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AMCP Podcast Series - Listen Up: Dr. Emmanuel Mensah, implicit biases and disparities in health care
Show Notes
Host Fred Goldstein invites Dr. Emmanuel Mensah, a Firm Chief and Faculty at Beth Israel Deaconess Medical Center / Harvard Medical School to discuss taking a look in the mirror and reflect on our own implicit biases and disparities in health care.
Transcript
Fred Goldstein 00:01
Hello and welcome to the AMCP Podcast Series Listen Up as we take a deep dive into the challenges, trends and opportunities in managed care pharmacy, follow the show social hashtag AMCP ListenUp. And to learn more about AMCP visit amcp.org. I'm your host Fred Goldstein. On today's show, my guest is Dr. Emmanuel Mensah, a firm chief and faculty at Beth Israel Deaconess Medical Center, Harvard Medical School, and the managing director of the Center for Integration Science and Global Health Equity at Brigham and Women's Hospital, Harvard Medical School welcome Emmanuel.
Emmanuel Mensah 00:39
Thank you, Fred. It's a pleasure to be here with you today.
Fred Goldstein 00:42
Yeah, fantastic. Looking forward to this topic. So why don't we start with how did you begin this journey of looking into implicit bias in healthcare? And what are some of the examples of these disparities in health care that have been formed that journey? Emmanuel Mensah 00:56 Thank you for the question Fred. So my journey started on a personal level. As a black man in America, I have dealt with implicit bias, microaggressions and racism. I don't think we just move on from it. But it truly hit me after the death of Philando Castile. This was in 2016. Stopped by police officer, and shots for reasons unclear. And for me, this really hit me hard because as I talked about the story of Philando, I became scared and became scared because I thought this could be the story of my son one day, I thought about all the implicit biases also the black woman face and thoughts of this could be my daughter. And so this is when I decided to start on a journey, a journey to explore these implicit biases, structural racism, and to truly understand how we could address these. In terms of examples, as you ask there are many of them. And I think that what's been revealing is their presence in every aspect of healthcare. Yet, despite this Fred in 2000 Those report, the majority of Americans were uninformed about the health care disparities, that many white folks were unaware that blacks fared worse than whites. This is different now. We saw this with the disparities with COVID. If you look at different, you know areas in healthcare from coronary bypass, renal replacement therapy, breast cancer, even pediatric kidney transplantation, you see these disparities.
Fred Goldstein 02:36
So Emmanuel, how does one economic status impact the disparities they face?
Emmanuel Mensah 02:44
Very good question, Fred. I think over the years, we often think of some disparities as related to economic status. But the truth is the there's a recent study, which was actually published in the New York Times, talking about childbirth. And it shows that money protects white mothers and babies, it doesn't protect black ones. And so economic status necessarily doesn't protect black folks. You know, this, this data from California showed that for every 100,000 births, 173 of the babies born to the richest white mothers die before their first birthday. At the same time, 350 born to the poorest white mothers die. Yeah, when it comes to black woman 437 babies born to the richest black mothers die. And 653 born to the poorest black mothers died. And so making the point that money protects white mothers and babies, it doesn't protect black ones. Fred Goldstein 03:44 When you think about it, that, you know, we always hear obviously, and we assume that poverty alone, it's obviously something that creates disparities. But even in the case of those families or women who have access and have funds, they still see a much higher death rate. So why do these disparities exist in the first place? And what are the lessons from history when it comes to these disparities? Emmanuel Mensah 04:08 Thank you Fred. When you look at these disparities, you start thinking of why and being the smart people we are, we can think of you know, socio economic factors, social determinants of health, you know, we can make a long list from insurance, but different neighborhoods, culture, comorbidities, etc. But the one thing that we don't think about is hidden bias, you know prejudice and stereotypes that often leads to this. And when you think of where this comes from, you know, I It reminds me of a quote that my mother always used to share with me, that the man who forgets where he's coming from, does not know where he's going, where he is, and will not know where he's going. History. I think when we think about history, and we learn from history, there's so many lessons to learn from history to guide us, but also to remind us of the sources of some of these disparities, one stories I one story I like to share is often the story of James Marion Sims, who was an amazing physician at that time, he was actually one of the first physicians whose statue was first placed in Central Park in New York. But as my eldest will say, until the lion learns to speak, stories of their hunt will always glorify the hunter. Now, it was lots of stories out there about James Marion Sims, abusing and experimenting on black woman. And yet despite all of this history, his statue was put up and he was known as the father of modern gynecology. Over the years, lots of protests in Central Park and his picture, his statue has been taken down. But again, when we learn from history, realize that there's so many instances where black bodies have been abused, whether as cadavers for experimentation. Now I'll be honest with you, Fred, rehashing these racially traumatic stories and videos, in order to educate folks about racism can be painful, especially at the expense of the wellbeing of black people. It simply reinforces some of these dehumanization. So it has to be done very thoughtfully. But for me, lessons from history, you know, lead to three lead three things one its created a culture of not viewing black bodies as equals, two its eroded the trust black people have in the health system. And again, it explains the current trends, we see in healthcare disparities and outcomes.
