Ethical Deviations and Inequities in the Delivery of Health Care (Matthews, 2/11/26)

A recording of this presentation is available HERE.

***

Special thanks to Dr. Adora Matthews, Sutter's CME of Inclusion and Belonging. She gave an important presentation on Inequity in the Delivery of Health Care-- as a celebration/reminder of Black History Month and a reminder of our commitment to delivering equitable and excellent care to every patient we serve. 

Dr. Matthews reminded us of four important historical occurrences that still contribute to fractured trust in the medical system for black Americans:

1) Dr J. Marion Sims, often referred to as "the father of modern gynecology", a white man, who operated on black slaves without anesthesia, perfected his hysterectomies and vesico-vaginal fistula repair on black slaves without consent, and contributed to a long-held notion in medicine that "black people don't feel pain the same as white people". After  all surgical assistants resigned due to discomfort with his work, he ultimately forced three black slave women (named Anarcha, Betsy, and Lucy) to assist him in these experimental surgeries.

A statue to honor these three women, the "Mothers of Gynecology" stands today in Montgomery, Alabama. 

2) The Tuskegee Syphilis experiment, which took place from 1932-1972, in which 400 black male sharecroppers were knowingly observed to study the natural history of syphilis, even after cure/treatment for syphilis was widely available (in the form of penicillin!). Spouses were infected, babies were born with congenital syphilis, extreme pathology was documented. This is widely considered the greatest failure of medical ethics in our country. This experiment didn't end until it was leaked to the press in 1972. A formal apology rendered by President Bill Clinton in 1997, calling the experiment "shameful and racist". 

3) Henrietta Lacks was a black woman who was treated in 1951 for cervical cancer at John's Hopkins University. After she died that same year, her cell line (HeLa) was used (without consent) for countless projects, including vaccine development, medical research, most recently for the COVID vaccine development. 110,000 publications are attributed to her cell lines, which are still in use today. The Lacks family was unaware of this use of her cells until 1973, when they were approached by a scientist who wanted to study them. 

These historical truths (and many others) contribute now to systemic inequity and mistrust. We must be aware of these histories, warned Dr. Adora Matthews, when we are caring for black American patients. We must be aware of them when we see current inequities. And while being aware isn't enough, it's a start.

Four current inequities for Black patients:

1) Healthcare access: black and brown patients have higher rates of being uninsured, are less likely to have preventive care, and less likely to have a regular PCP.

2) Chronic disease management: black American women have some of the highest rates (40%) of metabolic syndrome, which doubles CV risk, increases all cause mortality, and is associated with DM, CKD and stroke.

3) Maternal and fetal health outcomes: black women have highest rates of maternal mortality and fetal mortality, even when controlling for SES (see graphs below)

4) Pain management: Biased beliefs about black patients and pain tolerance dating back centuries with no evidence-- still exist today. There is literature from emergency rooms, hospitals and clinics that black patients are less likely to receive pain medication for the same painful condition.

Dr. Matthews reminded us that knowing the history (and the current inequities) is where we begin-- from here we begin to look at systems and address systemic racism in the daily work we do. We turn our grief, sadness, anger and despair into hope for our patients. We confront our own biases by attending lectures like these and participating in unconscious/implicit bias assessment ( Harvard's can be found HERE). 

Interrupting Racial Trauma: Strategies & Tools to Assist Health Care Professionals to Do No Harm (Washington, 2/17/2021)

A HUGE thanks to Dr. Sharon Washington for her wisdom on interrupting bias in the health care setting. Engaging in anti-racism is hard work. We know that every institution in this nation is struggling now to confront the recognition that race and racism are a fundamental part of who we are as a nation, as a society, and as a community. Healthcare is no different. I will add a summary of this Grand Rounds in the near future. Better yet: watch it yourself here: https://youtu.be/YpjNkCTNpxY

Hospital Care of the Patient with Super Obesity (Kirchner, 11/11/2020)

Thanks to Dr. Julia Kirchner for a great Grand Rounds presentation this week on Super Obesity. Dr. Kirchner walked us through the myriad of ways in morbid and super obesity add physiological complexities to patient care and can seriously affect patient outcomes. The list of acute and chronic health implications of obesity is long, and the physiology is dense but also very interesting! In addition, don't forget the role that our explicit and implicit biases play into our care of obese patients.

