Health Inequities in the Time of COVID-19

November 29, 2022

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The Medical Student Council Perspectives on Medicine series continues Thursday, November 17, with a lecture from Marietta Vazquez, MD, associate dean for medical student diversity. The lecture, “Health Inequities in the Time of COVID-19,” will begin at noon via Zoom.

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00:00Dean Vasquez, so that way we can
00:02give her the most amount of time
00:05for her wonderful talk today.
00:06So Dean Marietta Vasquez is
00:09a professor of Pediatrics,
00:10general Pediatrics and infectious disease,
00:12vice chair of Diversity, Equity,
00:14and inclusion in the Department of
00:16Pediatrics, and founder and director of
00:17the Yale Children's Hispanic Clinic.
00:19Has been appointed associate Dean of
00:21medical diversity as of May 3rd, 2021.
00:25In her role as Dean,
00:27Vasquez will work closely with
00:28PSM's Office of Diversity,
00:30Equity and inclusion to advance MD and
00:32MD PhD program programs and initiatives.
00:34And I believe, if I'm not mistaken,
00:36that will also include the PA program now.
00:39She will oversee the strategic
00:41deployment of resources and coordinate
00:42activities of the Office of Diversity,
00:44Inclusion, Community engagement,
00:45and equity, or DICE.
00:47There's a recruitment,
00:48retention,
00:48and professional development of
00:49students who are marginalized
00:51or underrepresented in medicine,
00:52and she has extensive experience as
00:54an adequate advocate for diversity
00:56and inclusion,
00:56and has led efforts to recruit and
00:59retain underrepresented minorities
01:00and academic programs.
01:01She as well,
01:02has mentored numerous medical students,
01:04and for the past year,
01:04she's directed all DI activities
01:06in Pediatrics, designing, building,
01:08and implementing an ambitious.
01:09Strategy for.
01:12The department's training faculty and staff,
01:14which encompasses support,
01:15education and recruitment.
01:16Dean basketball education is crucial
01:18to her role and has had multiple
01:19education initiatives on diversity
01:21and inclusion within the department
01:22on such topics as unconscious bias,
01:24microaggression,
01:24and equity in the workplace,
01:26which has led to Pediatrics
01:27becoming the first department
01:28within the School of Medicine to
01:30make diversity training mandatory.
01:32Deep ASK is this a served as the
01:34associate director of the Pediatric
01:36residency program from 2010 to 2018.
01:38Director of the LP Metrics Global
01:40Health track from 2010 to 2019.
01:42And at the Yale Pediatric Primary
01:43Care Center, she precepts residents,
01:45medical students and nurse practitioners,
01:47utilizing her expertise in refugee
01:49and immigration health research on
01:50clinical epidemiology of infectious
01:52disease in children focuses on the
01:54efficacy of vaccines and she has had
01:56direct impact on clinical practice.
01:57Finally,
01:57she is the first Latina to be
01:59appointed by the Secretary of the
02:01US Department of Health and Human
02:02Services to be a voting member of the
02:04Advisory Committee on Immunization Practices.
02:07Thank you so much for taking the
02:08time to speak with us today,
02:09Dean Vasquez,
02:09and we're really excited to get
02:11to hear your talk.
02:13Thank you Ariel for that very
02:16nice introduction and and for the
02:19and really for the invitation.
02:21I hope you can hear me well I'm.
02:26I'm connected from my home Wi-Fi and I
02:28have my dog next to me who goes wild
02:31every time somebody knocks on the door.
02:33So let's hope that nobody knocks on
02:35the door and I'm going to talk about.
02:38I decided to go sort of merge a little
02:41bit about health inequities with a case,
02:44and I'm going to talk about health inequities
02:47in the times of of in times of COVID.
02:53And a little bit about about.
02:57Some of the objectives, um.
03:00I want to use sort of our time
03:02so that we can through the
03:05presentation of a clinical cases,
03:08I'm going to talk about actually a real case,
03:10one of my patients.
03:11We can have time to identify and
03:14sort of reflect on the effects
03:16of implicit bias and structural
03:18racism and how health inequities
03:20affect the health of our patients.
03:23They have a some an opportunity
03:25to sort of go back and we're not
03:27going to have a lot of time to
03:29talk about historical context.
03:31But really think about the present
03:33day role of structural racism in our
03:36healthcare system and towards the end.
03:39I will point out some of these, Umm,
03:42how implicit bias affects what we do
03:45for for patients and towards the end
03:48talk about some strategies that all
03:51of us can use in trying to combat
03:53social racism at the institutional
03:56level and at the patient care level.
