Episode 236: ARM Episode 16 – Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting

The Clinical Problem Solvers

https://clinicalproblemsolving.com/wp-content/uploads/2022/05/ARM-EP-16_RTP.mp3

CPSolvers: Anti-Racism in Medicine Series

Episode 16 – Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting

Show Notes by Sudarshan Krishnamurthy

May 3, 2022

Summary: This episode was recorded in front of a live audience at the Society of General Internal Medicine’s 2022 Annual Meeting in Orlando, FL. In this episode, we gain insights from three antiracism scholars, Drs. Yannis Valtis, Ebi Okah, and Carine Davila, about research in their respective fields. Dr. Valtis is a 4th year Med-Peds Resident at Brigham & Women’s Hospital and Boston Children’s Hospital, and his research focuses on race and the utilization of security responses in the inpatient hospital setting. Dr. Okah is a family medicine clinician and NRSA research fellow at the University of North Carolina School of Medicine, and she studies the association between the use of race in medical decision-making and beliefs regarding the etiology of disparities in health outcomes. Dr. Davila is a palliative care physician at Massachusetts General Hospital and her work examines racial and ethnic inequities in patient-clinician communication. This episode was led by Rohan Khazanchi, and was hosted by Sudarshan Krishnamurthy and Utibe R. Essien.

Episode Learning Objectives

After listening to this episode learners will be able to:

1. Understand the association of race with the utilization of security responses in hospital settings
2. Understand the association between the use of race in medical decision-making and beliefs regarding the etiology of racial differences in health outcomes
3. Understand racial/ethnic inequities in trust-building healthcare experiences and describe the importance of improving trust in the healthcare system through trust-building experiences with historically marginalized communities

Credits

• Written and produced by: Rohan Khazanchi MPH, Sudarshan Krishnamurthy, Utibe R. Essien MD, MPH, Jazzmin Williams, Alec J. Calac, Victor A. Lopez-Carmen MPH, Naomi F. Fields, LaShyra Nolen, Michelle Ogunwole MD, Jennifer Tsai MD, MEd, Chioma Onuoha, Ayana Watkins
• Hosts: Sudarshan Krishnamurthy and Utibe R. Essien MD, MPH
• Infographic: Creative Edge Design
• Audio Edits: David Hu
• Show Notes: Sudarshan Krishnamurthy
• Guests: Drs. Yannis Valtis, Ebi Okah, and Carine Davila

Time Stamps

0:00 Introduction

4:20 Context and background of Yannis’ project

7:40 Framing of Ebi’s research

11:25 Inspiration for Carine’s work

14:50 Yannis’ explanation of his findings and potential next steps to intervene

25:45 Results from Ebi’s research

33:55 Carine’s findings from her work

40:00 Audience Questions

Episode Takeaways

• Our Black patients are nearly twice as likely to experience a security utilization as our White patients.

Along with previous literature demonstrating a higher use of restraints in our Black patients in the emergency department setting, Yannis’ work shows a higher use of security responses in Black patients compared to White patients. Simulation-based training interventions are currently being studied to help combat these inequities.

• Individuals who believe that genetic differences explain racial differences in health outcomes are more likely to practice race-based medicine.

Ebi’s research found that those physicians who possessed the belief that the etiology of racial differences in health outcomes was rooted in genetic differences were more likely to practice race-based medicine. On the other hand, those who believed that differences in social conditions explain racial differences in health outcomes were less likely to practice race-based medicine.

• Our Black and Hispanic patients are less likely to have had trust-building experiences and more likely to have had trust-eroding experiences with the healthcare system.

Carine’s research illustrated the presence of trust-building experiences and trust-eroding experiences at every touchpoint with the health care system. Further, her research shows that Black and Hispanic patients are less likely to have had positive experiences and more likely to have had negative experiences. In addition to a need for culturally competent interpersonal communication, health systems and structures must actively work to build trust with historically marginalized communities.

Pearls

• “When we heard the Code Gray bell go off in the hospital, all of us knew that there was a very high likelihood that we would be entering the room a Black patient.”

In the landscape of the murder of George Floyd, Yannis described how his team began to ask questions about how they could better protect their Black patients from police brutality. Although they began with a large focus on police brutality as a whole, they realized that the presence of police within the hospital had not been sufficiently examined. Although it had not been objectively measured, their clinical and personal experiences indicated that security responses were more often utilized for minoritized patients in the hospital.