For clarity, definitions of obesity:

Overweight: BMI >25-29.0

Obesity: BMI >30

Morbid or Extreme Obesity:  BMI >40

Super Obesity: BMI >50

• 9.2% of US population is severely obese
• Super obese is the fastest growing subgroup (maybe up to 1% of the population)
• Morbidly obese patients have increased ICU length of stay, with particularly well documented increased morbidity and mortality in obese trauma patients 
• In obese trauma patients: OR 1.4 mortality OR 1.8 in hospital complications (pneumonia, ARDS, UTI)
• Having a pulmonary diagnosis on admission increases with increasing BMI, and there is an increased need for non-invasive mechanical ventilation (NIMV)

Transport and transfer issues:

• stretchers with higher weight limits
• bariatric wheelchairs
• lift team
• adequate O2 for transport
• staff capability and training

Hospital Capacity issues:

• bariatric beds
• room layouts (doorways, hallways)
• bedside commodes, walkers
• lift equipment
• larger BP cuff (see Table 3), gowns, larger NIMV masks, longer needles
• imaging capabilities
• staff training

Physical Exam of obese patients, can be challenging: including heart and lung auscultation, abdominal exam and skin survey

Labs: 

• Obese patient tend to have higher baseline CO2
• We should use a higher BNP cutoff >54 (for BMI >40)
• Be aware of possibly inaccurate SCr (consider using a GFR calculator)

Imaging capabilities are often limited: 500lb weight max on CT scanner (30 inch maximum circumference), also higher rates of uninterpretable CXR (see image), challenges with ultrasound (difficult FAST exam, may need TEE)

Medications may need dosing modifications based on several factors, including weight, type of medication distribution, and renal and hepatic metabolism. Here is a link to a calculator for body weight calculations: idea/actual body weight and this is a really great resource for medication dosing in obesity called ClinCalc.

Okay, now for some serious physiology and pathophysiology

Respiratory issues are a BIG deal in the care of morbidly obese patients. Predisposing factors that make obese patients at risk for respiratory distress include: underlying chronic respiratory failure (that is why that elevated baseline CO2), difficulty with airway maintenance, higher baseline oxygen consumption, impaired central response to hypercapnia and hypoxia, and disordered gas exchange. 

• 42% of morbidly obese patients will require NIMV regardless of reason for admission
• AVOID SUPINE position (exacerbates everything), consider HOB elevated vs. reverse trendelenberg
• high PEEP may be indicated (starting 10, up to 20-25)
• care with fluids

Obesity hypoventilation is super common and important in our care of morbidly obese patients!

• BMI>30
• daytime hypercapnea (pCO2>45)
• disordered breathing during sleep
• all other dx excluded

Cardiac complications and Renal complications are common. Often these are acute on chronic. Take home points:

• Care with IV Fluids
• Consider ADJUSTED weight based dosing of IV fluids
• Have high suspicion for underlying renal and cardiac disease that may be undiagnosed but is very likely present. 
• care with nephrotoxic drugs
• low threshold for telemetry monitoring

lCVD=cardiovascular disease, IAP=intra-abdominal pressure, RV=right ventricle, LV=Left ventricle,

AKI=acute kidney injury, CO=carbon dioxide, AKI=acute kidney injury

And finally, how we treat patients matters!

Bias and Obesity:

"Weight appears to be the last acceptable bias", Rita Rubin writes in JAMA, article available here. The general population AND physicians show very high anti-fat bias and there is clear evidence of bias and discrimination against obese patients. There is an intersectionality with race and racism in this country that we need to be aware of, as there are higher rates of obesity in Hispanic and Black populations.  

