you've experienced or witnessed racism in health care that you'd be willing to share? How did that experience have an impact on the work that you do? Anyone can answer this question.

    Carol Major, MD: Well, I think I can start off. I experienced racism in health care pretty routinely — on a routine basis — and actually, probably the most egregious experience I've had happened, I'd like to say it happened 30 years ago when I first started, but it happened actually a little over a year ago when I was seeing patients. I had a patient's husband say that he didn't want his wife to see a Black doctor because I probably wasn't as good as the other doctors and I probably had gotten into medical school on some affirmative action programming and basically berated me in front of other patients that were in the waiting room and in front of our office staff. I was stunned. I was absolutely stunned.

    First of all, it took everything that I've ever accomplished in the past 25 to 30 years and basically reduced it to nothing. It made me realize that, regardless of how much I accomplished in my life and what I do, to some people I'm just only ever going to just be Black. It was a rude awakening and it was painful and it was humiliating and it was a really degrading experience, but it made me realize that I never, ever could let my guard down. That's what I understand. I just never let my guard down. I always have to expect that there's going to be racism, and when it happens, I'm not so surprised and I have better comebacks or I have a better way of handling it — but I think let my guard down because I've been practicing for close to 30 years now, and I let my guard down and it shook me up a lot more than I wish it would have.

    Brian Gittens, EdD: Yeah. Thank you for sharing that, Dr. Major. That resonates with me because sometimes we get into these professional positions — I'm a vice chancellor now — and you're thinking that you've sort of made it. We're in the club now and you get these rude reminders that you have not. When you ask that question, Dr. Fair, I was trying to figure out which example I wanted to share, as there's several, but I'll go to one that's a little more pointed.

    Like many academic health centers, we have mandatory flu shots. It just happened to be a day — I won't name the institution, but I was a leader in the institution and the associate dean, and so I was lined up to take my flu shot. I went with a colleague. To be fair, I was dressed down because I had to do a football practice for my youngest son at the time. I had sweats and things on. I'm on my way out of the door — might as well get my flu shot. My colleague, who was basically dressed in business attire, they asked her, “So, where do you work?” She was a director of finance and what have you. Then, even without asking me, the nurse who was checking us in turned to me and said, "Food service, right?"

    They didn't even ask me where I worked. I was stunned by it. Absolutely. I have a terminal degree in this space for almost 30 years, and just because I was a Black male and dressed down, what's the implication? Like Dr. Major said, you always have to be on guard, and secondly, I wear a tie and jacket everywhere I go so that I don't get mistaken for food service. Now, I’m mature in this space now, kind of a smart ass well. After I got my flu shot on the way out the door, I said, "Well, I got to go finish flipping those burgers." That was my response. That's just how you deal with those — with some sarcasm and the like. I corrected her, obviously, on the way in, but yeah, it was telling, though. It was telling. Unfortunately, I have lots of stories like that. Also, my office receives those reports as well, where people who are in professional environments get turned to and given the instructions on where to put their trash and things like that, women of color. And so that's a very recent one as well.

    Laura Guidry-Grimes, PhD: There was an ethics consult for a patient. Sorry, I should just say thank you so much, Dr. Major and Dr. Gittens, for sharing those experiences. What I was going to share is that there was an ethics consult for a patient who refused to facilitate discharge out of the hospital because she did not want to work with the resident who was trying to make arrangements for her. And the resident told me when I arrived on the unit that she was openly racist, calling him a terrorist because of the color of his skin.

    And he had subjected himself to this treatment from her for hours that day, trying to work with her despite her treatment of him. And he called our service when he was just at a loss for how to proceed. He had other tasks that his attending had sent him, and he just couldn't make progress. I thought it was admirable that he was so committed to trying to help her, but it did make me worry whether he felt comfortable letting the attending or others on the team know how he was being treated, and I've wondered whether there are better safe guards that could be put into place for health care professionals in these situations — especially trainees.

    Charles Vega, MD: I thought about this, and of course, I think everybody has witnessed acts of overt racism in clinical care. And obviously the person who is most affected — whether it's a staff member, a patient, one of the physicians — they're the ones who are the real victims, and it's truly impactful for them and oftentimes something they carry for a long, long time and will have a negative effect on the way they interact with that system for that time. But I also just want to point out that one thing I've really noticed is that I've been on some pretty high-functioning teams where we're taking care of complex patients, and when we see one of these events of racism, it really just craters the entire enterprise.

    It's amazing how it has — obviously, the effect is most profound on those immediately involved, but it really just drags everybody down. And when we are currently faced with so much stress and we are — I think — pushed to our very limits as a team, it's so debilitating to see acts of hate or racism that it's really hard to function and maintain that high standard we want, and it takes so much time to recover from it. So therefore, prevention and having a proactive plan for managing those cases is critically important to me. And we have to take it very seriously and show that the institution really supports us in trying to provide the most equitable care as possible and treating each other always respectfully in the health care environment.