• “It did not make sense that an innate risk for poor health was attributed to Blackness, instead of thinking about how society assigns privileges and benefits by race that results in varying health outcomes.”

Ebi discussed the context behind what inspired her project, explaining that her journey began in medical school when students challenged race-based medical curricula and the use of race as a risk factor for disease. While starting residency, she was exposed to the use of race in clinical risk calculators and was confused by the rhetoric around the innate risk conferred by Blackness, instead of the influences of racism and inequitably distributed social determinants on health outcomes.

• “There are known inequities in patient-clinician communication in historically marginalized populations that have immediate and downstream effects on health outcomes for these patients.”

Carine talked about her expertise in empathically communicating with patients as a palliative care physician. As she embarked on her project, she realized that improving serious illness care would require improving serious illness communication. She explained that the willingness for patients to engage in communication is rooted in how much they have been listened to in the past. Importantly, there is literature demonstrating inequities in patient-clinician communication with impacts on immediate outcomes, such as patient satisfaction and trust-building, along with downstream health outcomes

• “… we found that the chance of having security called on our Black patients was nearly double that of our White patients.”

Yannis described previous studies demonstrating that Black patients have a higher likelihood of being restrained than White patients in the emergency department and psychiatric settings. However, there seemed to be a lack of literature exploring this in the inpatient hospital setting, where patient clinical presentations are more varied and management depends more on clinician behaviors. His team found that 1.5% of White patients had a security response called, in comparison to almost twice as many (2.8%) Black patients. Yannis posited that this difference was due to explicit and implicit biases rooted in racism in our broader societal context. When thinking about an intervention to combat these inequities, Yannis described a project at the Brigham leveraging simulation-based training on interacting with agitated patients followed by a debrief session to have clinicians reflect on their actions towards patients and the role of race.

• “… we found that the belief in genetic differences explaining racial differences in health outcomes is associated with the practice of race-based medicine.”

Ebi’s work focused on how physicians think about race and how they engage in race-based medicine. Her project asks three main questions: 1) To what extent do racial differences in genetics explain racial differences in health outcomes? 2) How do values related to diet, exercise, and other cultural differences between racial groups explain racial differences in health outcomes? and 3) How do differences in social conditions, such as the environment and socioeconomic status, influence racial differences in health outcomes? Ebi found that the belief in genetic differences as an explanation for racial health disparities was associated with use of race-based clinical practices. Additionally, the belief that social inequalities explained racial health disparities was not associated with race-based practice.

• “Our Black and Hispanic patients are less likely to have had positive experiences and more likely to have had negative experiences with the healthcare system.”

People engage in positive trust-building and negative trust-eroding experiences at every touch point or every interaction with someone in the healthcare system. Carine explains that this forms the framework for how experiences within the healthcare system can be evaluated. Unsurprisingly, it was found that Black and Hispanic patients were less likely to have had trust-building experiences and more likely to have had trust-eroding experiences with the healthcare system. Trust in the healthcare system is dependent on so many factors, and boils down to what the system has done to demonstrate that they are trustworthy. The onus is on us as a system to build and earn the trust of our patients through trustworthy behaviors, especially when the system has historically not done that. An important way of improving trust in the system within historically marginalized communities includes the recruitment of clinicians to the healthcare system from within these communities, to increase representation and better reflect the diversity of our patient population. The presence of these diverse clinicians also changes the inherent nature of the space that healthcare occupies.

