The history of racism in medicine dates back to the early days of our country. But even today—generations later—disparities in health continue to impact communities of color as implicit bias, social determinants of health, and other factors get in the way of fair and equal care for all.
Join us for our two-part series—Addressing Racial Disparities in Health—as Dr. Terralon Knight, Board Certified Family Physician and CEO/Founder of Knight Coaching, Dr. John Vassall, MD, FACEP, and Physician Executive for Quality, Safety and Equity at Comagine Health, and Dr. Kellee Randle, MD, Hospitalist and CEO of Equity Ventures Plus discuss the history of racism in medicine.
Terralon Knight, MD, CEO/Founder of Knight Coaching
Terralon C. Knight is Medical Director of a major health insurance company and CEO/Founder of Knight Coaching, LLC. She is a native of Mississippi and received her undergraduate degree in Biology from Tougaloo College. She obtained her medical degree from the Warren Alpert Medical School of Brown University and completed her family medicine residency at University of Texas at Houston.
Dr. Knight has a passion for the underserved, with much of her career spent serving communities in the District of Columbia, Maryland and Virginia. She has been a Medical Director with United Healthcare for eight years and she professionally coaches medical professionals looking to move into leadership and administrative roles. When she’s not working, she enjoys traveling, photography, and family game nights with her husband and three children.
John Vassall, MD, FACEP, and Physician Executive for Quality, Safety and Equity at Comagine Health.
John Vassall is the Physician Executive for Quality, Safety and Equity at Comagine Health. The product of an immigrant family and an inner-city childhood, Dr. Vassall has his Master of Science (Microbiology) and Doctor of Medicine degrees from the University of Washington and internal medicine training at Grady Memorial Hospital, Atlanta Georgia’s public hospital.
He has been a pioneer in addressing racial disparities—opening a clinic for Black Americans in Seattle and serving in the 80s as the Chair of the Board for the Carolyn Downs Family Medical Center, the last currently operating medical clinic in the United States started by the Black Panther Party. In addition, he has served in many leadership roles on a statewide and national level, including serving as member of the Board of the Institute for Diversity and Health Equity.
Kellee Randle, MD, Hospitalist and CEO of Equity Ventures Plus, LLC.
Dr. Kellee Randle (Doctor Kellee) is a board-certified physician in internal medicine. She received her doctor of osteopathic medicine from the University of North Texas Health Sciences Center in 2010, and went on to complete her internal medicine training at Broward Health Medical Center in Fort Lauderdale, Florida, in 2013. Currently, she is a hospitalist in Dallas, Texas.
As the founder and CEO of Equity Ventures Plus, LLC, her mission is to educate healthcare professionals about implicit bias and empower minority communities to advocate for themselves in healthcare settings. She is respected for her medical opinion and known for her ability to make complex medical concepts understandable for her audiences.
In her spare time, Doctor Kellee enjoys volunteering with medical missions, traveling, exercising, reading, and spending time with her family. She is also an active member of Delta Sigma Theta Sorority, Inc.
Welcome to this month's edition of caring as communities. I'm Dr Enrique Enguidanos, CEO of community based coordination solutions. And today is part two of our two part series exploring racial inequities within healthcare. We're joined again by our three wonderful accomplished panelists, Dr. Carolyn Knight. Dr. Kelly Randall and dr. john vassal, and I provided some longer introductions during last month's session but I'm going to ask each of you to provide a quick introduction for our listeners. Dr. Knight.
Oh, thank you, Enrique. I'm Dr. Terralon Knight, board certified family physician speaker, author and career transition coach. I help women who are transitioning from clinical careers. Fine, flexibility, financial freedom. And I, you can follow me at Dr Terralon on all social media platforms. Thank you for having me today.
We're honored to have you. Thank you for being with us. Dr. Randle
Hi again thank you so much for the opportunity to be here with the distinguished panel, I am Dr. Kellee Randle, board certified internal medicine physician and Equity and Inclusion healthcare consultant, I offer training and strategies that help healthcare systems decrease their costs and improve patient outcomes, I can be found on all social media, as Dr. Kellee. That's Facebook, Instagram, Twitter, and LinkedIn, thank you so much for having me.
Also an honor to have you with us Dr. Randall. Thank you for joining us. Dr. Vassall.
