Update Course 2021: DEI – CONCORDANCE AND POST OP COMPLICATION STUDIES

Uh we're in for a very good session and before I get let Dan introduce it, um, I do want to say that the PDC, uh, found a paper that they found very important and it blew my mind. And I um, asked Mira to to go in depth on this. So Dan, uh, why don't you introduce the next session? Sure, thanks Todd. Um, so first well, you know, Todd, you mentioned this early on, it's amazing this forum where we have people literally from all over the world and I think there are people from, you know, there are 500 people on this session who are from literally all over the planet. And all over the world we have struggled with issues of diversity, equity and inclusion and the impact that has on the health care that we provide to uh the patients that we serve. Uh, Dr. Cogal is a pediatric surgeon who is dedicated her research career to uh um, understanding global health and uh problems with disparities and care. And so I think it's great to have Mira come and discuss this topic uh with us for the next 20 minutes. Mira. Thanks Dan. Um, thanks it's great to be here. Thanks for having me. I think um, this is a challenging topic. I think it's something that we're all grappling with and I uh as people know has come to some resurgence in the United States over the course of the last year or two years as this has become something we're talking about a lot, but I think it applies in our setting as well as lots of other settings to think about how do we provide the best care for our patients? Um, regardless of where they're from or who they're born to and how do we think about um, our our colleagues and how we all work together in and being inclusive. So, um we're going to touch a little bit on um those both of those topics uh today, but hopefully it'll be an interesting and I imagine very lively discussion. Um so we'll start with a case. Um, this case is a 14-year-old black male who presented with abdominal pain. His workup included a history, white blood cell count and ultrasound that were consistent with appendicitis, most likely perforated appendicitis. He and his mother who was with him at the time, report that this is their third visit to the ED over the past seven days for abdominal pain. The patient's delay in diagnosis is due to and here are the options: biological factors causing his presentation to be different, implicit bias amongst the providers caring for him, delay in presentation by the patient and family or D, all of the above. So I think, you know, while we're waiting and letting people uh sort through the poll and answer some questions, I think, you know, it's an interesting topic, right? We we have lots of conversations about why patients may present with a delay in presentation and this is true in appendicitis which is obviously very common, but I think what are people's thoughts about potential reasons that this kid uh might be so delayed in presentation or have shown up three times seeking care uh for abdominal pain? Thoughts from the faculty? I I'm more concerned about the um third time presentation that makes me feel like this patient was um delayed because of the provider's delaying in care and not the family delaying in presentation. That's my main concern. Thanks Dr. Lee. Other thoughts from people? Yeah, I'm not sure maybe sorry Dan. Maybe you're going to maybe you're going to talk about this, but um, you know, one of the things I think that happens with people who end up coming back three times is that there's this concept of anchor bias where somebody has made a decision and that everybody else then is very uh prone to look at it through that lens. And I think that applying the the diversity, equity inclusion lens to it really changes you know, it offers us a new perspective on why we think the way we do about what a patient may or may not have. Yeah, I think it's a great point and it extends, you know, beyond what we might see and particularly thinking about disparities and bias, but just to how we approach patients who have the same complaint over and over again for whatever reason and and how do we broaden the box um to think about what what might be going on with them. But I think there's so there's lots of potential components there. I don't know um should I keep Yeah. Well let's see. So Ellen, what do we got? Um, yeah, it looks like a lot of people are saying all of the above. um and then the next but then half the people are saying that is the implicit bias of the providers. Great. So I think there's, you know, there it can sort of be I don't know that there's always a right answer, right? I think all of these things play a role and and we'll talk about a couple of studies that I think are really important to understand um the disparities that we may see. I I think personally that it's probably, you know, mostly around implicit bias. I think to Dr. Lee's point, the fact that the patient has come in three times sort of suggests that the family was seeking care and not really that they were delaying um trying to get care for for what they thought was a concerning problem. I think the other thing, um, there's been a lot of data and literature out there talking about things we have historically always thought of as biologic um reasons that cause uh patients to present differently. They're number, you know, people talking about hypertension in African-Americans and you know, we've historically just said hyper African Americans are at higher risk for hypertension, but really race is a social construct and not a biologic one. And so that that genetic plausibility um argument comes under attack. So I think let's talk about some of the studies that are out there and and be interesting to hear what people think about them. Um, this first study, um is a study that came out in pediatrics in 2020. um and it looked at uh healthy kids. So one of the arguments around uh differences in post-operative complications and mortality for kids uh for sorry for patients um based on race was based on the fact that maybe African Americans have higher rates of um commobities. Maybe they're at higher risk uh from an operative standpoint. And and so this article really attempted to kind of undermine that and talk about that by looking at healthy kids. So kids with ASA one and two. um and they looked at uh over 170,000 kids across the Niskri database