Fred Goldstein 06:34
Could you define what you mean by hidden bias?
Emmanuel Mensah 06:39
Definitely. So describe hidden bias. I have an experiment I often do with my students and my colleagues, talking about our blind spots. There's so many things in the world, we often think of as visual mind bugd things that we see, our brain makes certain assumptions. And we often get the wrong answer because of associations we make. But just as we are visual mind bugs, so we have social mind bugs. And the challenge with social mind bugs are the cause unintended disadvantages for others. And with hidden biases, these are decisions that we sometimes make based on stereotypes, based on prejudice we might have. And I like to always say that stereotypes are not necessarily wrong. They're just not the complete picture. And when we make decisions based on these stereotypes, whether as a physician, as a lawyer, as a nurse, as a mechanic, we cause unintended disadvantages for others.
Fred Goldstein 07:38
So what can we do? And how do we interrupt our own biases?
Emmanuel Mensah 07:43
Yeah, you know, there's so many activities we can do to interrupts our own biases, many publications about this. So four quick things, and I'll share three major themes. One is to be open and aware of our own personal biases, especially in healthcare. And so these solutions I think about from a healthcare perspective. The second is increasing workforce diversity and valuing equity. Institutions which puts equity at the top of their strategy is very important. The third is create an accountability. And the fourth is utilizing decision tools and standardized processes. Because Fred, the issue is that these implicit biases are most influential when criteria are unclear, which is medicine, when decisions are made rapidly, which is medicine, when decisions are complex, which is medicine, when information is ambiguous or complete, incomplete, which is medicine, and when we are stressed or tired, which is often medicine. And so medicine offers the perfect pot of soup, for implicit bias, to just grow and to just just develop. So there are three things that I'd share with people to do. One is educate accept and act. Educators truly learn a lot of the history, current and past. And the truth is, this can be difficult, because sometimes when a lie is told long enough, it becomes a truth. And so getting to the true history can be difficult, but I encourage folks to do their best. The second, as I said, is accept accepting act. our own unique individual biases that we have. And the third thing is to act
Fred Goldstein 09:31
Do something about it, for sure. Are there examples you've seen where you've seen positive impacts?
Emmanuel Mensah 09:38
Yes, Fred. I can give you one example that is being talked about recently, quite a bit because it's made a huge difference for patients. And for years when we think about how the kidney functions we think about marker we measure co creatinine which is used to calculate a glomerular filtration rate. And for years and even in some institutions, right Right now it was the glomerular filtration rates, which we call GFR is estimated based on race. If you're African American, you have a certain number, if you're not African American, you have a certain number. This was problematic. Because if a person who's one parent was black and onr parent was white comes into the room, what GFR do you give to that person? Societally, we'll call that person black. And we'll give them the GFR of a black person. And this is where we argue that race is a social construction, not a biological construction. When we make decisions based on this, we make, we can make mistakes. And so over the years GFR has been edited, has been changed, the race factor has been taken out of it. And it's having a tremendous implication. The organ procurement and transplantation network, recently in 2022, approved the elimination of race based calculation for transplant candidate listing. And it improved waiting times. It's recently also approved waiting time adjustments for kidney transplant candidates affected by race based calculation. And I tell you, the difference between folks waiting for transplants was 64 months for blacks, and 37 months for whites. And and this has been immensely adjusted and corrected, whereby black folks don't have to wait as long for transplants compared to white folks. And so this is a good example of an area where there was a problem with the GFR and with transplants, and that was corrected. And now we see that the folks are working hard to ensure there is the equality in equity in transplants. And it's applied to so many other things in so many calculations and things we use in medicine, from cardiology, to cardiac surgery to obstetric, to urology, there are equity concerns in a lot of calculations and a lot of tools we use in medicine. And these are things we need to think about and how to correct these.