T"Weightake home

Caring for Incarcerated Patients (Lozada, 9/15/2020)

I have deep gratitude for a powerful Grand Rounds this week by Dr. Christina Lozada, on Caring for Incarcerated Patients.

Dr. Lozada presented statistics on the state of mass incarceration in this country, reflected on her personal and professional experience of caring for incarcerated patients during her training, and encouraged us to do better in caring for incarcerated patients.

The US has the highest incarceration rate of any industrialized nation in the world.

• 4.4% of the world's population, 22% of the world's prisoners
• 2.3 million incarcerated people in the US, 4.5 million on parole, and 3 million ex-convicts
• ~870/100,000 US citizens 
• 57% in state prisons, 27% local jails/prison, 9% federal prisons

Who are our jail patients? 

Disproportionately young people of color, poor people, mentally ill people, poor people

• 34% non-Hispanic Black, 24% Hispanic
• Black and Hispanic men are incarcerated at 5.1 and 1.4 x rate of whites
• Mean age 32.1 (jail), 35.6 (prison)
• 10% are Veterans, 12-17% were homeless in the year prior to incarceration
• More than half have less than a high school diploma

Females are the fastest growing population in jails and prisons

• Compared to men, incarcerated women have higher rates of chronic disease, substance use disorder, and mental illness. 
• Elevated rates of depression, PTSD and antisocial personality disorder
• Most incarcerated women have experienced childhood physical and/or sexual abuse
• 6-10% incarcerated women are pregnant

Mental health issues are important

• 25% of all inmates have a mental health diagnosis (even higher for women 30-62%)
• 70-75% have taken a psychotropic medication
• Depression, PTSD and substance use disorder all very common. PTSD associated with higher rates of risky behavior including prostitution, IVDU, substance abuse

Dr. Lozada invoked The 8th Amendment of The Bill of Rights (1791) and Supreme Court Case Estelle vs. Gamble (1976) as the two main pillars of federal law that protect prisoners and should ensure them adequate access to high quality health care. She also called us to review our very own Hippocratic Oath.

The 8th Amendment guarantees freedom from cruel and unusual punishment. Estelle vs. Gamble ensures: access to care (including hospitals and specialists), ordered care (i.e. ordered by a physician), medical care without bias to the incarcerated status, proper medical records, confidentiality, autonomy (right to refuse care). 

While the law guarantees provision of care for prisoners, it frequently falls short of an acceptable standard of care. This is because standards are vague and/or undefined. There are differences in budgets and policies across federal, state and local jurisdictions.

Three important ethical issues to take into account in caring for incarcerated patients that may not be well-respected or well understood.

• Privacy: incarcerated patients have the same right to privacy as any other patients (including HIPAA protections, having officers in the room during interviews/examinations, etc)
• Autonomy: incarcerated patients have the right to make their own medical decisions and the right to refuse medial care as well
• Surrogate decision maker: incarcerated patients have the same right to designate a surrogate decision maker in case they are unable to make their own medical decisions (the warden is NOT the default surrogate)

Correctional Care Companies (private, for-profit corporations that are contracted to provide health care inside jails and prisons) have inverse incentives for care delivery

• These companies get paid per patient per day: while they provide direct medical care (e.g. urgent care, chronic disease management), any care that requires transfer to hospital or specialist care comes out their profits
• There have been hundreds of lawsuits against them, multi-million dollar settlements
• Investigative reporters have uncovered hundreds of preventable deaths: including ignoring visible and growing cancerous tumors, placental abruption and chorioamnionitis leading to fetal demise, untreated DKA, undiagnosed ruptured duodenal ulcers, and more.

What do we know about how shackles in the hospital impacts care?

