All right. Good morning, everybody. Welcome. Um, to, uh, sort of, to a grand rounds, uh, this morning. Um, and I'd like to welcome Doctor, um, Abel Hader. Um, he is, uh, coming to us from Brigham and Women's. Uh, he's an active trauma and acute care surgeon, researcher, and Kessler director, uh, for the Center of Surgery and Public Health. Um, it's a joint initiative between Brigham and Women's Harvard Medical School and, uh, the TH Chan School of Public Health. He's also deputy, deputy editor of JAMA Surgery and president of the AAS or actually I um met him when I was uh first-year research resident at AAS meeting and it's nice to see you again now. Um, Doctor Hader is credited with, with, um, really looking into and uncovering the racial disparities after traumatic injury, um, and really establishing the field of trauma disparities research. Um, he's, uh, he's a prolific researcher, um, uh, excellent trauma surgeon, um, and, uh, really, um, uh, uh, very prolific mentor as well with over 115 research trainees. Um, so, uh, and most recently, he, um, won the prestigious award, the, uh, 2017 Ellis Island Medal of Honor. Um, so it's really a great, um, uh, privilege to introduce Doctor Hader. Thank you. Good morning. How are we all doing? Good. Come on, it's, it's early in the morning. We're surgeons. Come on, you can be better than that. Come on. How are we doing? Great. All right, perfect. Well, it really, um, is, uh, uh, these are some of my disclosures. Um, it really is a pleasure to be here. Uh, as, as you mentioned, you know, um, I've done work on healthcare disparities, and as I'll show you in a moment, my first publication ever in healthcare disparities happens to be amongst children. And so to come to the number one hospital in America for children or the world, uh, is a truly a great honor and thank you so much, uh, for having me here today. I also want to acknowledge a few things that we have the opportunity to be doing together. And, uh, that is the, uh, Harvard-wide Surgical Health Services Research speaker series. And if you haven't seen it, we'd love for you to come by. We have about 8 of these a year. Um, they're usually held at one Brigham Circle. And this brings together, uh, surgical health services researchers from, of course, Boston Children's, MGH, the BI, and, uh, Brigham and Woman's. We also at the Center for Surgery and Public Health have a collaboration with several of your health service researchers, especially for the surgical residents from the Brigham who do their uh research years and academic years here. Here's just a representative recent publication by Ron Benaini. Uh, and you can see who the senior authors are, uh, uh, just giving you an example of the kind of work that we've been able to do together. So, uh, Doctor Schoenberger, Doctor Willowhi, it really is a pleasure to work with, uh, all of your faculty to do these kind of health services research projects. So thanks for making that, uh, happen for us. Thank you again. Now, uh, um, you know, I truly believe that equality is the cornerstone of medicine. If there are any tweeters, or people who use Twitter, uh, you know, uh, this is one that I'm actively asked for every time I give a talk, that this is something that's very important. And if you ever wanted to tweet something from my slides, this is the one that I hope you would, uh, pay attention to. I know it's sort of not cool to ask to be tweeted, but this is the one, that I think it's OK to, to do that for. Um. So, first, I just wanted to show, uh, you know, what might be the first publication that I've seen on health care disparities. You'll see that it is from the New England Journal of Medicine. It's all the way down here in the corner of New England Journal of Medicine, 1977. Uh, many people in this room probably not born then. Uh, but that paper showed that for people who were getting an operation at Johns Hopkins Hospital in Baltimore, um, if you didn't have insurance, and the only kind of insurance you could have back then was Blue Cross Blue Shield, um, if you didn't have insurance, you were much more likely to be operated on by a surgical resident for your inguinal hernia repair or your open cholecystectomy, of course, only open cholestectomies back then. And this was done between the years from 1954 to 1974. So 20 year period then, you would get operated on by a surgical resident, but if you had insurance, you would get operated on by an attending. Uh, and if you were African American, even if you had insurance, which was rare, but even if you did have insurance, you are 4 times more likely to be operated on by a surgical resident versus an attending. So this is data from several, you know, decades ago. But even today, there is data across the surgical spectrum, which shows healthcare disparities, uh, in a wide variety of fields. And if you look at some of these things here, you know, more likely to die of breast cancer, uh, more likely to receive heart surgery at lower quality hospitals. Twice as likely to die due to complications after abdominal operation. You might think, well, a lot of these things have to do with access, a lot of these things have to do, for example, with cancer, late diagnosis, and so on. And so one can rationalize or think about, well, this is probably why healthcare disparities happens, it's just because of access. But we think that in the emergency department, you know, that's the great equalizer, that everybody can come to the emergency department. We don't check your insurance when you come there. We don't care really who you are, you just show up and we're supposed to take care of you. So folks think that there's no, there would be no healthcare disparities in the emergency department. But turns out that, um, you know, there was some data suggesting back in the 90s that there is healthcare, there are healthcare disparities in the emergency department. This paper showed that. Uh, um, amongst children, uh, who had, um, a, uh, minor head injury or had, for example, fallen off a swing, uh, if they were from a suburb, they would come to a big hospital like this, uh, and