Fred Goldstein 12:02
Do you see a larger, more general movement across all of those specialties to begin to address each of those areas, Emmanuel Mensah 12:09 Differs by specialty, obviously, there's some more momentum in some specialties than others. But I think the ones where I see less momentum, the issue is honestly just ignorance and not making it a priority. And this is where my first point is educate is very important. Because when we educate, we measure and we collect these some of these data, we highlight the disparities, and then we can address them. Fred Goldstein 12:32 One of the hot topics today is obviously AI, machine learning, and its incredible potential, maybe, as well as rapid adoption. So how do you see AI playing a role in worsening or improving these disparities?
Emmanuel Mensah 12:48
AI is fantastic. It can make a huge impact in healthcare, and we are all very excited about the momentum, with ChatGPT etc. But the challenge with a lot of AI out there is also what I call GIGO, Garbage In Garbage Out. And we live in a society full of implicit biases and disparities that has a high risk of taking all this bias data inwards. And bringing this data outwards. I'll give you an example. In 2019, Optum, actually had this medical algorithm, which was favoring white patients over sicker black patients, because it assumed white patients were sicker because more money was spent on their health care than black folks. But we know the reason why there's this disparity, of course, it's not because black folks are less sick than white folks, if anything, sometimes its the reverse. And so being very careful about the data that goes into AI. I am working with some colleagues to actually figure out how do we modify the data before it's actually an input for analysis. And we are calling it A Equity and we just started working on it. They have some amazing smart students and and colleagues out of Mount Sinai who are actually working on this currently.
Fred Goldstein 14:01
That's a fantastic project it sounds like, and I know, one of the major issues just has been a lack of data regarding minority communities in the data sets, which obviously leads to incorrect results coming out of the backside. So ensuring we get adequate representation, whether in studies or clinical data, etc. is critical for these AI models to work. So to close out, Emmanuel, any final thoughts?
Emmanuel Mensah 14:26
Yeah, one of the things I will say is that, I know it's wonderful to see so many people working on this topic and these issues and the commitment from different corners. And you know, we all work really hard to make a difference in the lives of our patients. But the fact that these differences exist, also tells me that we have a lot of work to do. And it's not just about being a good doctor or being an advocate etc. But its about being thoughtful, and realizing that our humanity is intertwined with the humanity of others. And so I'm hopeful you know with everything that's going on. I am hopeful. I'm hopeful because I know that lots of folks out there are making a difference are going to make a difference. But I also want to warn that this journey is hard. I've been on this journey for a while. It's really hard. It's difficult, and it's challenging. And so part of me being on this podcast is to come and tell listeners something that Milton always tells me whenever he sees me. Milton is an elderly black gentleman at Beth Israel Deaconess, medical Harvard Medical School, and since I was a medical students every time Milton sees me, proud of seeing a black doctor; always runs up to me and says Doc keep moving on. And so I'm here to tell you all the same thing, keep moving on. Because when I look at some of the worst crimes on earth, from slavery, to colonization, to apartheid, to Tuskegee, to the Holocaust, there's so many others. What bothers me about these crimes is that are so many good people did nothing. So Martin Luther King framed it well, when he said, in the end, we will remember not the words of our enemies, but the silence of our friends. Thank you Fred.
Fred Goldstein 16:08
Oh, it's my pleasure. What a fantastic episode. And thanks so much for sharing your thoughts, Emmanuel.
Emmanuel Mensah 16:14
Thank you Fred
Fred Goldstein 16:21
And thank you for joining us today. If you like this show, you can find all our episodes at amcp.org/podcast on our show page at Healthcare NOW Radio.com or on your favorite listening platform by searching Healthcare NOW Radio. You can follow our show social hashtag at AMCPListenUp. And don't forget to share, like and follow AMCPorg on LinkedIn, Twitter, Instagram and Facebook. I'm Fred Goldstein for AMCP. Until next time,
About the Hosts
Fred Goldstein is the founder and president of Accountable Health, LLC, a healthcare consulting firm focused on population health, health system redesign, new technologies and analytics. He has over 30 years of experience in population health, disease management, HMO, and hospital operations. Fred is an Instructor at the John D. Bower School of Population Health at the University of Mississippi Medical Center and the editorial Board of the journal Population Health Management.
AMCP Podcast Series - Listen Up: Dr. Emmanuel Mensah, implicit biases and disparities in health care
Host Fred Goldstein invites Dr. Emmanuel Mensah, a Firm Chief and Faculty at Beth Israel Deaconess Medical Center / Harvard Medical School to discuss taking a look in the mirror and reflect on our own implicit biases and disparities in health care.