• inability to break falls when ambulating
• difficulty positioning during seizure management
• reduced mobility increasing the risk of thrombosis
• impede physical exam maneuvers
• prevent development of physician-patient trust
• reinforce stigma and judgement of incarcerated patients

Of note, The British Medical Association advocates that patients should be examined and treated without restraints or prison officials unless there is a security or escape risk

Patients who are incarcerated often experience their hospitalization as a negative one. They feel judged and mistreated. They feel unlistened to and mistrusted. Medical providers often refer to them as "jail patients" and describe them as unreliable, social outcasts, deserving of their medical ailments. Many of us do not have formal training on caring for incarcerated patients nor are we aware of laws and policies in place to ensure they receive good medical care.

What can WE do as medical providers caring for incarcerated patients?

• Ask prison officers to remove shackles in order to fully assess patient
• Ask prison officers to remove themselves from the room or stand at the doorway for more privacy
• Use accurate and stigma-free language that prioritizes individuals over characteristics
• Avoid defining people by the crime for which that are accused or convicted
• Ask if the patient consents to discussing PHI in front of law enforcement officials or asking officers to move out of hearing range
• Try to make a patient that is incarcerated feel more comfortable disclosing potentially legally detrimental elements of the medical history
• Become familiar with hospital policies related to the care of incarcerated patients
• Incorporate education of these topics into credentialing or regular hospital-based education meetings
• Take a tour of nearby jail medical facilities and put together a list of resources and contacts
• Ensure careful discharge planning as times of transition

And finally, consider the following thoughts:

Resources:

• AMEND: UCSF center designed to improve health inside correctional care facilities https://amend.us/providing-acute-care-for-seriously-ill-incarcerated-patients-in-the-community/
• American College of Emergency Physicians: https://www.acep.org/administration/resources/recognizing-the-needs-of-incarcerated-patients-in-the-emergency-department/
• AAFP Davis DM, Bello JK, Rottnek F. Care of Incarcerated Patients. Am Fam Physician. 2018;98(10):577-583.
• https://www.prisonpolicy.org/

Mental Health Disparities in Latinx (Flores, 7/29/2020)

A big thanks to CEDAWG and Dr. Yvette Flores, clinical psychologist and professor of Chicano/a studies at UC Davis, who gave a powerful and heartfelt Grand Rounds presentation this week on how to consider and approach the mental health of marginalized groups, particularly Latinx , in this time of COVID. Again, it is hard for me to give her words justice in summary, but the following is my attempt.

Dr. Flores started with "stating the obvious": 1) That racism, sexism, homophobia and other forms of discrimination affect the mental health of those who experience them, 2) That stress affects well-being and 3) That yes, in fact, we are all in this together.

If I don't wear a mask, I affect you.

If my grandchildren don't wear a mask, it affects me.
We are all a little anxious, depressed, and experiencing past traumas as we live this pandemic.

We all need to be in this together, including in mental health.

Dr. Flores spent some time reviewing the important effects of stress on mental health.

Social stress: stress is produced not only by personal events but also by the social conditions that surround us-- and for all our patients, their intersectional identities (gender, class, nativity, immigration status, length of residence in the US). 

Minority stress: high levels of stress faced by members of stigmatized minority groups (race, gender, sexuality, linguistic ability, physical/mental abilities), including:

• lacking proper social supports
• socioeconomic status (SES)
• interpersonal discrimination

Marginalized status affects physical and mental health.

Good stress vs. bad stress: a little stress has been found to improve performance, but a lot of stress can become problematic. In what ways is minority stress a risk factor? And how may minority stress also be a protective factor?

I love considering the possibility that the very minority stress our patients are experiencing may make them simultaneously vulnerable and resilient. 

What has COVID-19 Revealed?

1) Health disparities have been made more visible

2) Xenophobia and hate crimes against Asian Americans

3) Disregard for these disparities from politicians at the highest levels

4) People of color disproportionately work in front line jobs

5) Disproportionate unemployment rates for Latinx and African Americans

6) Ageism (are old people important enough?)

How can we translate scientific data in a way that people can understand?

How do we frame the message?

"There is no one to blame here, but we all have responsibility."