    Malika Fair, MD, MPH: So, thank you all for sharing such deeply personal stories. And one thing that Dr. Gittens mentioned that is concerning is that there are so many stories to tell, and I know that in our community, unfortunately, there are countless acts that we have to respond to and come up with systems so that these stories won't be told again. But fortunately, Dr. Vega, thanks for providing some solutions at the end there of what things need to happen in the future. And this next question is for you, Dr. Gittens, because this has, as I mentioned, been a really interesting year where we've shined a light on the inequities that exist in our society with those communities that have been hardest hit by the pandemic, as well as our national reckoning over racism. Can you describe for us — Do you believe that this has caused a paradigm shift in medicine? And what is different now? What still needs to change?

    Brian Gittens, EdD: Absolutely. I think it's always been there, and one way or another, when we talk about health care disparities, when we talk about inequities with regard to health care and the like, but the pandemic in particular, along with what’s sort of like a perfect storm with the pandemic and the social injustices and the highlight — and those things coming together to really highlight the issues. And I think that the change, though — that I've seen at least at our institution — is it being reframed as a health concern. Literally, social inequities and social injustice has been reframed as a public health concern. Because as we know, especially when you're dealing with a pandemic, you can't have one group compliance, one group with access to health care, one group receiving health care, and the whole group or the whole universe of people not being impacted. And so, I think that has been the biggest shift.

    So, what it did — for us at least and I believe nationally — is brought this to the forefront, giving people the opportunity to serve as allies who may not have been in the past and to pay attention to this pervasive issue. And recognizing that it's not individuals, it's not people making bad decisions, choices. It's not just those things, but the issues are systemic. They're embedded. Sometimes I get asked to consult and people want to talk about systems and the system’s all messed up — and the system is not messed up. The system is working just the way it was designed. The system is working just the way it was designed. It's designed for some people have access and to exclude some and to include others, etc., etc.

    What we have to do going forward is recognize that, get familiar with those uncomfortable truths about the systems that we put in place: that we have socioeconomic barriers, we have implicit bias barriers, we have systems in place that — to protect some and not protect others. All the way and oftentimes you just have to follow the money, but we'll get to that conversation. But you look at payer mixes and things like that, how we sort things as well.

    But I think the biggest change, I believe, is rather than being in this latent form and with just hoping that it will go away — that with the broader appeal that it's been pushed to the forefront, we have to pay attention to it. And for the first time, I'm really excited because I see a lot of resources being put towards these efforts. When we talk about either bias trainings — when we talk about people having consultants come in and really look at their systems, and this is across industries, including academic medicine. And so, I'm really excited about the potential of real change happening as a result of that, because I think that people are realizing that the status quo is no longer tenable.

    Malika Fair, MD, MPH: So, in addition to that change happening right now, that change has to keep happening even with the next generation of physicians. Dr. Major, you lead the University of California, Irvine, School of Medicine's Leadership Education to Advance Diversity—African, Black and Caribbean communities. And this is the first medical school program in the nation designed to specifically develop physician leaders who will serve the unique needs of ABC communities. Can you tell our listeners more about this work?

    Carol Major, MD: Sure. So, as you mentioned, Leadership and Education to Advance Diversity in African, Black and Caribbean Communities, or LEAD-ABC, is a new mission-based education program at UCI School of Medicine, and it basically stemmed from a realization of the importance of increasing the number of Black physicians in our country. Right now, Blacks make up approximately 30% of the U.S. population, whereas only 3.6% of the positions in our country are Black, and so that's a pretty wide gap differential right there. And a lot of studies have shown that minority patients feel most comfortable with minority physicians. It leads to greater patient satisfaction and actually assists patients in receiving more effective health care. So, at UCI with LEAD-ABC, we came up with this concept and this idea to develop the next generation of physician leaders that are committed to public service, social justice, and advocacy within ABC communities.

    So, our students are actually getting out there in the community and actually making change. And the mission is to train and support students in medicine who want to work with patients, who are really committed to working with patients from ABC communities and who want to work on reducing the health care disparities within those communities. And it's only our second year that we've been in existence, but we've actually started to see some really positive change. Our students are embracing this challenge that we've given with gusto, and they're very passionate and enthusiastic about making change in the community. So, it's exciting, it's really an exciting thing to happen. Plus, we actually have significantly increased the number of African American students that have applied and that are in our medical school — at least first-year class. We have 11 students out of 104, which is a huge increase in our African American student population. So, we're all very excited about the program.