they would get a head CT scan. However, if they were uh in an inner-city environment, who happened to be a minority, they'd go to a potentially smaller hospital, and they would be much less likely to get a head CT scan. So, there's a question of quality of care for minority children. And so, based on that study, um, we started with what was our first healthcare disparities project, and that was to identify disparities in clinical or functional outcomes between children of different races. After traumatic brain injury. And to do this study, we looked at the, back then, what was called the National Pediatric Trauma Registry. There are about 40,000 patients in that registry. We found 7000 of them who had moderate to severe traumatic brain injury. And we analyzed 7000 of them, about 4700 white kids, 1200 black kids, and 1000 Hispanic children. And this is what we found. Compared to the white children, and the white children are here, the reference group, the red line, we found that black children had an increased odds of needing to be discharged to rehab. Increase odds of having a functional outcome deficit in their ability to talk, and their ability to walk, and their ability to eat. So we found functional disparities. We didn't find any difference in mortality after traumatic brain injury, but as you know, mortality is very low because of the great advancements that have happened at hospitals like this. But what we did find is that when these kids go home, either they couldn't go home, or they had these kind of functional uh deficits. So, now, when we first published this work, this was back in about 2006, some folks really, really liked it. Some thought that this was important. That's me as a fellow, uh, receiving an award, uh, and I used to look much younger. I don't know if you can see the picture, but it's true. Um, and, uh, Some people didn't like it at all. This is the letter to the editor, written after uh we published that work, in which the, some folks wrote that, you know, even talking about healthcare disparities is just not the right thing to do, because that would uh insult those who take care of injured children. And so, back when we started this work, folks didn't even want to hear about this kind of work. Of course, um, our response was that, uh, all of our, all of the authors on that work were people who worked at primarily minority trauma centers. And if we were questioning anybody's uh care towards minority patients, we were questioning ours first before anybody else. But our real response to this was to truly come up with why these things happen, and use the best possible uh analytic tools to understand this. So we ourselves said that the first paper we did, we could not look at, for example, insurance status. And, uh, insurance status in many instances is a good predictor of socioeconomic status, especially before we had Romneycare or Obamacare, right? And so, back then, what we did is we thought we'd do our next study, looking at the interaction between race and insurance. And for that, we did this in adults now, and we looked at the National Trauma Data Bank. This was a large data bank. At that point, it had about 1.5 million incidents, and 700 hospitals from across the country contributed data to the National Trauma Data Bank at that time. And this is what we found So, uh, this is the reference group. These are white patients who happen to be insured, OK, so white insured patients, and you compare white insured patients in this data set, and the end here is about 375,000 patients, by the way. Uh, uh, compare these white patients to black patients, and we found that the similarly injured black patients had about a 20% increased odds of death, even though they were insured. You take a Hispanic patient with insurance, similar injuries, there are about 50% increased odds of death. Now you take a white patient and compare them to an uninsured white patient. So very similar injuries, skin color is also the same, it's just that they don't have insurance. Their odds of that goes up by about 50%. And if you don't have insurance and you happen to be a minority, your odds of that, you can see exponentially increases 80% to 130% more if you happen to be Hispanic. So, this came out in 2008. And uh after we published this, you know, there was a lot of uh attention towards this work. Folks got very, um, you know, interested in it. Uh, and then that led to the creation of what we call the National Disparities Working Group, which brought together several hospitals from around the country who uh began working in this field. Uh, we used a public health problem solving approach towards healthcare disparities, uh, in which we first we're going to identify the problem and create awareness, understand mechanisms that lead to this, and then finally create solutions and then disseminate them. So, identifying the problem and creating awareness, what we did after we published our work, we worked together with all of those groups who had individually published similar work, and then pooled all the data together to do a meta-analysis. Again, just looking at the specific question, does skin color, is that associated with your outcome after traumatic injury? And the meta-analysis of all these publications, uh, confirmed that black trauma patients were 19% more likely to die after traumatic injury. So, very similar results to what we had, uh, initially found. So, that kind of really laid the stage for, you know, this wasn't just us finding it, many other people had shown this as well. But when you looked at what we surgeons believe regarding this kind of data, something very surprising, um, When we surveyed about 546 fellows of the American College of Surgeons, FACSs, we found that 50% or more believed that the evidence for surgical disparities in general was very weak. But more importantly, Almost all the surgeons believe that the reason we have healthcare disparities has nothing to do with them, or their practice, or the way their hospital runs, but it's 90% related to patient factors. Right? And so, we did what we always teach our our trainees never