Role of Gender: For the working class, life and work are often synonymous. How does unemployment affect men? How does unemployment impact women who are single parents and have to work? People of  color will often go to work despite the risk because of their gender or cultural mandate that it is their obligation to provide. But this is also a class issue (always need to think intersectionally).

What are the protective factors in communities of color that might mitigate the crisis?

1. Resilience: Immigrants are tremendously resilient. It takes incredible courage to make the journey that many immigrants (particularly undocumented immigrants) make.
2. Stoicism:  coping, "it's alright, I am fine", challenging for healthcare professionals to care for someone who says they are fine (when they clearly aren't). Dr. Flores' rec: Bring in partner if there is one/
3. Religious faith: "Si Dios quiere" God willing. Can be frustrating because seems fatalistic but is also protective. How can we leverage this?
4. Networks of support:  Overcrowded and/or Multi-generational households, which make them more vulnerable are also the very support structures that allow people to survive. How do we mobilize the 
5. Positive ethnic, racial and gender identity: reaffirm their identification (whatever they may be). Call them what they want us to call them. 

Remember that mediational factors may ADD to minority stress

• Internalized racism
• Controlling images (often propagated in the media-- more serious and perverse than stereotypes), many are gender specific (angry black woman, loud Latino, Latino male as criminal or rapist). How does this affect internalized perception of people of color?  How are people in power speaking about these controlling images?
• We must uphold the identities of the people with whom we work: we need to counter these controlling images (mental health workers)

And finally, on coping: how to potentiate coping, so we can be better healthcare providers and caretakers. 

Dr. Flores called this digging into our ancestral well: we have all learned lessons from our family that can help us to serve our patients. In times of crises, we can draw from the stories/legacies that the elders and ancestors have shared with us (and with each of our patients), which can help transform our fears into opportunities

Where do you draw your strength to continue to care for your patients?

Self care is essential during COVID-19:

It is important for us to promote self-care and resilience as we do this work.

Gendered expectations (nurture ourselves in order to refill the well)

Remember to check out and disconnect in order to connect to ourselves 

Cultural traditions can offer balancing and healing: including prayers, smudging, meditation, mindfulness, exercise, baking, cooking

Health Equity (Muodeme, 7/23/2020)

Special thanks to Dr. Ada Muodeme for her thoughtful and thought-provoking Grand Rounds this week on Health Equity. 

A friend and healthcare provider asked me this week, "Why are you hosting  so many Grand Rounds on race, racism, equity, and inequity?" My response is the following: "We bring you these topics because we-- the Sonoma County medical community-- need formal education on these topics. We need race discussions in our academic centers, in our hospitals, in our clinics, in our classrooms, break rooms and beyond. Grand Rounds is a natural place to start these conversations."  

And I am so grateful to our brave residents for being the leaders of this education!

While social justice was definitely integrated into my own medical training, race and racism in medicine were definitely not a part of any training. I did not get taught about how race and racism are structurally a part of medicine. I was not trained on allyship, anti-racism or white privilege. These are topics most white people (myself included) need to hear, read about, grapple with, and consider both personally and professionally. While many of our current residents come to us now with formal training in race and medicine, their teachers have little to none. 

And so we do this work.

This is another GR presentation by a BIPOC better listened-to than summarized by a white gal like me, but here are a few key points:

• Dr. Muodeme reminded us that healthcare comprises only 10% of an individual's health and well-being-- the remaining 90% includes behaviors, environment, societal factors, etc. She grounded her talk in the historical perspective of the African American citizenship status and health experience from 1616 to 2020-- slavery, Jim Crow, and Civil Rights. 

• Dr. Muodeme also shared with us a definition of health equity: "The attainment of the highest level of health for all people". Health equity-- she continued-- requires valuing everyone equally, societal efforts to address avoidable inequities and injustices, and the elimination of health and healthcare disparities.