03:59I have no conflict of interest to disclose.
04:02But when I talk about this,
04:04I always say the one thing that I
04:05want to disclose is my patients are
04:07near and dear to my heart and many.
04:10There most of the things that I'm
04:12going to talk about today I'm very
04:15passionate about and those will become
04:18quite obvious throughout throughout the talk.
04:21In terms of health inequities,
04:23the COVID-19 pandemic really has
04:25has exposed or deviled some of
04:29these structural barriers that drive
04:32health inequities and there are many.
04:35And when we talked about health
04:39inequities pre pandemic,
04:41I felt like I needed to explain
04:42a little bit more what we meant.
04:44But one of the things that that
04:46has really come to the forefront
04:48and COVID has been a great example.
04:51Is how through the last three years,
04:54we can see how.
04:58Die or things can be we can see what
05:01impact an infection can have in the health.
05:05But we've also all been witness to
05:08how the impact is not exactly the
05:12same for for everybody's differences
05:14in health, differences in, in,
05:18in the economic impact and and how.
05:24Something as simple or as complicated
05:27as an infection or a disease can
05:31exacerbate existing social vulnerabilities.
05:36And this slide is it, it kind of
05:39walks you through structural racism,
05:41disparities and equity.
05:43So it's important to understand that
05:45how structural racism impacts health by
05:48presenting sort of a working definition of
05:51his of health disparities and inequities.
05:54And we know that there can be inherent
05:56differences between populations and
05:58the quality of healthcare and that's
06:00kind of represented by the different
06:03heights in the bars in this graph.
06:05And these differences between the
06:08healthcare quality of one group and
06:11the other can occur for multiple,
06:14multiple reasons.
06:15It could be because of patient preferences,
06:19right.
06:19If you choose one therapy over the next,
06:22it could be clinical appropriateness.
06:24So some patients go to the ICU and
06:27get ICU level care and that can be
06:30based on their severity of illness.
06:33But their structural forces,
06:34such as the design of healthcare systems,
06:38public policy,
06:39legal and regulatory climate,
06:41and bias and discrimination that also
06:44play a role in healthcare disparities
06:47are the differences in the quality of
06:50healthcare between populations that
06:52are not due to patient preferences
06:55or clinical appropriateness.
06:57So in the case of healthcare, differences
07:00between race is structural racism.
07:03Contributes to these systems,
07:04policies and regulations that
07:06then create these disparities,
07:08these disparities disparities.
07:11So in the ideal sense,
07:15right?
07:18The differences, right?
07:19If you eliminate the disparities,
07:23then the differences between two
07:26populations should only be based on
07:29things that they can actually control.
07:33So now I'm gonna go.
07:35To our case presentation and
07:37this is I want us to sort of
07:41move us back to August of 2020.
07:45And I'm going to talk to you about
07:48an 8 year old male Hispanic male who
07:51presented to a large urban pediatric
07:54health clinic in New Haven with his
07:57mom and it was again the end of 2020,
08:00I happened to be in clinic.
08:04This is the pediatric clinic.
08:06And I actually was taking
08:08care of somebody else.
08:09And it's like I walked through the corridor.
08:12I could see this young man with his
08:15mom who was being walked into a room.
08:19And what struck me was that he seemed a
08:22little bit out of breath and he had to stop.
08:26While walking a very short distance,
08:29and as I always tell the medical students,
08:31Pediatrics is the art of observation.
08:33So it's not about what patients tell us
08:36often is being in tune to what's around you.
08:39And I immediately detected this and
08:41ran to one of our members of our team,
08:44one of the nurses, and I said,
08:45what's going on and where is
08:47that patient going?
08:48And she said, well, the mom says that he's,
08:51he's here because he can't breathe
08:53well and he has a hard time walking.
08:55He probably has.
08:57Has asthma.
08:58So I saw as they moved him into that room,
09:01I finished taking quickly,
09:02taking care of the patient that
09:04I was taking care of.
09:06And I said I I want to sign up for
09:09that patient, what's going on?
09:11So I go in and indeed it's the bomb says,
09:15well,
09:16he can't breathe well and he's
09:19been having difficulty walking.
09:21She brought him into the clinic
09:23because of of this chief complaint,
09:25and she had told the nurse through the
09:28interpreter he was supposed to get better,
09:30but he didn't.
09:31I was supposed to be here before
09:33so that he could be seen by many
09:35doctors that he was supposed to see.
09:38He was recently hospitalized
09:39and I called several times,
09:41but nobody called me.