I'm John Vassall. I'm a general internist by training and currently working with two consulting companies in Seattle. I'm trained as a general internist and did primary care internal medicine. Also, was very heavily involved in organized medicine both at the physician level as a trustee for the Washington State Medical Association, as the Chief Medical Officer for the largest health system in the state of Washington. At the national level on the Board of Trustees for the American Hospital Association, and a non local level, on the board of trustees of the Washington State Hospital Association. And I'm very active in my community. I was the chair of the board of the Carolyn Downs Clinic. Carolyn Downs was a Black Panther, and the clinic is still operating as the only still functional operating clinic started by the Black Panther Party. Thank you for having me here.
Dr. Vassall we're honored to have you. Thank you very much. Terralon, John, and Kellee, thank you for helping us lead this important discussion. The year 2020 has been a year, like no other. I think it's fair to say that our generation has not experienced a year, like 2020. Among the multiple issues we struggled with has been COVID, and the covid 19 pandemic has certainly highlighted helped us highlight some of the issues and disparities that have been ongoing within minority populations for quite a while now. I just want to throw out a couple of pieces of data. The CDC recently reported that Hispanic children are eight times more likely, and black children are five times more likely, to be hospitalized with severe covid, as opposed to their white peers. The Harvard Medical School recently found that workers of color, were more likely to care for patients with covid, more likely to report using inadequate or inappropriate protective gear, and nearly twice as likely as white colleagues to test positive for Coronavirus. I'd like to start today's conversation by by just opening the floor to to get your comments on these inequities we're seeing during the COVID pandemic. John perhaps you can offer your thoughts to start.
Yes, thank you. I have a couple of thoughts you know means that the black kids getting this disease, more severe and Hispanic kids particularly. I can't help but reflect on the 545 children who were separated from their parents at the border who cannot be reunited with their families. I have kids, it's a very emotional thing to me. And you can see when you see the conditions on which those children were held. It's not surprising that they would be exposed to infectious diseases, when they were crowded together in what people refer to as cages and don't have the benefit of their parents and their family, taking care of them. Now, obviously that's a specific instance but it's one that is illustrative to me of some of the issues that our immigrant neighbors and some of our immigrant communities are faced with. And I think that that's certainly part of the reason why we're seeing the severity and the incidence of disease in that community,
Thank you John. Kellee, Terralon, would you have any additional thoughts to offer?
I would say our Hispanic population is being disproportionately affected by COVID for several reasons. And I think the most obvious thing is the fact that they were disproportionately cared for, before the pandemic, in pretty much every aspect of health care and resource allocation. However, the major factor I think that affects Hispanic populations with COVID and to some extent, African American as well, is the fact that these cultures live multi-generationally. And it is not uncommon for Hispanic families to have the grandparents, parents, and children all under the same roof. And I think the extent to, I guess, to personify how important that is and how big of a social determinant, that is, is looking at New York City, and it's really not surprising that New York City has gotten hit so hard with COVID because look how many people live on top of each other in one city block, how many folks live in a two bedroom apartment, because the rents $5,000 a month. So it takes six seven people to pay that rent. And how do you socially distance in a two bedroom apartment, you can't, and you don't. And so you spread; everybody's a super spreader.
Also when you live in major metropolitan areas, and you're on public transportation you're exposed in so many different places. And I think a lot of the health care policy will call it that, the health care policies that were enacted for COVID treated everybody as if they were a monolith—as if everybody lived in suburbia. And everybody's in a single family dwelling with, you know, to a mom and dad, 2.2 kids, and a dog—and that's just not the reality for most Americans. And so our Hispanic families and our African American families who live and depend on their community, their family unit to make ends meet, to care for children are absolutely at. higher risk. Those are also the families that are most likely to do your frontline jobs, and tons of people who work in in retail, who are working at the gas station, working at the grocery store. Who are your healthcare workers, who are your nurses, who are your custodial staff, your bus drivers, all of that both people are constantly being inundated with other people's germs and it's difficult to socially distance driving a bus or being an educator. So I don't think it's very surprising that all our underinsured or uninsured and minority communities are harder hit, because they were already dealing with a stacked deck, and then you go bring a pandemic into the to the fold. It's hard to work from home when you drive a bus. It's difficult to drive to work from home when you are the cashier, so they were our most vulnerable population to begin with, and I think COVID has just magnified what we already knew.