References

1. Valtis YK, Stevenson K, Murphy E, Hong J, Ali M, Shah S, Taylor AD, Sivashanker K, Shannon E. Race and the Utilization of Security Responses in a Hospital Setting. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
2. Okah E, Cronholm P, Crow B, Persaud A, Westby A, Bonham V. The use of race in medical decision-making is associated with beliefs regarding the etiology of racial differences in health outcomes. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
3. Davila C, Ravicz M, Jaramillo C, Wilson E, Chan S, Arenas Z, Kavanagh J, Feltz B, McCarthy B, Gosline A. Talking the Talk: Examining racial and ethnic inequities in patient-clinician communication. Oral Presentation at Society of General Internal Medicine 2022 Annual Meeting. Orlando, FL.
4. Okah E, Thomas J, Westby A, Cunningham B. Colorblind Racial Ideology and Physician Use of Race in Medical Decision-Making. J Racial Ethn Health Disparities. 2021 Sep 7:10.1007/s40615-021-01141-1. doi: 10.1007/s40615-021-01141-1.
5. Ogunwole SM. Without Sanctuary. N Engl J Med. 2021 Mar 4;384(9):791-793. doi: 10.1056/NEJMp2030623.
6. Corbie-Smith G, Henderson G, Blumenthal C, Dorrance J, Estroff S. Conceptualizing race in research. J Natl Med Assoc. 2008 Oct;100(10):1235-43. doi: 10.1016/s0027-9684(15)31470-x.
7. Nash KA, Tolliver DG, Taylor RA, Calhoun AJ, Auerbach MA, Venkatesh AK, Wong AH. Racial and Ethnic Disparities in Physical Restraint Use for Pediatric Patients in the Emergency Department. JAMA Pediatr. 2021 Dec 1;175(12):1283-1285. doi: 10.1001/jamapediatrics.2021.3348.
8. Carreras Tartak JA, Brisbon N, Wilkie S, Sequist TD, Aisiku IP, Raja A, Macias-Konstantopoulos WL. Racial and ethnic disparities in emergency department restraint use: A multicenter retrospective analysis. Acad Emerg Med. 2021 Sep;28(9):957-965. doi: 10.1111/acem.14327.

Previous Episodes Discussed:

1. Lindo E, Nolen L, Paul D, Ogunwole M, Fields N, Onuoha C, Williams J, Essien UR, Khazanchi R. “Episode 2: Dismantling Race-Based Medicine, Part 1: Historical & Ethical Perspectives.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2020/11/17/episode-141-antiracism-in-medicine-series-episode-1-dismantling-race-based-medicine-part-1-historical-and-ethical-perspectives-with-edwin-lindo/ November 17, 2020.
2. Eneanya A, Tsai J, Williams J, Essien UR, Paul D, Fields NF, Nolen L, Ogunwole M, Onuoha C, Khazanchi R. “Episode 4: Dismantling Race-Based Medicine, Part 2: Clinical Perspectives.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2020/12/16/episode-148-antiracism-in-medicine-series-episode-4-dismantling-raced-based-medicine-clinical-perspectives/. December 17, 2020.
3. Manning KD, Corbie-Smith G, Khazanchi R, Nolen L, Fields N, Ogunwole M, Onuoha C, Tsai J, Paul D, Essien UR. “Episode 6: Racism, Trustworthiness, and the COVID-19 Vaccine.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2021/02/25/episode-162-antiracism-in-medicine-series-episode-6-racism-trustworthiness-and-the-covid-19-vaccine/. February 23, 2021.
4. Roberts, DE, Onuoha C, Khazanchi R, Nolen L, Fields N, Tsai J, Essien UR, Paul D, Ogunwole M,. “Episode 8: Dismantling Race Based Medicine Part 3: Towards Justice and Race-Conscious Medicine.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2021/05/10/episode-176-antiracism-in-medicine-series-episode-8-towards-justice-and-race-conscious-medicine/. May 10, 2021.
5. Onuoha C, Khazanchi R, Fields N, Ogunwole M, Williams J, Essien UR, Tsai J, Nolen L, Paul D. “Episode 9: Moving Towards Antiracism in Medical Education.” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/2021/06/10/episode-181-antiracism-in-medicine-series-episode-9-moving-towards-antiracism-in-medical-education/. June 10, 2021.

Disclosures

The hosts and guests report no relevant financial disclosures.

Citation

Valtis Y, Okah E, Davila C, Krishnamurthy S, Essien UR, Calac A, Fields NF, Lopez-Carmen VA, Nolen L, Onuoha C, Watkins A, Williams J, Tsai J, Ogunwole M, Khazanchi R. “Episode 16: Live from SGIM: Best of Antiracism Research at the Society of General Internal Medicine’s 2022 Annual Meeting” The Clinical Problem Solvers Podcast – Antiracism in Medicine Series. https://clinicalproblemsolving.com/antiracism-in-medicine/. May 3, 2022

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