to do. We blame the patient, right? Instead of looking at ourselves, we blame the patient. And so, um, You know, the next step was there to then figure out, you know, what are the mechanisms that lead to this, and we work with the NIH to come up with these 5 different buckets that may lead to surgical uh disparities. And so today, I'm gonna specifically focus on that provider issue, right? Because we all thought that we had nothing to do with it. So that's why for this next 1520 minutes or so, I'm gonna focus on very, one very specific issue that may be related to the, to the way we treat patients. And that is, and it's a little sensitive to talk about, uh, do we treat patients differently based on race? Specifically, that's a pelvic fracture. Specifically, um, do we care about the fact that there's this open pelvic fracture, or do we just care about the fact that the person's black or white? And I'll come back to who this patient is, uh, at the end of the talk. Now, to just set the uh discussion, I want to take you to my first night on call as a trauma attending. Um, how many people are uh attending surgeons here? Right, so many. Do you remember your first night being on call ever alone, right? Taking care of somebody, all right. And so this was my first night on call. Uh, um, and by the way, I was a 2nd year trauma fellow at the time, uh, and it used to be that for the 1st 6 months, the trauma fellows would have an attending in-house with them, uh, but you can see this is August and nobody was with me after July, somehow. And so this person comes in, of course, their heart rate's high, their blood pressure is low after being shot. She was actually a 16 year old girl, right? So, almost a kid. And we took a ride up to the operating room. Uh, she was briefly pulseless on the table, cross clamped aorta, found the injury through the inferior vena cava, fixed it, lots of small bowel, large bowel injuries, fixed all those, left her abdomen open. This is back when we hadn't really started damage control resuscitation, so we give too much fluid to people. Uh, and so, it took about Three different takebacks before we could get her, uh, her abdomen closed. Eventually, we did get her abdomen closed, about 40 units of blood or so, 37 units. Uh, and then, uh, out of the uh ICU on post-op day 12, and then on post-op day number 17, refuses all care. Right? So we're trying to say we need to take your temperature, uh, no, we need to draw blood cause you apparently had a fever, no. Anybody comes in, throws that person out of the room. So, uh, let me just ask some of the surgical residents, how would that make you feel? Who are the trainees or the, or the fellow? How would that make you angry, angry, yeah, OK. Any other ideas? How would that make you feel? Dr. Modi, how does that make you? Uh, frustrated, frustrated, right? I felt the same way. My friend angry. I felt like maybe she's being ungrateful for that 37 units of, of blood that she received. Also, remember, I had trained my entire life. To take care of this, this patient and this problem. But what I didn't recognize is something that was so apparent. And that was that this woman. was shot in a police shootout that she, this young girl was taken hostage uh by a person who was apparently dealing drugs and running away from the police, and he took her hostage and brought her into a convenience store. There was a shootout. He got shot and she got shot. In fact, he came in a moment after she came in. You figured out that I wander, OK. She figured out, he came in a moment after her. It was one of those situations where, like, right out of the movies, brand new trauma surgeon, right? Uh, one person comes in, goes up with the surgical resident. I remember the, uh, Debu Bosi was a surgical resident, sent her up with him, and then the other guy brought him to the OR. He was coding as you put him on the table, opened up his chest, cross clamped his aorta. By the, by that time, Elliott helped my partner showed up, he's like, Haider, what What are you doing? I'm like, what do you think I'm doing, right? Anyway, uh, we got his pulses back, and then Debubosi runs out and says, look, uh, you know, she's about to code as well, so I run into that room. I mean, I knew what had happened, right? And I still didn't give her the benefit of the doubt that maybe she is suffering from an early form of PTSD, which is what was happening, that anytime we would talk to her about her injury or any physician that would come to her, she felt like that moment when she was going into shock and she couldn't understand what was going on, and she was scared, and she was a little kid. Right? And I didn't give her the benefit of the doubt to understand, you know, how she was probably feeling. She was having hallucinations. Anytime we would touch her, she would just feel like she was going through the whole thing, so she just didn't want to deal with us. Now I don't think that we intentionally treat people differently or patients differently, but it may be that we unconsciously don't know better, right? And I might have thought that, well, you know, uh, violence is very endemic in Baltimore City, which is where I work, and so she should just be like everybody else, and I shouldn't treat her differently, even though she was just a little kid. Right? Now, um, it might be that, uh, you know, this unconscious bias plays a role, and there's been a significant amount of work on unconscious bias and its association with how we treat patients, primarily based because of this implicit association test. Again, made here at Harvard, and it's a uh a computer-based test of social cognition. Has anybody taken the IAT, right? So, several people in the room have taken it, especially the leadership, right? Uh, now, uh, it turns out that more than a million people have taken this test, right? a million people have taken this test. And I'll ask somebody from the back, can, can, can I get a volunteer from the back? You don't have to get up, just you have to do some simple math. Who's gonna help me? The gentleman drinking your coffee all the way in the back there, that you made that mistake. All right, can you, there you go. So, can you help me add this up? Uh, 27 + 27, how much is that? 54? You could say it a little bit louder. All right, and then 16. 