Absolutely. And I was just gonna add to what Kellee said though, when you have when you have this population with the most vulnerable population and you couple that with their lack of resources lack of access to health care resources, then definitely you're going to see them when they're sick of things, you're going to see them with the highest utilization, you're going to see them when they're at their sickest, and you're going to see them in most likely in the ER at their worst. We're likely not going to see them early in their symptoms, we're going to see them likely at the end, so definitely don't have much to add. Kellee covered covered it beautifully.
Terralon, what you did mention I do as an emergency medicine physician, I can tell you, I mean that the work that our nurses and physicians are doing in the trenches and Kelly as a hospitalist up on the, on the floors in the ICU, is amazing—putting themselves at risk, every day but, you know, oftentimes, the general public doesn't think about the housekeeper's. I think about Guyana—who works in my ED cleaning up the room. After what has been the probably the highest risk, and or our technicians coming in and performing the COVID swabs, you know. In our minority communities, minorities do tend to be more of the higher represented within those higher-risk positions that don't have the option to not come into work or to serve as a telemedicine Doc.
Last month we, we were talking about, historically, some of the trends within communities that lead to disparities, and you know John spoke we spoke about food differences. I think about communication in my daily work in the in the emergency department, but I think just out in communities in general how just basic differences in communication are represented within minority groups—or the health care that minority groups receive. Are we, as a medical industry, communicating effectively, so that the recipient is hearing what we're saying or that we're listening to information? Kellee when, when you're performing an intake, as a hospitalist I'm assuming you're able to get information that perhaps physicians not of color wouldn't be perceptive about picking up on. Could you comment on that a little bit?
You mean as far as, as it relates to what's happening at home with them?
Certainly. I was thinking of myself. I mentioned last month, about being able to speak to my Spanish speaking patients and get information that—had I not been there—may not have been picked up, and I can imagine every day in your work as a hospitalist you must encounter situations where you're getting information that others wouldn't. And how do we as an entire industry become more cognizant about receiving that information and giving that information?
Yeah, okay, I definitely understand where you're coming from. I think the thing about COVID is so in most hospitals, you know, language is no longer really a barrier. It's a lot easier obviously if you're a native speaker and you can just kind of fluently go back and forth and discourse. But I think one of the bigger things, is the fact that people just don't understand...
Can I interrupt for a few seconds for some of our non medical listeners? Language is less of an issue because we have translation services that we avail ourselves—is that correct?
Yes, we have several options and at my particular hospital we have a tablet that basically has an interpreter that comes on that you can see the interpreter. It's kind of like a FaceTime type of a situation, so the patient can see you, you can see the interpreter, and the interpreter can see you and the patient. And that's really a modality that most hospitals have been employed since covid because it puts it keeps your frontline workers at minimal risk. It doesn't do a lot for your nurses because they still have to be available to the patient, but as far as your physician workforce, we've really tried to minimize the number of us that had to actually go into a covid unit. Just because, you know, we're limited in resources right so if you take out the whole physician workforce, there's not anybody left to care for the patients.
But as far as what we're getting from the patients, I think there's just a misunderstanding sometimes that people don't quite understand, you know, the necessity for wearing a face mask. I think people don't understand, you know that we're all tired of COVID, we're all tired of wearing a mask, all tired of washing our hands. The disconnect is that folks are assuming that because we're seven months into this, there's now some relief, or that we've been at this long enough, and that's just not the way viruses work. It's not the way pandemics work. We don't get to just "tap out," although it's an attractive option. I wish it was one we could utilize but I think people are getting fatigued, just with the constant inability to just hop out and run in the store for five minutes without a mask. So I think that's the real big take home, that we are getting from the healthcare side at this point in the pandemic.
I think earlier on in the pandemic it was just misinformation and miscues. People saying "Oh, it's not airborne, oh no you can't catch it like this, oh I already had it I can't get it again." All these misnomers about it, and and that was leading to, you know, increased cases but I think now it's just people being fatigued and just being done, you know, just this attitude of "I'm done with this, I don't want to hear about it anymore. Ignorance is bliss." And I think that's part of, you know the reason why we're where we are where we are right now, so nothing from the standpoint of that I think would help from the disparity standpoint because I think the root of that is the same as if we're talking about diabetes or high blood pressure or anything else. But the issue is now that we're seven months and and people are just tired of complying.