    Malika Fair, MD, MPH: And thanks for sharing that information. You mentioned the importance of having physicians who represent the populations that we treat. Dr. Vega, in your opinion, how does this relate to Latinx communities?

    Charles Vega, MD: Well, I concur with Dr. Major, and I'm director of UC Irvine's program in Medical Education for the Latino Community. And as you probably know, Latinos are the plurality of folks who live in California, and we suffer the same types of disparities in terms of number of health care providers who are Latino versus population. It's not too dissimilar from what Dr. Major just described as well. So, our program has been around since 2004, similarly graduating physician leaders who want to see patients and be involved with Latinx communities over time, but really do something beyond patient care. And our statistics really speak for themselves. So, 123 graduates who are out of training now, they're done with residency and fellowship — the majority are taking care of poor Latinx patients.

    Only 15% are in private practice. The rest are in clinics like mine right now — a federally qualified health center. They're in some kind of county health system. They're working where the need is greatest, and over 50% are doing some kind of leadership outside of their clinical practice. So, they are involved with their local public health departments. They are involved with schools. They're doing mentorship. 75% of our students are doing mentorship and really helping that next generation of folks who really care and have experience with these communities and who want to go back and take care of communities that need good health care providers. They're doing that work, and so we're really proud about this movement.

    And I'll just say that UCI — these programs have really changed the entire culture of the School of Medicine, because we have allies now who have great skills and assets that I never even considered necessarily when we were starting PRIME-LC, but it's moved the needle for our whole institution. And if other institutions, I think, can make these similar kinds of changes, we're looking at a very different type of health care professionals coming out of school with very different ambitions and goals — and that's how you start changing systems.

    Malika Fair, MD, MPH: We started the conversation talking about the new oath that medical students can take. And Dr. Vega, you just mentioned that through the PRIME program and other similar programs such as LEAD-ABC, it's changed the culture of the institution and impacted allies. Can any of you talk about what education and training is needed for all students to address racism and other forms of oppression?

    Carol Major, MD: Well, I know that with PRIME-LC and with LEAD-ABC at UC Irvine, our students actually are very much involved in actually rewriting the curriculum — instilling a lot of different learning sessions in the actual medical school curriculum. Actually, our students have kind of taken over the whole process, and it's really been very impressive, and it's actually led to an increased interest from other students that aren't part of LEAD-ABC or PRIME-LC to be involved in advocacy and allyship, and it's been very overwhelming and very exciting new turn of events at the university.

    Brian Gittens, EdD: So, I've been a part of several academic medical centers, and I think for us, we're at the stage now — at UAMS at least — where we're actually reviewing the curriculum, especially in medicine, ensuring that stuff of bias — ensuring that it doesn't kind of slant one group against one another and things like that. I think the next step though — once we just make sure it's not bad, not harmful — is to actually be more proactive and go in and start to ensure that it's promoting this notion of diversity, equity, inclusion. As part of our strategic plan, we're trying to prepare a culturally responsive health care workforce, and I think it starts with our oath. When you talk about culture, I was a former Marine, and I know how important indoctrination is with regards to culture as well.

    I think the Hippocratic oath is an opportunity to kind of set the foundation for that, but you also have to ensure that every action in the curriculum and the experiences after that build upon that initial foundation as well. There's a consistency there, you have to be targeted with that. And so that's what we're working on. Laura and I are working on looking at our oaths, looking at things across our health professions now — ensuring applicable to the challenges of today, making sure it resonates with our students, but also working on creating a equitable environment whereby students can learn. And we have work to do, but I'm excited about the progress and the intentionality being associated with that.

    Charles Vega, MD: I can just add that I love the concept of creating anti-discrimination, anti-racism curriculum and building it proactively and creating frameworks, and the real challenge is to try to, one, evaluate how it's doing. And so, I think that there's a lot of value that we haven't paid as much attention to in evaluating how our learners are performing in these areas, and we've developed some models using objective-structured clinical exams to really look at that here at UCI. And then I think it's also... While we want, I think, good networks and institutions that we can rely on that support these efforts over time so they don't just go away in the next academic year or when something else new is flying in front of us, but they also have to be able to shift. Because culture is constantly changing and shifting, and the priorities and the needs of our communities are changing as well, so it has to be baked into those institutions that they have some flexibility as well. And I think that will help us respond to new challenges. As we've seen in 2020, those new challenges can be severe and really require everything we've got.

    Laura Guidry-Grimes, PhD: I would just add that I think part of what the curricular development should be looking at is the ways in which patients and families and health care professionals can be multiply marginalized, right? The point about intersectionality and how someone's experience of racism can be interlocked with experiences of sexism, or heterosexism, or ableism. And so, looking at different forms of oppression through that kind of lens, and then what our trainees' responsibility was — their role in that. And I think part of the challenge is to train students to consider the implications of complicity and complacency. Many of our students think that racism has — and other forms of oppression has — nothing to do with them or their future medical practice, or they think that racism is a problem for our politicians and activists to address and not them. And I think there are two sort of big learning barriers here. One is a rejection of anything that makes them uncomfortable, and another is distancing themselves from how they are morally implicated by systemic issues like racism and other forms of oppression.