09:44I was told that over the phone that he was
09:48OK and to wait for for for an appointment.
09:52This patient came in part by
09:55bus part walking.
09:56The mom said that he probably
09:58takes about five or six steps and
10:00then they have to stop for him
10:02to kind of rest a little bit and
10:05then they walk again and he rests.
10:08She talked about how he had
10:10problems sleeping,
10:11that this 8 year old slept upright,
10:15that she would prop him up with
10:17a lot of pillows so that because
10:20that made it a little bit easier
10:23for him to to breathe.
10:26Talking to her a little bit more,
10:27I learned that he had COVID-19.
10:30He had COVID-19 relatively
10:32recently and since he was in
10:36the hospital and was discharged.
10:39They haven't really left the house very much,
10:41so Needless to say, this raised all sorts of.
10:46Times and concerns in, in my mind,
10:50getting a little bit about his recent,
10:54pertinent recent history.
10:56He's a school aged child.
10:58He developed COVID-19 two or
11:00three months before his visit,
11:02and at that time his symptoms were fairly
11:06common for what we would call adult COVID.
11:10He had fever.
11:11He developed cough, wheezing.
11:13At that time.
11:14She called the clinic.
11:15Now we're talking about.
11:17June of 2020,
11:19very early during the the pandemic
11:21and she was told that if if he had
11:25those symptoms that he should not come
11:28into the clinic that he should stay
11:30home and to call if he was worse.
11:33So so they did and.
11:37He stayed home. He got worse.
11:40Eventually he was so sick that he had to
11:42be brought into our hospital by ambulance.
11:44And when he came in,
11:46this is in his admission,
11:48his oxygen saturation.
11:49His was so low. He had had fever.
11:52He had increased work of breathing.
11:54He was found to have COVID-19.
11:58He had a chest X-ray that showed
11:59that he had pneumonia and had
12:01multiple laboratory abnormalities.
12:03He was admitted to our hospital.
12:05He stayed in our hospital for about five
12:07or six days on his until his fever improved,
12:11until he didn't need any
12:13more supplemental oxygen.
12:14And then he was sent home a little
12:17bit more about this young man.
12:19He has a history of asthma.
12:22He has a high, high,
12:24high BMI.
12:25His his body Max Index is way off the chart,
12:29so much higher than the 99th percentile.
12:33Alongside with that he has
12:35obstructive sleep apnea.
12:37He has high blood pressure and
12:39pre diabetes so as an 8 year
12:41old he has the weight.
12:43Of you know what,
12:4430 year old basically he has as you
12:47can see some of the medical problems
12:50that we oftentimes see in in adults.
12:55When I spoke to the mom,
12:58she related to me well.
12:59He was supposed to follow
13:01up with infectious diseases,
13:02my specialty pulmonary
13:04cardiology and endocrinology.
13:10In terms of his social history,
13:11he was raised by his mom, single mom.
13:14They're of Hispanic origin.
13:17The patient had not been in school.
13:20He had been doing school virtually,
13:22but since he got sick, he hasn't been
13:24able to keep up with their work.
13:26And this family suffered from food,
13:30transportation and financial insecurity.
13:33The patient spoke English.
13:35His mother spoke a little bit of
13:37English but preferred Spanish,
13:38and this mom worked full time.
13:40And she felt quite guilty because
13:45during very early in the pandemic,
13:47she was not able to stay home.
13:49She had to go out of the home and work.
13:52And not observe sort of the guidance of
13:55staying home and show and sheltering.
13:57And she got COVID at work and she
14:01was the one who gave our patient.
14:05COVID so,
14:06so take a step back and and I said to
14:09myself well you know how how did this happen?
14:12How does this 8 year old who was
14:15in the hospital very early on for
14:18almost a week with COVID leave not
14:21get better and not have follow-up
14:24like what you know what happened
14:27here and this is kind of a timeline
14:30from the time that he was diagnosed
14:33to he was admitted to the time.
14:36That he was discharged and these orange uh,
14:40stars represent times when the
14:44mother called several.
14:50Telephone numbers that she had for
14:52the for the clinic and for whatever
14:55reason then it's what we reflect
14:58referring to is lost to follow up up
15:00until the time when he shows up to
15:03to our clinic at discharge a patient
15:05like this should have left with clear
15:08guidance on when to follow up with
15:10the primary pediatricians when to
15:12follow up with infectious diseases.
15:14He did have one video call with infectious
15:17diseases should have had follow up with.
15:20Echnology, pulmonary and cardiology.
15:22But but that didn't happen.
15:27Some of the things that.