As I was thinking about it yes—whether or not we on the medical side are communicating appropriately and adequately with our patients—for me the answer is "no." Communication is a complex thing, and but there are several parts to that. One is the giving of information. The other is the receiving of information. Something that is done, orally, you know, speaking, something good is done with body language, and something that is done with inflexion.
And then there's the receiving of the information. And there's hearing it, there is understanding it. And there's believing it. And I think one of the problems is bias and not believing the information that patients are giving. You've heard the term "I can't breathe." You know the reason that that that that sentence sticks with me so much is because it is associated with disbelief. Somebody saying "I can't breathe" and somebody doesn't believe. And that happens in a medical setting.
Often, one of the reasons why we see a higher incidence of maternal mortality in black women is because the health care practitioners don't believe them. When they say "I'm hurting, I've got a problem. I can't breathe." You know, that happened to Serena Williams. When she threw a pulmonary embolus, and said, "I can't breathe" somebody was not listening. So, part of the problem is that we are not believing our patients and we need to. And that's part of communication. You need to start believing our patients.
The other part of it is patients have to be have to feel comfortable in giving us the information. And very often because of the suspicion that—black patients particularly but other patients actually—all patients at some level have some suspicion of the medical system. I think the black folks perhaps more so than others, but not uniquely, may not give you as a physician the information that you need because they don't understand the question you asked if you're using too much terminology. They don't know what you want to hear, and very often patients are trying to please you and trying to tell you what they think you want to hear, or they don't really know what among their symptoms is really important. So it's very important for us to set an environment where patients are comfortable in telling us everything that they know, so that we can select out of that what we need to know. And we have to believe them.
So, like to add to that, that influence can be very powerful so with communication. So, we can influence them so we can deliver information, and the patient can very well understand and give you that information can repeat it back to you, but who in their circle of influence can convince them to carry out what you're delivering to them?
I feel like we can learn so much from the Tuskegee syphilis experiment. I'm just been fascinated and have been studying it so much lately. But it would not have been—the Public Health Service would not have been able to carry it out for so many years—without the help of Eunice Rivers—without the black nurse. Those men trusted Eunice Rivers. She was a nurse who was keen in convincing and driving the men who were enrolled in the study. She drove them to their appointments she visited with them. They were not as easily convinced to be enrolled in the study, and to go see these white doctors, so they needed this black nurse to to earn the trust of those men.
So when we talk about communication, it's often about influence. Who can gain the trust of the people that you need to deliver the message? So, for me that's always been key. I actually carried out a study in residency when I was trying to pre educate and increase organ donation among African Americans in Houston. And so what I did was I did a survey amongst a small cohort of folks. And, of course, most did not believe in that. They had all of these beliefs about what happens with organ donation. And all of them were African American but after answering all of their questions and educating that—no, no one's going to sell your organs—dispelling all of these myths, I gained their trust because I look like them and because I answer all of their questions. I was able to convince, most of them to find their card and say that they would donate their organs. So, you know, this is, you know, it really, it really is important than their circle of influence. When you're delivering the information.
Well, and I as I listened to Terralon, I think of the current COVID environment in which only two family members or one family member may be able to join the patient in that emergency department. Kellee, I don't know how it is up in your ICU or as a hospitalist, but sometimes, no family members can join a patient if they have covid and that takes a difficult to communication situation and just makes those disparities even worse, during the COVID environment.
Absolutely, especially if you're talking about Hispanic families because, and the husband's the patriarchs in the family. And most of the time decisions are made with the community, or the family unit in mind, so when you're separating out family members, you're making what seemed like unilateral decisions. So you've already got a language barrier, because the vast majority of people that are coming in and going out of those rooms that are not speaking Spanish fluently, or for all intensive purposes you can say Chinese, Japanese whatever the dialect would happen to be. That's not English.