of 30-day mortality post-operative complications and adverse events which were cardiac arrest, sepsis, um, those were the major things that they were looking at under adverse events. And they found that African-American children had increased odds of all three in our systems. They had a over threefold times higher rate of dying after an operation even though they were healthy. They had an 18% greater odds of having a post-op complication and a 7% greater odds of serious adverse events. And these were otherwise healthy kids who were having routine operations within our system. So really problematic data um that obviously suggests underlying uh challenges within our systems and the ways in which we prevent uh present and care for patients. Um, do you want me to pause there and talk about that a little bit or share the other article? Uh, so let's just see what people, I mean, what are some thoughts about I mean, this is pretty shocking. Um, this calls attention to, you know, you can say all you want about DEI and inequities in the workplace. But this article is so upsetting to me. Um, and the other one probably even more, but is this this surprises me, um, and it probably shouldn't have. I agree with you Todd and that's part of the problem, right? It it it shouldn't surprise us. Um, but it does and I I really think that I agree with you. This is shocking data and unfortunately we're seeing now that we're the spotlight has been focused a little bit at least in the United States, we're starting to see more and more objective data to substantiate what's been talked about for a very long time and largely ignored. Mark? Well yeah I I was going to say I don't even know that it was necessarily being ignored. What's remarkable to me is that we didn't notice this which goes to show you our own biases. So, can I tell you something inter this is what I thought about. I'm I'm actually very embarrassed to admit this because it's clearly my fault. Uh, but we published a paper in Jama um in 2003. And Mira the paper we published, our conclusion was wrong now that you're pointing this out to me. Our paper was published to say, oh, there's disparities in perforation in appendicitis. And you know what? The highest rate of of perforation is in Asians. Number one group. Asians had the highest rate of perforation then African-Americans. Um, and our conclusion had nothing to do with and it was nowhere even mentioned back in 2003 to you know, 20 years ago. Wasn't even mentioned that could there have been implicit bias related to this. It was all, oh, maybe it's genetic, maybe it's resistance to care, blaming the patient rather than in any way introspectively saying, I bet you if we did this paper again in 2023, we would find the same results but with implicit bias being the reason. That's a great point, Todd. I'm I'm curious there's there's some conversations going on in the in the chat uh and I know Alice is is Stanford. Dr. Stanford's done a lot of work in this areas uh contributing there. thank you. I I'm curious if any of the other folks from around the world have similar problems in their country. It may be different cultures or different different ethnic groups that are you might be treated differently or have different outcomes. But is anyone else looking at this in other countries as well? I'd love to see in the chat as you uh go on. I think it's a great point Dr. Mulken and as as Dr.nan mentioned, I spend a chunk of my time working in resource limit settings and I think, you know, there's a really striking example. There was a patient a paper published looking at gastrosis mortality um and thinking about gastrosis mortality around the world. It was led by Naomi Wright um I clicked on the okay button but I'll do it again. Mac, I think you're unmuted. Um, led by Naomi Wright and it was a great study and really, you know, highlighted the difference in gastrosis mortality across the world. So when we think about gastrosis in the United States in our patient population because of TPN, because of Niyus, because of the resources that we have, right? Our mortality rate is, you know, close to zero if not quite in zero, but you know, in in many resource limit settings particularly because of the unavailability of um TPN, but also because of social concerns around diagnosis such as gastrosis, the mortality rate used to be close to 100%. And and there have been significant efforts to reduce that, but there's lots of disparities that show up um in that way too based on resources and access to care and I think Dr. Stanford's talking also about about access to care in the US, right? Insurance and the ways in which it allows you to present, who can you present to? How seriously are you taken? Um, and Dr. Grant talking about, you know, the ways in which we think about black patients and there's lots of articles about pain thresholds, you know, particularly in the ED literature around treatment of pain uh in patients with appendicitis amongst other, you know, uh ideologies and whether or not we we treat pain equally in patient populations. Um, okay, well let's move on to the other study which as Dr. Bosky said is is additionally concerning but also tells us something about what might be underlying um what we see. And this this is a study uh that was also published in in 2020. um and it looked at uh concordance between physicians and patients and really understanding uh infant mortality. So, you know, it centers on the fact that we see wide disparities in infant mortality um between black and non-black patients in the United States. Um and this study looked across Florida between 1992 and 2015 at 1.8 million births and looked as the concordance between the physician race and the race of the newborn that was born. And found that black black newborns have a 58% reduction in their mortality if they're treated by black physicians. So looking at the same percentage, you know, same populations of newborns, the you see a a huge difference in mortality rates between black and white infants, but that you can make a dent in that mortality rate for black infants by treating them with black physicians. And I think this is important for a lot of reasons it points at implicit bias and the ways in which we approach our patients and think about our patients, but it also points at the oh the importance of diversity in our systems and that by