70? OK. I, I made you add it up just so that you remember. So 70% of Americans have about, uh, have an unconscious preference towards whites, right? And if you sold this to a social psychologist, they will tell you that they're not surprised, because the country is about 2/3 white, so people unconsciously prefer people who look like them, who they can relate to better, who they grew up around, right? So that's not surprising, but the question is, Uh, do these unconscious biases impact how, uh, we treat patients? And there are actually multiple medical studies that suggest that they do, right? There's a great study from Lisa Cooper where she audio taped the interactions of family care practitioners and saw how they, the, saw how unconscious bias amongst physicians relates to uh how they treated patients, and physicians who had an unconscious bias against black patients, they treated black patients very differently than they would treat white patients. And so, we were concerned that this might be an even bigger issue in the trauma world, because, you know, trauma surgery happens at night when people are tired, you know, you're more likely to stereotype. In fact, we train people to stereotype, right? We say, you know, blood pressure low, heart rate high, gunshot to the abdomen, go right to the OR, right? That's how we train people. And so it might be that when we're tired and cranky, we're less likely to give people the benefit of the doubt and, and understand where they're coming from. So, we thought that this might be more important in the trauma world, and that's why we did a series of studies using the implicit association test. What we did in most of these studies is that we would give clinical vignettes. So, we would give you a clinical vignette with a black patient, or some people would get a white patient, and we see how those people were treated by the persons taking the test. We would then give them an IAT for race or social class and then try to associate um their unconscious preferences and how they ended up treating patients. And of course, we asked them some direct race, direct questions on race and class preferences as well. So, for the first study, and I'll show you three different studies we did on this, uh, or four actually, uh, the first study was on Johns Hopkins Medical students' classes 2013 and 2014. And, uh, this is what we found. On there, explicitly when you ask them, this is in green. The vast majority of them said that they prefer people equally, black or white. But if you look at their implicit preferences, their unconscious preferences, and you add these up about 20%, about 30%, about another 20%, Nearly 70% of them, just like the general population, nearly 70% of them had an unconscious preference towards whites, right? And I loved showing this data to those, those, you know, superstar medical students, cause it just goes to show that we could be the smartest people, we, we, we could think we're the smartest people in the world, but we're just like everybody else, that we have the same unconscious preferences. And when we tried to relate that to how folks Um, you know, treated the patients on clinical vignettes, this is what we found. For the vignettes on pain assessment, for the vignettes on informed consent, reliability, trust, if you look at these, black, white, black, white, black, white, black, white. They're all the same. We found no difference in how these medical students would treat patients. At all. And so, of course, we could not find any difference in how uh or any association between unconscious preference and how they would have treated patients. So we said, well, maybe these are just really good human beings and they're medical students, and they haven't gone through residency training yet, so they haven't been jaded yet. So, um, uh, you know, maybe that's where this is coming from. For, so for the next study, we looked at residents, right? And we found nearly the same thing. Then we said, OK, well, maybe it may have to do with social class. So we created an IAT for social class as well. And we found that most residents even explicitly said that they prefer the higher social class. But or explicitly and implicitly, but we could not find any association between social class or race IAT and how they would treat patients. Again, they all treated patients the same. So then we thought, well, maybe it has to do with nurses, that our nursing colleagues might be driving some of this, right? We wanted, we asked this question. One of my co-investigators was a very senior nurse. And so, if you're thinking that you might have seen graphs that look very similar, yeah, these are unconscious preferences towards race. This is unconscious preference towards social class, and, you know, both implicit and explicit bias, and you'll see that it's nearly identical to what we found from the medical students and the residents. And when we looked at the clinical vignettes for the nurses, which were built for nursing uh uh problems, we found no association, again, in how they would treat black versus white patients on clinical vignettes. So then we finally saw, thought that this must be coming from the top, that surgeons might be the reason for this. And so, we did a very similar study amongst uh surgic members of the Eastern Association for Surgery Trauma. So, these people were all double board certified in both uh general surgery and surgical critical care. And we did about 250 people, and this is a large undertaking. You had to log on to a website, and then you had to take, do these clinical vignettes, then you had to take the IAT, then you had to answer more questions. It takes about 25, 30 minutes. And if you wonder, Doctor Chanberger, how we got 250 surgeons to do this, uh, the answer is a $200 Amazon.com gift card, did the trick. We were oversubscribed in about 10 days, right? And you'll see that their results are very, very similar