The vast majority of people are not fluent in whatever language you're speaking. So, there has to be a certain amount of angst and anxiety and mistrust because they don't even know what you're saying for one. And then for two. You know, if you are buying into the larger narrative that, or at least when it was very prevalent, that this isn't a real thing or this is a hoax, you're going through all these things in a foreign country and everyone's discussing you. But you don't know what's being said and don't understand the implications of what's happening. But I think to dive to Terralon's point, and what I kind of got is a good take home and maybe a good thing that we can try to employ, is that—while it's obviously not feasible to have someone of every ethnicity in the emergency room to kind of break down those initial barriers—what we can do is, whether it's during their hospital care or in their post acute care is have someone reached out to them who is fluent in Spanish/their language, so that you don't have that disconnects. Make sure that when they're getting discharged to someone who is, you know, medically adept, whether that's a physician or a nurse or a patient educator. However, the hospital is set up to have a fluent conversation with that person so that it's like a conversation. And it's discourse as opposed to even with a translator there's some disconnect there sometimes, and, you know, and things have to be repeated and, you know, technology fails and all those types of things. So I think this is a really good takeaway or something we can expound upon.
You can't have someone who speaks, Hindu, you know, in every corner of the hospital but what we can do is make sure that we have a patient liaison, or whatever fancy thing you want to call them, that engages with the patient through the process so that if there are disconnects or cultural things that need to be communicated that they that can be done at some point in the acute or post acute setting. But, you know, to kind of quantify how much is happening in such a small amount of time, you're also asking physicians who are overworked stressed, dealing with COVID on every level, you know they're dealing with it at home with their own families they're dealing with it at work everywhere they go—and you're asking a stretched population to extend themselves further. So we have to come up with some come with some healthcare solutions that don't always lead everybody to throw it in the physician basket, because that's not the answer and what you're going to do was increase burnout and have more people disenfranchised and then you'll lose the really good physicians.
I think you're bringing up a good point Kellee. I think it's already too late by the time they get to you. We need to put our energy and our thoughts into prevention. We're talking secondary prevention by the time we get to you. Our energy and our thoughts need to go into initial prevention, or primary prevention, I'm sorry. So, like you said, as a community we need to put our thoughts into more community health workers, especially, if they have insurance on the payers to put more funding into community health workers patient education program. And even if the patient isn't funding. Local Government could put it into the health department because if you invest there then your communities will be healthier. So, I, you know, cross and then for, you know, if we don't have enough, we talked about having health care workers that look like the community that treats them so if that's not possible possible invest more funding into cross cultural education, right. So, I think starting there and thinking more about prevention waiting, because then if not, you'll end up spending more on the back end where, you know, the healthcare is way too expensive. In the acute setting, right. So, that's just where I'm thinking right now.
Well you know when you speak to that Terralon, I think back a few years to the implementation of the ACA, and something very interesting happened when we had 40 50 million additional individuals get insurance in the country. We saw about a 10 to 15% spike in emergency department visits, and that baffled everyone at the time because they thought "we've got more individuals that should be having health coverage. Why then are we seeing more and not less acute visits?" And really what happened in that situation is we hadn't yet created the infrastructure for primary care visits. We had individuals that suddenly had coverage, and the emergency department was the one place to go now over a couple of years.
We worked through that and we got broader coverage for individuals and those emergency department visits, but I've used that as a success in that at least individuals were recognizing they had coverage, and they weren't waiting, as long to get seen, and frankly I think within our minority communities that's probably why we're seeing more covid crisis. Those of means can come in and get tested early, but if you're waiting too long, and the situation has evolved with COVID, there may not be the ability to turn back from that situation.
I think one of the other things to consider is insurance is only as useful as your ability to actually utilize it. So if you were a job and you are a custodian, I don't know of any job that's going to let you take off two hours in the middle of the day to go see or to go to a two o'clock appointment. And, you know, how many families can afford to miss half a day okay to do that even if they can take time off? I'm gonna lose half my income for the day to pay out money that I didn't have even if I had gone to work. So people were asking people to make choices about what they can afford. And the question, and the issue, really isn't how sick are you? It's can you still work? If you can still go to work, then you're not that sick. And then that sick goes to three months, and you're not only that sick—you're endstage now, or whatever the case may be. And those are the decisions that are being made, because they can't afford to take off their jobs. It doesn't work that way when you are working for an hourly wage. And even if you have insurance if you can't get to the doctor to use it, it doesn't help you and most doctors offices, even if they are open til six or seven, okay you get off at five, you got to go pick up your kids, you got to get them fed, like there's so many variables that go into the decisions that people make and they may make them out of necessity, and not necessarily out of what we would consider to be sound judgment. But the one place that is open 24/7 365—Christmas, Mother's Day, and Easter—is the emergency room. So, if you have not put community resources in place to address health or childcare, transportation, you're not going to move the needle forward with community resources, because they're not going to be able to get to us.