having, you know, patients who look like their providers who look like their patients, you have an opportunity um to really allow people to see and understand people who are are different than than than we are. Um, Todd, you you mentioned that this was particularly shocking. Can we talk. No, we have to just stop. We have to stop for one second. I mean, we just have to stop because there's been a lot of information given to us today. We've learned, I mean, it's very rapid fire. The update course is very frenetic. There's a ton of content coming in. We need to stop for a second. This is the most upsetting paper and, you know, uh for Stephen and Marge and Rob when you discussed this brought this article to the PDC. Um, I don't know if I'm allowed to like bring it out, but I hope I am because I thought um, this is horrible against us as clinicians. I mean, what what does this say about I mean so we're we're isn't educated? I mean there's no there's nothing where we're we're we're in diverse cultures. still, this is happening. Um, this is very alarming. This is a point to stop and say, what the heck is going on here? it's not just the birthing mortalities um, but I mean the moms, right? Um, between black and um white moms uh in the United States, at least the mortality is over uh 300%. It's um, uh more. and these are young black women. Um, I mean, you guys know that I'm slightly involved in social media. I mean, I see residents, women residents who are close to who who live in uh a health institution who has the ability to uh to to seek care uh prenatal care and they're still dying. Um, we need to I I agree with you Todd. It's upsetting, um, the fact that the mortality of of of infants from um black uh mothers is high, it's probably because it' continuation of whatever is going on in the physiology while they're in utero. Um, you know, higher um uh higher uh prematurity rates, um, and and it needs it needs to be highlighted and we need to start thinking about it. And and and a part of it too, you know, in terms of what um, Dr. Cogal has said uh regards to implicit biases, etc, etc. I mean, that's kind of one of that um points with a family centered care that we talked about before. validate uh their uh their concerns. Uh, you know, and and listen to what the a patients are saying and their parents and their caregivers and whoever it is that brought them there. And not say, it's just constipation. Um, you know, they they look weird, they smell funny, they, you know, they smell like pot uh, all these things, um, you just need to kind of say this is my patient. What's going on? Thank you. Can I Todd, can I point towards Dr. Garcia because I think um, you know, as we're talking about the physiology, right? And the and the things that we're seeing the ways in the context, all of those pieces. I know this is work that Dr. Garcia spent his life working on and thinking about and I would love to hear his comments if he has any. I mean, I do. I mean, I think, you know, one of the things, I mean this is not new. This has been um available uh information for decades. And 20 years ago Collins from Chicago just demonstrated that uh a highly educated uh black woman, uh lawyer, um who will have uh a higher risk of dying in childbirth than um a white woman uh with just about a high school education. We have a clear understanding of some of the underlying mechanisms and I put in the chat about toxic stress and static load. Bruce's work. Uh I urge you all to look at the biological embedding of adverse early childhood experiences the Sackler uh colloquium uh that was done that really highlighted uh the basic neurobiological mechanisms that have contributed to not only what we're seeing now, uh but also uh outcomes as far as educational and economic attainment. So there is an underlying neurobiological embedding of toxic stress uh that is particularly especially um located. I mean certain neighborhoods. Uh and um and it's and it's not just unique to blacks. Sir Michael Marmot in his early work demonstrated that classes of individuals who are gainfully employed in the National Health System actually had higher mortality rates the lower they were on the um socio economic ladder. So, does that help Mira? Of course. And I think, you know, um Dr. Garcia, when you walk away from conversations with him, you usually get a reading list and so I think he's he shared some great resources, but perhaps Vic, you could put a couple of them in the chat for people as well so that they could look up what you're talking about. I think, you know, the AS paper that that we tend to come back to a lot, you know, the work of Rob Samson, those things that really are central to understanding the impact of neighborhoods um and context and on epigenetics and other things that we see um for our African-American patients and the fact that what happens in their first month of their life impacts, you know, their neural development and all of those pieces. And and so I think there's a lot there. There's some great conversation in the chat. I think about thinking about how we make an impact there, right? How we, you know, some great questions about what it how do we improve diversity? How do we change the systems and uh Dr. Stanford's timing in with some some fantastic suggestions about institutions and about representation and the ways in which those things um matter. We had planned to touch a little bit on on sort of DEI within institutions, but I don't want to cut this conversation short. So I wanted to throw. Well here's so I I was going to answer your direct message to me Mira. This is your session. You you know how to get this done effectively and I'll open this up to anyone to figure it out. We've got 10 minutes left to make a difference. So, you know Vic is saying if this has been around for so long, obviously, it's been around for so long. Finally as we've learned from this idea of repeated no information to people not just at one conference but at 10 conferences a year until things start actually changing. I'm willing to wager a bet and this is very cynical of me that if you repeat this study in 10 years, it's going to look the same. So tell me how it won't. Like we can like let's like I can't figure out how do you the fact that a child's race will get, that child will get better care from someone of their same ethnicity than someone of a different