    So, we have to create spaces that teach students how to live with discomfort, which is a big task, right? None of us likes to be uncomfortable, but I think it's one of the biggest learning points of 2020, in a way, is learning how to be uncomfortable and have those kinds of really difficult conversations with each other and to have that introspection. The topic of racism and racial privilege should be making students uncomfortable, and they should embrace that discomfort as an opportunity to be humble and to learn. And we have to emphasize the moral role that they have if they are silent and if they're passive on this issue. So, to reinforce a lot of the points of my co-panelists here as far as being actively anti-racist, being actively involved in combating bias in health care. And if they are passive, those are choices, and they do reflect on moral character.

    And so, having the concept of everyday racism — the empirical work on everyday racism and other forms of oppression, as well as intersectionality — be part of ongoing curricular efforts, instead of one-off events where students can opt out of learning and being uncomfortable, I think is really important.

    Malika Fair, MD, MPH: You all have hit on two themes from 2020 — about living with discomfort and being okay with that, and also being ready for whatever new challenges we'll face. We had several challenges this year, and there will probably be new ones next year. I'd like to hear from each of you on the panel today, as we wrap things up: What is the number one thing that academic medicine can do now to address racism and patient care, to improve the health and health care for our patients of color, and to be ready for the next big challenge?

    Carol Major, MD: I think academic medicine just — we need to have a voice. We need to speak out more. And the way that I try to work with my students and other people that I might have any influence on is I do it by modeling. I show what it's like or what it means to take care of a patient regardless of their socioeconomic status, regardless of their color. I show good modeling. I teach my students how to treat patients with respect. And I think that that's one of the most important things. Students need to have good mentors to look up to. And I think that if you have a faculty that's full of really good, strong mentors that speak out against injustice and speak out against health care disparities and model good behavior to their students, I think that it'll be good for them. I think that academic medicine will have an important role in their lives.

    Brian Gittens, EdD: I would agree. And just to build off what Dr. Major was saying with regard to modeling and the like, I think we have to continue to be leaders in this space in academic medicine. I think that leadership in and of itself has the most instrumental impact on culture within an institution — through modeling, through providing adequate resources, through rewarding for behaviors that you want to continue to promote and punishing those behaviors that you want to mitigate. So, leadership in itself, and then having that leadership, and then having your sub-leaders and your directors and your supervisors, and having that cascade down through the organization, creating a new culture. Because I'll oftentimes say this, but diversity, equity, inclusion isn't something that you do. It ought to be how you do everything. And that's the ethos that you want to permeate within the institution. That only happens when the leaders decide that "this is who we are, and this is embedded in our DNA, the very fabric of who we are, and to see everybody."

    And so, what that does, though — you start to sort out who you attract, the type of people who come to your organization and things like that, as they interview, and they feel and see this. And I think that's how you start to shift, and your learners too will feel that energy and carry that forth as well. So, if you want to create the type of organization that prepares our learners to live and practice in a more equitable way, it starts with improving the culture, optimizing the culture of the institution.

    Laura Guidry-Grimes, PhD: And just to piggyback off of those excellent points, schools and training programs should be ensuring that they have educational leaders and experts who can create the right kind of educational space to discuss these issues. Not just anyone can do this work well, and we need people like Dr. Gittens, Dr. Major, and Dr. Vega in programs all over the country. You need that kind of expertise in the institution and that kind of commitment.

    Brian Gittens, EdD: And then we also have to understand that there's no one single answer or right way to do this. And in fact, a lot of that, when we talk about trying to be intentional about every single step of our process — from the folks we have in our institution, to the way we interact with each other, to the way we interact with patients and communities — this is a work in progress for many of us, and so we have to be sure to share those processes and really, I think, develop some best practices and some standards. And that will help, I think, level set everything so that we can move forward as a unit in academic medicine, as a country.

    Malika Fair, MD, MPH: So, you all have definitely highlighted some of those best practices today. You are the example of the leaders that you spoke of in your closing comments of modeling this behavior, and I really appreciate you all joining us in this conversation on “Beyond the White Coat” to get us further along in this discussion on how we in academic medicine can address racism, how we can practice anti-racism, and how we cannot be complacent or complicit in our strive to improve health and improve health equity in our nation. So, I want to thank Dr. Gittens, Dr. Guidry-Grimes, Dr. Major, and Dr. Vega for joining me today on this episode.

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