15:30I struggled with and talking to her well,
15:33she she thought people would call her back.
15:37And when she called, they said,
15:38well, there aren't any appointments.
15:40Somebody will call you.
15:42Why didn't she push?
15:44Why didn't she demand on the
15:46phone that her son be seeing?
15:49How did things fall through the cracks?
15:51How? Why? Uh.
15:57While was while he was impatient,
15:59what was communicated, how was.
16:03How was that message of?
16:06All the medical problems that he had
16:09and and the importance of a follow-up,
16:13I wondered how much time
16:15was dedicated in that.
16:17During the discharge process.
16:20What did those discharge papers look like?
16:23How complete the information was?
16:26What was that plan like?
16:28In how much detail was it
16:31discussed and in what language?
16:36How would you feel if you were
16:39the patient's mother? And I know
16:42where this is all virtual but.
16:46I can tell you about how I would have felt.
16:49I can tell you about how I felt.
16:53I used the word. Apology.
16:56I am sorry. I am so sorry.
17:02So many times, so many times
17:06apologizing on behalf of.
17:10Anybody that I can think of,
17:12I felt frustrated.
17:15I felt angry.
17:17I felt embarrassed.
17:23And and a little bit powerless.
17:33At one point I remember hearing.
17:37One of the members of the medical team
17:41during the visit say, gosh, you know,
17:45she probably didn't care enough.
17:47To bring her son. Take care.
17:52And and I want us to sort of
17:54take a step back and think about.
17:57When we talk about missed appointments,
18:00you know, delays in follow-up care,
18:03how often we use the term.
18:06To kind of explain ours errors,
18:11our shortcomings in explaining
18:14to our patients, to our families
18:17in a way that they understand.
18:20How often we try to hide the lack of not
18:24our lack of knowledge and our lack of
18:27understanding by reflecting it into oh,
18:30this patient is limited
18:32or this mom is limited.
18:34She just didn't understand we did.
18:36Everything right and and they didn't and.
18:41What I what I would love for,
18:43for all of us to reflect on is.
18:47Going beyond that understanding
18:49and I and I oftentimes use this
18:52visual of the iceberg that what you
18:54see or or that that trigger to say
18:57well they just missed appointments.
18:59It's you know it's it's their fault.
19:02That is the easy answer because we
19:05just see the reality in an in in
19:08somebody else as the tip of the iceberg.
19:10Well, they didn't show up.
19:11They must not really care as much or or or.
19:16That that we don't sort of take the
19:19time to understand that situations
19:21are very complex and I'm the 1st to
19:25tell you that I didn't understand
19:27the entire reality and the fact all
19:30the factors in in this revolving
19:33around around this this case and
19:36that it really takes time and effort
19:39and opening one's mind and trying to
19:42understand our own biases and and.
19:46Acting with cultural humility and
19:48with humility. Period.
19:49To understand that maybe there are
19:52other factors that led to this problem
19:55that led to this an 8 year old who
19:58left the hospital and months later
20:01comes back and can barely breathe.
20:03Umm.
20:05Understanding and equities and care,
20:07structural inequities,
20:09understanding that.
20:10Maybe it's CC for me to get in a car
20:16and get to my appointments that if.
20:20My kids miss an appointment or
20:23if I'm not called by my child's
20:27providers that I have the ability to.
20:32And the power.
20:33To get on the phone and if they don't answer,
20:36then, you know, I'll send an e-mail,
20:38I'll go online and I'll you know,
20:40I'll, I'll make things happen but that.
20:44Perhaps just because that's what I
20:46would do and that's what I can do,
20:48it doesn't mean that those who don't
20:51act in exactly the same way don't.
20:54Don't care. Umm.
20:57Some of the barriers we can
20:59easily identify well,
21:01you know it's hard to get to healthcare
21:04if you don't have transportation
21:07if if you're poor and you,
21:10you know all of these treatments,
21:13even getting to to a clinic is
21:16is is expensive.
21:18But poverty might play a role that
21:21language barriers play a role.
21:22The lack of health literacy
21:24very well may play a role within
21:26some of the health inequities.
21:27That that we know, not knowing
21:29how to navigate the system.
21:33But we can't stop there.
21:35We can't say, well you know why
21:37she spoke another language and she
21:40didn't understand the beautiful
21:42and well executed follow up plan
21:45that was shared with with this mom.
21:48We can't just stop there because
21:51that might be just the tip of
21:53the iceberg and we need to
21:55understand situations as a whole,
21:57as complex as they are.
22:01So to think about sort of disparities.