to what we found amongst the medical students, the surgical residents, the nurses, and now amongst attendings. And they too, did not have any association with how they would treat patients. So amongst all these studies, we found unconscious preferences towards whites, but we could not link that to how they would treat patients. So very different for the surgeons, uh, and um uh the medical doctors. And I think the reason why we found this difference, or we didn't find a difference, is because of the work that we do. All these clinical vignettes were built for emergent problems, problems where, you know, it's pretty obvious what the solution is. But in those medical students, the medical studies, what was going on is, you know, they had to, for example, talk about how you're gonna manage blood pressure, or what kind of, you know, uh diet you're gonna take. So when you really need to understand your patient well and, and make a close contact with them, for example, decide what kind of cancer treatment they need or something, you know, that's where I think these unconscious preferences come in. Just like I had with that young lady, Tisha Craig, that I, I needed to help her beyond operating on her, and that's where my ability to take care of her failed, probably because of my biases. Another uh operative hypothesis is that it doesn't have to do with biases, that it might have to do with in-group favoritism. Right? Where we can relate better with somebody, so we prefer them a little bit. And I'll give you an example uh of this from a recent time when I was on call. And that was that I had a person who came in. 30, 40 year old man, uh, and he was struck in the head after, uh, a fight in a bar with a beer bottle, right? He was bleeding pretty profusely, and he was very inebriated, saying all sorts of profanities when he came to the emergency department, right? We need to evaluate his head. Or brain, and so he got what's lovingly called a social intubation, right? Now, he gets intubated, we get the CAT scan, turns out he has no brain injury, all the bleeding is from the scalp, right? Fix that up, gets extubated in the morning. It's extubated in the morning. And despite all the profanities and all the badwill he created, um, when I talked to him, When he was awake and sober, he was a great guy. He went to the same engineering school that my brother had gone to. And he lived in a really cool condo on the water, which I wish we could have lived in before we needed to have a yard and stuff like that, right? So there are all these cool things about him that I was impressed by, and I said to him, listen, it's Sunday morning, right? Cause this happened on a Saturday night. It's Sunday morning, uh, why don't I keep you in the hospital an extra day, so that I can hook you up with the alcohol counselors, so that you don't do this kind of binge drinking again. Pretty reasonable, right? But the question is, would I have done that for a person, for example, who was homeless, who came in. And when I thought, and I would look at that person, and first I wouldn't have that whole conversation about where you went to college and how he lives in the place where I wish I lived. Uh, but I would also rationalize it saying that, well, you know, this person doesn't have insurance potentially, and so won't be get, won't be able to get access to rehab, and really won't benefit from staying an extra day. Right? Maybe that's what operates uh and leads to these uh differences in how we end up taking care of patients. And so here that brings me to the question I posed in Grand Realms, and that is, should we be interacting with children like we do? With adults. Now, there are not too many studies looking at unconscious bias and children. There's only one that I know of. And the big issue with that study is, is that the bias that we're talking about is mostly directed towards the parents and not the child. And so we don't know really how to uh operationalize any studies in that field, and so what most people believe is that we have this kind of in-group favoritism, especially people with children. You know, physicians with children might have an in-group favoritism towards kids, and they might treat them a little better. Then they perhaps would have treated. Uh, their, their adult, uh, parents. And so not being a person who treats kids, I'll leave it up to you to decide the answer uh for this question. And hopefully somebody will make comments about it by the end of this talk, and I'm gonna uh just finish in 10 or 15 minutes, uh, so that we can have some discussion. And finally I want to talk about, you know, how we're trying to create solutions, uh, to make a difference here. And I'll start with acknowledging the American College of Surgeons. So, the American College of Surgeons, after all this data came out, created, um, what's called the Committee on Healthcare Disparities. And the biggest thing that the Committee on Healthcare Disparities was able to do was to uh put out this statement from the college saying that you cannot have quality without access to care. This was really a directional shift for the college, where the college really focused on just quality and didn't really care who had access. But now the college came out and said, you know, every American should have access to high quality surgical care. This was a big change for the college. The other thing the college has done is supported a uh uh a library of almost all the different types of uh health care disparities literature that's out there, uh uh for surgery. And They're organized, uh, according to those five things that I initially showed you. This work was done with the NIH and you can go to their website and search and get a synopsis on almost all the work that's been published, at least till about 2017. Another thing they did is to create the National Research Action Plan. Uh, and, uh, I'll show you a short video to kind of describe a conference that we put together to come up with this National Research Action Plan for surgical disparities research. Of course, it takes a very modest surgeon to show a video