ethnicity uh is astonishing and I have no idea why we think that that won't change again in a decade from now. and Mira, correct me correct me if I'm wrong, but I think that in that paper it's not even the child's doctor, it's the it's the obtrician that delivered them, right? So it's the prenatal care that is. It is though interestingly the concordance between the prenatal care between that obtrician and mom did not they showed did not have an impact on maternal mortality. So it seemed to have an impact on neonatal mortality but not maternal mortality in that paper, which I think is interesting but not worth getting into the weeds about. I think Todd makes a great point about what do we do, right? What are the ways in Right. So what have you done and tell us because I will tell you I I I don't like going to conferences very much. I have ADD. You guys all know that. But Mira the one you ran was really well done. And I know that when we went on Clubhouse, I was critiqued for saying that we're doing conferences on this and doctors are there's no way you can teach them. Stop the conferences. You'll never be able to teach them. The thing you did was impactful. So what are you doing and what are others doing in their hospital that's not just to check the box, but actually going to make an impact? So I guess I have a couple of things that I can throw out there for people to think about and I'm sure others have comments. I think, um, you know, I think all these pieces tie together. We talk about representation and I think that matters how we think about diversity, equity and inclusion within our own institutions matters and it has to start at an early age. Pipeline programs can't start um when folks are in college. They need to go back quite a ways and be able to provide opportunities to folks early. So I think there's some areas to think about with that and we're not going to get to these articles, but I think really recognizing that there are disparities that continue, you know, you can bring females to medical school but you might not necessarily get them to full full full professor level, right? All the ways in which those disparities exist. So I think the representation piece matters. I think thinking about how we treat people within our systems and that's what Todd's referring to. Um, the University of Michigan and some really great work out of there creating the cultural complications curriculum which I think a lot of people have heard about, but if you go to cultural complications.com, there's a great website that allows people to really start within surgical departments talking about these issues and we've started doing this within our department led by Dan, um to really grapple with these issues and have honest conversations about cases that maybe do make us uncomfortable, but to approach them in a way that is sort of similar to M&M and into a format that we know about, but let's talk about issues of bias. Let's talk about the ways in which gender schemas affect how we evaluate people, right? All of those things that play a role. And then the last thing that I would say is that what we do within the walls of the hospital is probably not enough. Um, and so I think really thinking about how we have an impact um early and, you know, Dr. Garcia often quotes to those of us who work here at Cincinnati Children's that if you live in the neighborhood right around Cincinnati Children's and you don't leave by the time you're 10, you know the the profound effects on your life expectancy and your life trajectory and and the ways that we've tried to solve those problems historically haven't worked and so I think there's some great work around social innovation labs and recognizing the complexity of the problems and the need to really address poverty and context at its roots and discussions around social determinants of health. I think, you know, we're spending a lot of time in neighborhoods working on how do we get at the root drivers of these problems and not just try to put band-ids on them when people are within our walls, but really start to address them from day one, right? From prenatally even if you look at some of these studies and thinking about how we have an impact. So those are the some thoughts for me but I'm sure uh others have thoughts as well. I think Mira, you summed it up well and the problem is the degree to which this problem has been sort of woven into the fabric of our society and it's I think that we can do things locally and and so we can start with a microcosm of of a department or an institution and begin to work on these things. The next level is to start doing things like working on pipeline and the most complex in my mind and Vic is the expert on this is beginning to address those things that are beyond the walls of the institution like the social determinants of health that but we we should not and cannot abdicate some responsibility for addressing those things. And I and I think to to a really important point that's being made in the chat, but I think is that we can't do those things in isolation of the communities we serve. And that if we're really wanting to grapple with these issues at the community level, we have to do so in partnership in solidarity with those voices at the table, really seeking and asking to understand um what the problems are from their perspective because we can come in with a lot of assumptions about what we think makes a difference, but but understanding how the community feels about it and individuals within those communities is really central. Can I just give one quick example, Mira? So I again, I don't get much out of lectures. I don't. Like I don't pay attention. But first of all, I can come to you as a white male and ask you a question and you don't look, you answer me and don't I don't feel nervous to ask you, hey, am I an idiot for asking you this question? Is this a microaggression? What's the best way to say this? And the one example of the way you did it where you presented these cases with these breakouts we talked about it. They is that I did not know about microaggressions until you taught me about it. And every one of them were things I can clearly see I would have kept doing. Uh, without someone pointing out to me, those were microaggressions. And I I oh yeah. I never I never would have realized it. Um, and and there's a so um, I think