22:06There are many, many factors,
22:08many more than than, even more than.
22:12I'm sharing here that it could be,
22:15you know, lack of access to doctors,
22:17systemic racism, negative stereotypes.
22:19You know, this mom doesn't understand
22:21or this patient doesn't really.
22:23They have they,
22:24they have distrust of the medical system,
22:26so they don't come.
22:27So I shouldn't, you know,
22:28why should I bother?
22:29Access to transportation.
22:30I talked about how for them to come to clinic
22:34even though the clinic is relatively close.
22:36Buy in. In New Haven,
22:38it takes taking a bus and and walking.
22:43Communication barriers? Stress.
22:46Um.
22:46Financial or insurance barriers.
22:49Multiple things can.
22:52Can play.
22:57Play a role. Nice this snap. OK.
23:03So. Think I alluded to this before.
23:07After discussing the medical plan and
23:10making sure that he was OK, you know,
23:13that he needed oxygen, etcetera,
23:15I overheard somebody say, well,
23:17I just don't understand why some people
23:19don't take good care of their kids.
23:22And I asked the question what are the
23:25racial implications of that comment?
23:28Are there policies that lead to
23:30poor access to care and and how
23:33are those relevant to why this
23:36patient now has presented twice?
23:38What put this patient at higher risk of
23:41pulmonary complications and I was very,
23:43very concerned not only about pulmonary
23:45complications but cardiac complete
23:47on undetected cardiac complications
23:48from COVID and an 8 year old.
23:50We didn't know a lot about the
23:53effects of COVID on children at
23:55that time and how do you raise these
23:58discussions with the team members
24:00after you know the the comment that.
24:04Umm.
24:05That that I overheard.
24:08So we need to think about a few
24:12things that that play a role.
24:15The idea that racism is more than
24:18prejudicial attitudes and actions,
24:19that there's sort of a structural
24:22presence in in systems.
24:26Sorry, I'm having a hard time.
24:30Forwarding the slides. Ah. There.
24:39Umm. Let's think about some of
24:44the policies and access to care.
24:47So think about what you read in the CDC
24:49and the Centers for Disease Control,
24:52which is, you know, where?
24:54Most of us get our guidance,
24:58especially during during the pandemic.
25:00Think of the CDC guidelines.
25:02So if you have COVID.
25:05He should stay at home.
25:07Isolate. Wear a mask.
25:10Not go to work, not go to school.
25:14You should stay in your own room.
25:18Preferably use your own bathroom and have
25:22family members come and bring you the meals.
25:26And we're in 90 fives to
25:29try to decrease the the.
25:31Contagion to other family members,
25:34and I ask you.
25:37Who were those guidelines for?
25:40How do you think?
25:42Individuals who like my patients,
25:45mom in the middle of the pandemic.
25:47Couldn't stay home.
25:49They had to go to work. They.
25:53Couldn't stay behind and just, you know.
25:58Stay in their home to try to decrease
26:01the likelihood of getting infected.
26:04Just did these policies or
26:08recommendations guidelines.
26:09Speak to um.
26:12Refugee and immigrant families who?
26:16Live two or three families in apartments.
26:20Did these guidelines speak to
26:22individuals who all lived in in
26:25one room and were simply not able
26:27to to isolate and and follow them?
26:30So I think it's important for us to
26:34understand that perspective that even even.
26:38From the Center for Disease Control,
26:41who's putting together guidelines there?
26:46In a way, these guidelines were
26:48not for for for everybody.
26:51And I also wonder,
26:53would things have been different
26:54if this patient was white?
26:56Would it have been different
26:58if his mother spoke English?
27:01And I've shared a little bit about how
27:04I felt as the healthcare professionals
27:06seeing him in clinic and and sharing
27:10some of my feelings of frustration
27:13and sadness and anger and and.
27:17And shame towards.
27:19What I stand what I stood for at
27:22that at that time and realizing well
27:25you know is this mother going to
27:28trust me and and what we are doing
27:31given given what what has happened.
27:36There are clear disparities in COVID-19
27:40survival and there are, as I mentioned,
27:43in equities and how we communicate.
27:45There are different differential
27:47experiences causing distrust
27:48in the medical field for sure.
27:51And there is stereotyping of
27:53not only Latina individuals,
27:54this this patient happened to be Latina,
27:57but stereotyping with with.
28:00Many other groups,
28:03and there's some facts that COVID
28:05has affected populations of color.
28:07Way more than other groups,
28:10black individuals have received
28:11smaller shares of vaccination.