• But what I appreciated most about Dr. Muodeme's presentation was her focus on the concept of unconscious bias, and the process of self-reflection and self work we all need to do to help mitigate those biases. "I don't know a doctor who comes to work thinking I don't want to right by my patients today," she said. "I don't know a doctor who thinks I am going to treat my black patients differently". And yet, we know we do. The system does. And we do. 

And so, pay attention, watch your thoughts, all. And see you next week!

Allies and Accomplices: How Health Care Providers Can Cultivate Equity (Washington 7/15/2020)

Well, Dr. Sharon Washington did it again. And this time on Zoom (which is no easy task). She pushed us. And moved us. To think differently. To act. To do better. To question the insidiousness of race and racism embedded in our society and in medicine. To not be not racist, but rather to be ANTI-racist. She is such a tremendous speaker and incredible teacher, and we at the Santa Rosa Family Medicine Residency are so lucky to have had her with us this last year and a half. 

A summary cannot really do Dr. Washington's work and words justice. I highly recommend you watch the Grand Rounds if you did not attend live, but nevertheless, here are some highlights. . .

Racism is not merely one individual's negative thoughts about another person of a different race. Racism is more layered and complex. It includes:

• internalized: the devaluing of one's own identity and culture according to societal norms
• interpersonal: the way in which we perpetuate racism on an individual basis
• institutionalized: the way in which institutions perpetuate racism
• structural: system of public policies, institutional practices, cultural representations, and other norms work in various, often reinforcing ways, to perpetuate racial group inequity

Dr. Washington highlighted the legacy of inequity for African Americans in the US dating back 401 years (see image)

Dr. Washington reminded us that:

• There is racial bias built into almost every aspect of healthcare.
• Significant health disparities exist for people of color in chronic disease (diabetes, cancer, heart and kidney disease), infant and maternal mortality, stroke, addiction and mental illness.
• People of color receive fewer/less breast cancer screenings, kidney transplants, vaccinations, eye exams cardiac care, cancer pain meds, revascularization procedures, and mental health treatment.

In order to not be part of the problem, health care providers have a responsibility to be ANTI-racist: the active process of identifying and eliminating racism by changing systems, organizational structures, policies and practices, and attitudes so that power is redistributed and shared equitably.

What is allyship? 

Allyship is a person of one identity group standing in support of another identity group 

• allyship is not a noun, it's an action
• allyship is about listening
• allyship is not a proclaimed identity--> trust is earned
• allies don't take breaks
• allies educate themselves (and don't expect marginalized people should teach you)
• allies don't need the spotlight
• allies focus on those who share their identity
• when criticized or called out, allies listen, apologize, act accountable, and act differently going forward

What is an accomplice? 

"While an ally will mostly engage in activism by standing with an individual in a marginalized community. An accomplice will focus on dismantling the structures that oppress that individual or group-- and such work will be directed by the stakeholders in the marginalized group" (Teaching Tolerance)

• accomplices assess an organization for inequities in hiring, promotion, pay, evaluation, termination, etc
• accomplices encourage major institutions benefiting from inequities to invest in marginalized communities
• accomplices engage in anti-racist assessment of laws, policies, institutions, and systems
• accomplices divest institutions from (private) prisons, detention centers, and institutions engaged in systems harmful to BIPOC
• accomplices promote self care for BIPOC
• accomplices create systems of accountability for supporting hate speech and behavior

Examples of what allies and accomplices can do in medicine:

• Petition the laboratory you use to stop reporting GFR differentiated by race
• Hold a fellow physician accountable if they send a racist email or make a racist comment
• Interrupt micro-aggressions when they are happening
• Don't vote to appoint someone to the board unless they divest from investments that perpetuate racist structures
• Pass the microphone to the marginalized person next to you whose voice is not often heard

Questions to ask yourself:

• In what ways can you be an ally?
• In what ways can you be an accomplice?
• In which institutions do you have agency to create structural change?
• What is holding you back from taking action?
• What commitment can you make to move you toward meaningful action?