of them speaking while they're speaking. Uh, but I wanted to just, uh, share this with you. And so, uh, so based on that work, we came up with this, uh, uh, national research agenda. Um, the top five, things, uh, led to then, um, uh, this, uh, um, NIH, uh, announcement for surgical disparities research. Uh, and really, it's the only RO1PAR out there, uh, that actually has surgery in its title. Right? And so this was a big deal where the, um, you know, NIH really put its money where its mouth was. Uh, the first round funded 7 RO1 grants. The second round has funded now 10 RON grants. And so you can see through that conference, uh, we have brought more than 70 to $80 million of research dollars to this topic, and specifically, uh, for surgeons. Now, not all surgeons have gotten the R1s. They're nursing colleagues and others who have, uh, but it's a really big, uh, I think, uh, investment towards from the NIH towards, uh, solving this problem, and we have our surgical community, particularly the American College of Surgeons under the leadership of LD Britt, uh, to, uh, thank for this work. Now, one of the top research priorities from that conference was to improve patient-provider communication. And I think you might have noticed that's really the focus of what I've been talking about, how biases or other issues impair our ability to communicate with patients, and that is a mechanism that leads to disparities in care. And, um, to counter this, uh, many people have talked about cultural competence, right? That, you know, if you're culturally competent, you could do a better job. I think it's very difficult to be culturally competent in many different cultures. In fact, I don't think you can become competent in any culture unless you really live in that culture, because if you think about competency, that means that there's some measurable things that you're able to do. So we're gonna have to be able to do that for all the different types of people that we meet. Therefore, we've proposed this idea of cultural dexterity, where you can use, uh, uh, you know, your mental and physical skills to understand and then adapt to each unique patient in order to provide patient-centered care. So we're thinking of promoting cultural dexterity over cultural competency. And the first project we did in this work, uh, was, uh, jointly sponsored by Boston Children's Hospital. It was through the Harvard Surgical Affinity Research Collaborative Project. And, you know, all, uh, 4 of the hospitals were involved and funded this work, uh, at a pilot level. And we created what we call the Provider Awareness and cultural dexterity toolkit for surgeons, or the PACS Project. And, uh, what the PACS, developing the PACS Project was basically, we were trying to create a curriculum. And what we did is that we first did qualitative in-depth interviews, and that was really what was funded through the Harvard Surgical Affinity Research Project, and to understand from surgical residents and patients, and more importantly, surgical faculty, about what are the issues with providing uh patient-centered care, and how can we, what do we need to learn to improve our communication ability and improve our cultural dexterity. Based on those interviews, we then create, uh, did a um national workshop. Uh, and, um, uh, the workshop had people from around the country, uh, and they helped build the curriculum, but most importantly, uh, are these people in the front here. These are actually all patients, and it wasn't just experts, but it was patients. It were patients who helped us. Uh, really come up with a curriculum that would be patient-centered and that would actually help, uh, with patients. In fact, one of the ways they thought we should evaluate, you know, the people who go through this curriculum is instead of just giving them some sort of test or something, they thought that we should actually ask patients how physicians were performing. Of course, that idea came from the patients and not from any of us. Uh, so, what does this curriculum have? The curriculum, um, up here are, uh, what we found during the qualitative interviews, and down here are how that informs the learning goals, right? And so the first learning goal is to build trust, uh, with your patients, and how do you do that? And we actually have a whole session and space learning on how do you build trust with your patients, especially in a surgical environment. The second thing was learning how to communicate effectively with patients who have limited English proficiency, right? And, uh, you know, many of you here take care of patients from all across the world, and you might think to yourselves, how many times you've been properly trained to work with an interpreter, right? They're actually quite a number of nuances that you can learn to really improve your ability to work with an interpreter. So, a lot of our, our, uh, curriculum focuses, uh, on that. Another thing was how to assess and manage pain, right? And if you want to read any uh of the uh Quotes from the residents, I want to direct your attention to this one. This is perhaps one of the most shortest yet loaded quotes you're ever gonna see. Certain patients handle pain a certain way. What do you think they mean by that? Right? That's why we thought that managing pain would be another very important aspect of this curriculum. And then 4th was lead meaningful informed consent discussions, right? Now you see what this person is saying up here, I'll let you read it. Right. If you don't get their feedback. Basically she's saying, That if you don't really ask patients, you know, or tell them what you're gonna do, it's quite easy to get consent from them. Right. So this is beyond now cultural dexterity. This is basic professionalism, right? Basic being a surgeon. And so, that's why most of the ser of the program directors who are working with us, doing this have let us uh take out their, uh, some of their didactic uh talks, and let us insert these uh talks uh during our pilot work for the uh PACS curriculum. Uh, we've adopted a strategy of designing, implementing, and then