28:13So if you think of all the vaccines,
28:15if you look at shares of vaccination
28:18and compare to the rates of
28:20COVID infections and deaths,
28:22to the proportion in each one of the
28:25populations that has received vaccine there,
28:28there are tremendous inequities reflecting
28:32the disproportionate level of infection.
28:34So similarly to blacks,
28:36Hispanics have received.
28:37Smaller shares of vaccination
28:39compared to the share of cases in
28:41most states for which we have,
28:43we have reports.
28:45And if you compared whites to other
28:48groups those who identify as wife have
28:51why white has have received higher
28:54rates of vaccination compared to.
28:59To their to the number to the number
29:02of to the number of cases and and this
29:05was shown this is just a clip from
29:08Florida where we know and and and these
29:10are data from the government that
29:12blacks and Hispanics had lower access
29:16to monoclonal antibody treatments
29:18even though their rates of infection
29:21were were were much higher so and
29:24again this slide tells you that if
29:27you know if you sort of look at.
29:29Burden of disease to.
29:33To availability and and actual
29:36receipt of some of the treatments
29:39and preventive measures.
29:41They're they're not.
29:43They're not equitable in that,
29:45in that in that sense.
29:49California's close to 40% latinae,
29:52but they made-up about 45,
29:55or over 45% of the COVID-19 cases.
30:01And my colleague and mentor,
30:04doctor Peter Hotez of
30:06Baylor College of Medicine,
30:08this is a quote that he
30:10shared with me, he said.
30:11This is the quote referring
30:12to the COVID-19 pandemic.
30:14He said this is robbing Hispanic community
30:16of a generation of mothers and fathers,
30:18brothers and and sisters. Umm.
30:26So about as I mentioned if you look at.
30:32These are updates.
30:33As of August of 2022,
30:35about 16% of COVID deaths were among Latinos.
30:39And if you think about the weighted
30:42population, it accounts for about.
30:45If if you do a weighted estimate,
30:48it's about 33% of the of
30:51the deaths from COVID.
30:54And this is really another
30:56way of sort of looking,
30:58looking at it that if you compare
31:01compared to white non Hispanic persons,
31:05those of black American non Hispanics
31:10had about a 3 three times the
31:13hospitalization rates and twice
31:15the number of deaths and and these
31:18these are the proportions in in
31:21Hispanic or Latino population.
31:25Looking, looking at us.
31:27Because I always say that it's.
31:30A good first step is to sort
31:32of look at our own home.
31:34We know that the impact of racism
31:36is across the board and that
31:39it it continues to to occur.
31:41And there are data both from
31:43the US and from our own center,
31:46of how this turns out.
31:48What does this mean?
31:49Well,
31:50there is a an article.
31:52That came out last year to show
31:54that black newborn babies in the
31:56US are more likely to survive
31:57childbirth if they're carried
31:59forward by black doctors.
32:00So this idea of of of ethnic concordance.
32:04But there are three times more
32:06likely than white babies to die
32:08when looked after by white doctors.
32:10And again these are this is this is
32:13an article that came out in 2020.
32:18Data from our own hospitals from
32:20my department of Pediatrics.
32:22This is a study that was conducted by
32:26right here at Yale that showed that
32:29in our pediatric emergency medicine,
32:32there are disparities in the use
32:35of physical restraints depending
32:37on what your ethnic group,
32:40racial or ethnic group so that if you are.
32:44Teenager coming to the emergency
32:46room and you're a person of color?
32:48You're more likely to have
32:51the staff use restraints,
32:54so.
32:57You know, this is not just the
32:59shine of light on negative aspects.
33:01This is to to bring up these issues that.
33:06We need to take into account when in in
33:09our spaces not only in the clinical space.
33:13I think some a lot of this.
33:14I mean of course this is focused on a case
33:17but a lot of these concepts also relate to
33:20how we communicate with each other at home,
33:22in our communities within our
33:25workspaces in our offices.
33:28We know that there's a big role and
33:31implicit a big role for bias in in in
33:34all of our interactions and. I don't.
33:37I don't think I need to go into much detail.
33:40We all know that we all have biases.
33:43These are sort of prejudices that
33:45we have towards one thing,
33:46person or group.
33:47And the biases can be our own
33:50individual or they can be grouped
33:53biases and healthcare workers.
33:54Just because we're physicians,
33:56healthcare providers,
33:57it doesn't mean that we don't have biases.
33:59We have the same biases as
34:03the general population and.
34:05These biases do impact the care that
34:08we that we provide to to patients.
34:12So if we think about how does.
34:15By us connect to structural
34:17or institutional racism,
34:19we can think of sort of structural racism.