So we have to stop victim shaming and blaming saying "we gave you this health center or we gave you extra office hours" when they're still facing other challenges like "but what am I gonna do with these three kids". Otherwise, we just chase our tails and we keep throwing money at a thing, and not doing it in a systematic way. You can't look at every community the same, what is going to work in this community may not work in that community. And who's going to be able to tell you the nuances of the community, other than people that live there, work there? And so I think to Dr. Terralon's point, you have to figure out how to get engagement in the community and get them involved, because if you sit on your tower and come up with all these solutions for their problems, and they don't buy in, you haven't fixed anything—all you did was waste money and waste time. So we have to get serious about really wanting to make changes and getting the players at the table who can actually help us to do that. Community A, it's going to look different than in Community Z, and we have to stop treating everybody the same.
I can't think of a better plug for our listeners to keep on listening to our podcast is to set our addressing the social determinants of health. Well that that you you summarize that beautifully Kellee. Thank you so much. But yeah, and I think of our navigator roles that have began to appear in emergency departments and in hospitals and discharge planners, and that's really the point is to try to to delve into some of those issues early on, and I think we do need to to incorporate community inclusion and some of those goals. But the step in the right direction. We could be going on for much longer we're coming close to the end of our time. But there's one other issue I want to delve into and John, I'm wondering if you might lead us. You've been involved and lead, so many groups, and I'm sure have confronted both personal and inequities within administrative and leadership goals as well as patient in equities. I'm hoping each of you could perhaps give some thoughts about how we might identify and address health inequities in real time. Are there common traits, or are there things that that you would like to see happen in an ideal situation.
I go back to what I mentioned with regard to black maternal mortality. And the concept of really trying to listen to patients, recognizing that, if we come from a different background, we're not going to totally understand. But if we start with that open mind and open heart and understanding that we will not be able to understand everything, we will want to dig deep and really listen and really open up the communication for the patients to feel comfortable in telling us what they need because the patient knows what happened with them. We don't know. We have to get that information from the patient. And I think a little bit more humility on our part as practitioners would go a long way in helping us close some of the gaps, and some of the inequities.
Thank you for calling us from the medical professional. I thank you for calling us out on that John. I appreciate that. Terralon, would you have anything to add?
I'd like to see underrepresented minorities—African American, Latino, all underrepresented minority—medical school admissions increase across the board, as well as faculty diversity increase. So that we'll reflect the communities that we serve as as physicians well as in hospital board positions. And I'd like to see cultural competency programs become mandatory, not just for medical school, but also for hospital staff. I see that lacking, and I think that's absolutely imperative. I think it should be not just mandatory, but ongoing. Those are my top two
Dr. Randle, anything that you would like to add?
I think they covered most of the bases. I think really just a focus on community-based solutions is going to be paramount to making incremental changes. And so I don't know best way to do that necessarily because it looks different, depending on what part of the country you're in and the demographic that you're you're serving. So, if this were a business model in any sector other than healthcare, how would they approach this? If Elon Musk had an issue and it was affecting his bottom line across the board, how would he address that? We need to look at healthcare as the business that it is, and also look at it through the lens with some sensitivity be that cultural, as well as just with an understanding that people want to be well, that people want these things for themselves and there's barriers in the way. And we need some people to be on every level, health care administration, local community leaders our mayors our governors, our senators—we need everyone on every level to have to see it as a priority. And I think if we all do a little something in our corner of influence then maybe we can actually put some changes in place that will actually help.
Kellee, I couldn't have said it any better. Thank you so much for that. Dr. Knight vassal Dr. Randall. It's been a to honor, having you for these leading us in these discussions for the last two months on such an important topic.