hopefully we'll do national, uh, expansion, and, uh, the curriculum really initially focuses on these three tenets of, of, uh, what I call cultural dexterity, and that is, uh, curiosity, respect, and empathy. And so if I would have gone back to that same patient, Tyishhu Craig, and if I, instead of being angry and frustrated, if I was curious, but why is it that she's doing this, right? Why is it that she doesn't want us to take care of her, right? If I would have treated her with respect, like, you know what, it's not that everybody who comes from inner city Baltimore is OK to be shot at, and this should just be expected, right? If I would have just not believed that. And if I would have treated her with more empathy, perhaps the way I would have treated her would have been different. And the few days that she suffered, where, you know, we didn't know how to take care of her, and she was, we thought she was being mean to us, that would not have uh happened. Now, um, uh, the curriculum focuses on these four things, and we recently published, uh, what our curriculum is gonna be in annals of Surgery, and, uh, um, have done some early implementation. We've done it, uh, mostly at the 3 adult hospitals, uh, uh, BI, MGH, and Brigham and Women's. Uh, and we had some positive, uh, feedback from our surgical, uh, residents, and many people thought that this would actually We help them provide improved care. Uh, this curriculum now is the subject of a, uh, 8 academic medical center trial. Uh, and, um, we, uh, uh, are doing an intervention in group, in one group that has 4, folks. This intervention is just about to start. The other group is gonna get standard training, and then we're gonna be able to check for the the, um, durability of our intervention a year. A year later for the first group, and then we're gonna do the second group, and that way, we'll have like a case control as well. So, it's a, a multi-step, uh, uh, uh, randomized trial, and, uh, we, um, have the following outcomes, of course, what you'd expect, knowledge, attitude, and skills of the residents. But most importantly, we have, uh, outcomes specifically for patients. We, apart from having clinical outcomes through Niscri and so on, um. We have patient uh satisfaction and communication outcomes, and the way we're doing this is that, uh, we actually go to the patient, or the plan is that we're gonna go to the patient and show them a picture of the surgical resident who's taking care of them, and ask them, is this doctor taking care of you? Do they come on rounds every morning? Is this your doctor? Do you identify with them? And if they do, then we're gonna ask them questions about that doctor's uh communication skills, and so on. Uh, so I just wanted to finish with that. Uh, this is our group from the Center for Surgery and Public Health. Uh, um, this is from this year's, uh, graduation party, uh, at my home, and, uh, uh, we again invite any of your colleagues who want to work with us at the Center for Surgery and Public Health, and thank you again for having me. Well, Doctor Hayter, I'd first like to thank you for bringing this critical, uh, and important topic to us. The, the statistics that you showed were really quite daunting as far as uh survival from, from one of the early slides for like breast cancer and, and such. And yet you showed later that Physicians, residents, nurses, when queried if, if race or insurance played a role in their care of the patients that it, it didn't. So I wonder how much of this is also due to not blame it on patient factors, but other factors outside really of the immediate surgical care. And, and one of the issues that's been published recently is about Women with breast cancer and their ability to follow through with post-surgical therapy and whether they got to the uh doctor's office to get their adjuvant chemotherapy or whether travel, job restrictions and such prevented them from doing that. I thought also for the one where you showed different cognitive outcomes for, for children after trauma that, that You know, the blacks and the uninsureds did not or showed more injury and yet I presume you showed that the level of trauma was comparable. How much of that could be attributed to their participation or Uh, receipt of post. Post-trauma care that, that, um, many people have shown is, is important. Have there been studies that have looked at, at that role outside of just doctors? We're not doing it right, but are there social issues that are preventing them, other patients from getting appropriate care? Thank you for asking that question. And, uh, you know, uh, I think you go right to the heart of the matter. We have found these healthcare disparities. Uh, and then when now we track them out, we realize that they're, uh, you know, beyond what's just happening in the hospital. I do believe that, you know, things that happen in the hospital probably make a difference. Uh, and that one major driver of healthcare disparities is the quality of care that patients get. So, for example, a lot of minorities. Patients end up going to hospitals which are not as good as, for example, uh, Boston Children's Hospital, and we have some data to show that minority trauma patients end up going to hospitals that have worse outcomes. And overall, that's why minority trauma patients end up having, at a national level, worse outcomes. But we have recently been doing a study called the Forte Project. It's a functional outcomes and recovery after traumatic emergencies. And in this project, we have been uh following up every single trauma patient from the Brigham, Mass General, and Boston Medical Center, and we phone them every 6 months and every, and at 12 months after they get discharged. In the last 2 years or so, we have collected data on nearly 2000 patients. And the number 1 thing that we found is not injury severity being associated with how they're doing. It's actually socioeconomic status because we get do a whole slew of those kinds of uh measures. Uh, it's education, and really it's pointing towards this lack of the ability to follow up that you talk, talk about. Whether