34:24As something that's overtime,
34:27normalize and legitimize and it sort of gives
34:32one group advantage over over the other.
34:35And it's the result or the compounding effect
34:39of societal norms that are often invisible.
34:42Cultural representation right in the media,
34:45how people discuss or define race.
34:49Ideologies. And many of these are sort of.
34:54The foundation Foundations institutional
34:57practices, so in the educational
35:00or criminal or justice system,
35:01and somewhat like policies.
35:05Oh my. Said it, and there it is.
35:10Um. So all of these sort of
35:16work to reinforce various ways.
35:19Are you gonna stop?
35:21Umm, sorry.
35:23So the they reinforce waste to perpetuate
35:26these racial inequities for persons of color.
35:29And, you know, bias is.
35:33Relate conceptually related
35:35to structural racism,
35:36because operation of explicit and
35:38implicit biases at the population
35:41level then leads to this accumulation
35:44of discriminatory practices.
35:49You know, getting back to sort
35:51of this comment on, on, on.
35:53Well, you know, could it be that
35:56this mom didn't have time for, for,
35:59for the patient, for, for the child?
36:02I think I want to take a moment
36:05and talk about cultural humility
36:07because there's always common ground,
36:10right, regardless of your race,
36:11ethnicity or socioeconomic factors.
36:14We all care about our children and
36:18and just because I care about my kids
36:21or I care about my own health. It.
36:25Doesn't mean that other people do or
36:28don't in the same way that I that I do.
36:31And I think that the word and
36:35the term humility goes along way.
36:38We need to be aware that.
36:43My views and how I approach my health
36:45might be very different from somebody
36:48elses and and and we need to approach
36:51each other with the humility to
36:54understand that I don't understand
36:56everything about somebody else's reality.
36:59Because if we think for example if I
37:03think that I understand everything
37:05there is to know about Hispanic
37:09patients if I assume that.
37:12I got it down by the mere fact
37:14that I belong to that group.
37:17Assuming that can can be can be problematic.
37:23Oh my God.
37:25Um, so,
37:27so again getting back to
37:30getting back to our patient.
37:34He was seen by all of his subspecialists.
37:38He continues to struggle with
37:41his increased weight that.
37:43Continues to be and I think that
37:45continue to be a struggle for him
37:48throughout his the next three years.
37:51He has slowly improved.
37:52He's able to walk better and sleep better.
37:57He's now back in school and attending
38:00all of his follow up appointments.
38:03So I'm happy to sort of report that
38:05in terms of his overall health,
38:07he's better, he's now able to
38:10to get the care that he needs.
38:13But now sort of for the last few minutes,
38:16if Stella stops barking and
38:19you guys can hear.
38:21How can we provide communication
38:23and overcome stereotype threat?
38:25Well, the first thing to to
38:28to acknowledge is that to know
38:32thyself is the beginning of wisdom.
38:35So start by sort of taking a deep dive
38:38into who you are and what are your biases.
38:42I have them.
38:43I I work in this, in this area,
38:45and I'm always the first to
38:47say I have my own blind spots.
38:49I have my own biases,
38:51and I.
38:51We need to recognize our own
38:54and there are all sorts of sort
38:56of tests that that there are.
39:01Umm.
39:06Sorry. Let me. I'm sorry, Ariel.
39:09Oh, there you go. Somebody's taking her.
39:13To build the best therapeutic
39:15relationship with with your patients,
39:17you really need to sort of understand
39:20your biases and find ways to to
39:23mitigate these and how you do
39:25it is really through hard work.
39:27So the bottom line is that.
39:31You need to do your work.
39:35Go to as many training sessions,
39:39read, talk to people.
39:41Start having the tough conversations.
39:44Don't just say, well,
39:45you know what, I know it all.
39:48Is somebody missed?
39:50In their communication with their patient,
39:53they're wrong.
39:54And right now I think I think we all
39:57need to sort of do the hard work and be
40:00humble enough to understand our role.
40:02And that the only way that we're
40:05going to to achieve mitigating
40:08these biases is through hard work.
40:11Some of the strategies that you
40:14can that you can adopt causing
40:16most of the times when I've or
40:19most of my mistakes have been.
40:22When I don't take that pause and and
40:24try to reflect and say well what are
40:27what are we trying to accomplish here?
40:30Who else needs to come to the
40:32table huddling with your with
40:34your team members not assuming.
40:36Well,
40:36if they didn't give this patient
40:38a follow up appointment it means
40:40they're wrong and we're right.
40:41No trying to get information.