it be because the patient can't navigate, whether it's because the patient doesn't have access, that they have mass health, and they can't get into the better rehab and so on. That's where we're finding all the differences lie. So we could do as much as we want to improve, uh, you know, patient care, and, you know, Doctor Mooney is the, uh, past president of pediatric trauma Society and so on, and has done so much work in figuring out how to improve our ability to respond to patients who have severe injury. We could do all that stuff, but still end up with differences in outcomes, race-based or not. Uh, because of what happens after patients get discharged, and I think that's the next frontier, that if we're gonna improve our long-term outcomes, we have to begin focusing on how do we take care of patients after they leave the hospital. Additional questions for Doctor Hayden. Doctor Jackson. Uh, thanks very much, Adil. You know, uh, the data you showed regarding implicit bias is incredibly, uh, compelling. Um, I was wondering though, in your major slide from the American College of Surgeons, it said that access is the first step. And, uh, are there studies from other countries where there is a multi-ethnic society? For instance, if you looked at the city of Toronto, which has 6 million people, all sorts of colors. And yet everyone has the same insurance. Do those disparities, uh, uh, in healthcare become ameliorated, or is this just an intrinsic problem that we treat people who are like us better than those who are not like us? Um, instead of taking you to another country, I'll take you to something that we can all be proud of as Americans, and that is our military. And, uh, you know, we uh at the Center for Surgery and Public Health are very privileged to have access to the military Tricare data set, which is the claims data for all military beneficiaries. Now, you know, our fighting force is a couple million people, but the, uh, about 10 million people have access to healthcare through the TriCare net because these are all dependents of our active fighting force. So if you look at those 10 million people and look at healthcare disparities, it's remarkable to see that, you know, now the military is, is even more diverse than the country, right? And their disparities virtually go away in the military system, especially in the military treatment facilities. So the military runs about 77 hospitals. We know about the big ones like, you know, Walter Reed and Trippler in Hawaii, but there are many other smaller hospitals as well. And even in those smaller hospitals, it doesn't make a difference if you're black, white, or whatever, uh, the outcomes seem to be the same, especially for military treatment facilities. So you're absolutely right, there is a way to ensure that everybody gets the same care, and all we gotta do is look at our own military, uh, to see how it can be done. Any additional questions? Doctor Mooney, Uh, thank you for the excellent talk and the, uh, always uncomfortable topic. Um, when I worked in Northern New England, we were very jealous of the access to healthcare in Boston. And here when we see a kid that we send up to like recently a child went back up to rural Maine, about 2.5 hours north of Bangor, who needed physical therapy, we just realized there's no way this kid's getting the care that he needs. Have you guys looked at urban versus rural cause our countrysides, uh, the rural facilities are being wiped out, and those that are left behind are just very, almost like treatment centers without the resources we have. But have you considered urban versus rural? Yes, uh, uh, our group has not personally looked at, uh, urban versus rural amongst children, but we have looked at it for adults. And we actually have a, uh, a presentation coming out, uh, next month at the American College of Surgeons where we're showing, um, how lack of access to emergency treatment increases mortality pretty substantially, uh, for folks from. The rural, uh, area. I think if, uh, anybody wanted to build a career, uh, in health services research, uh, especially if they are from a rural area and understand the issues there, this is a great place to, to, to build your career. There's a lot of resources out there to study issues with the rurality, and we just frankly haven't done anywhere nearly enough to understand how we're gonna take care. Of that population and it's very important as a country for us because, you know, the as the infrastructure in our rural areas continues to deteriorate, more and more people have to be coming to cities and then the cities gets more burden and we lose what some of the great things are about America. And so we need to really focus on that and thanks for pointing that out, David. Doctor Fauza, final question. Thank you, very nice talk. One of your first slides on traumatic brain injury that Doctor Schonberger alluded to, uh, actually, if I understood correctly, showed better outcomes on the Hispanic patients. How did you interpret that? This is a very interesting uh question. Uh, the, the data on Hispanic patients is complicated because there's, it's a very heterogeneous population. You could have very rich people who would be classified as Hispanics, for example, Cuban people in Miami or uh uh New York City, for example, versus you could have folks who would be called uh undocumented immigrants in some of our border states, and their abilities and what happens to them is completely different. Uh, I think this data is largely the NPTR data is largely from large cities, and maybe that's why it shows that Hispanic children did better. But in the adult data, you know, you saw, which was much more nationally representative, um, Hispanic, uh, adults did worse. Or it may be that, uh, Hispanic children by growing up in America. Uh, end up having the benefits that everybody else has compared to their, uh, uh, adult counterparts. So difficult to really interpret, uh, honestly speaking. Doctor Haider, thank you so much for bringing this topic to us today. Thank you. Right
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