40:44Who else needs to be at at the at the table?
40:47Who else has information and always bringing.
40:52Persons of trust and individuals who
40:55can help you build trust with the with
40:59the patient and plan communications,
41:01right?
41:02Just when you communicate with others,
41:05try to have a plan of who else
41:07should be there and what are
41:10some of the best practices.
41:12I like this slide because it.
41:14Breaks sort of our are some of the
41:17strategies that we have to mitigate
41:20biases by organizational strategies.
41:22Individual strategies which you can
41:25do on your own, and some of these.
41:31Strategies that include some of the
41:33ones at the level of institutions
41:36and some of the ones that you can
41:39that you can do on your on your own.
41:41But but you know I'll I'll end by
41:45saying many of us find ourselves
41:48struggling to talk about these concepts.
41:51It's it's not easy to to talk about
41:55the impacts of race, ethnicity, racism.
41:58But it's important to have.
42:00These conversations and it's not until we
42:04start doing that hard work first on our own,
42:08educating ourselves and having going
42:11through that period of discomfort
42:15of talking about our mistakes and
42:17and how the ways that we can improve
42:22and improving our knowledge.
42:27That that we then get to to to ensue,
42:31change, read articles,
42:34watch documentaries, or.
42:37You know as much as you
42:39can and and you know not.
42:41Be afraid to sort of say you're wrong.
42:45Apologize often.
42:48And in the end I think.
42:54We've learned a lot about
42:57health inequities during COVID.
42:59COVID is still with us.
43:01There's going to be hopefully not
43:03as bad and not in the near future,
43:06but there will be other times
43:08when we will be challenged.
43:10By situations like what we've
43:13experienced in the last three years.
43:16So these challenges are going
43:18to continue to to occur.
43:20And I think this has been sort
43:22of a wake up call to for all of
43:26us to think about how prepared
43:29are you and what are you going to
43:32do when faced with challenges.
43:34Again, thank you very much.
43:36I'm going to apologize for my loud dog I.
43:41I didn't realize she would
43:42be barking so much,
43:43but it's been a pleasure and
43:46if you have any questions I'd
43:48be happy to to answer them.
43:53Thank you so much, Dean Vasquez,
43:55for that incredible talk. It's just.
44:00Incredible to me how much reflection and
44:02teamwork and being able to learn from each
44:04other and just staying humble can make
44:06such a huge difference in people's lives.
44:08So thank you so much for sharing that.
44:11And about the dog, I think she's
44:13adorable and very sweet and never need
44:15to apologize for a dog in my book.
44:17So. But that being said,
44:20disclosure statement,
44:21I have my own dog that also decides
44:24that she when she wants to bark so.
44:27If anybody has any questions,
44:29please feel free to put them in the chat.
44:33There is a question and answer option and
44:35we can go through them with Dean Vasquez.
44:43Or if we'll give it another minute or so,
44:46but if nobody has any other questions,
44:49I just want to thank Dean Vasquez
44:51incredibly much for her time and all
44:53the incredible work that she does.
44:54This has been a great way to continue
44:57our MSN perspectives, which our theme
45:00is equity and inclusion and access.
45:03And so this is a just another
45:05great opportunity to hear from you.
45:07All right, we do have one.
45:09What did it take to connect the
45:10patient to all the specialists?
45:15Well, that's a that's a good question.
45:18In the era of electronic medical records,
45:21you can request new appointments,
45:25but I'm a little bit old school.
45:29I. Looking at the patient,
45:32obviously you're going to you know take
45:35care of of of the patient then and there.
45:38I was very concerned about his heart and
45:42his lungs so I picked up the phone and.
45:46I looked online to see
45:48who was who was on call.
45:50Um, and I directly.
45:51I used my resources.
45:53I called directly attendings and
45:56fellows to try to advocate so.
46:00So I think youth resources that you
46:05have in hand, don't be afraid to
46:08pick up the phone and talk to people.
46:10This was back at the time
46:14when the only faculty member,
46:15so the only physicians in
46:16the hospital were those.
46:18Call people will not in their offices.
46:20Before I could have just walked
46:22up to somebody's office so.
46:26So reaching out and and pleading
46:29the case it wasn't you know a
46:32lengthy explanation but if you can
46:35summarize the case in A2 liner
46:38a child post COVID who's working
46:40hard to breathe and I think may
46:43have restrictive lung disease post
46:44COVID or who I think may may have
46:47you know congestive heart failure I
46:49need this child to be to be seen.
46:52So that was sort of the SOS and
46:54that was my approach in in sort of.
46:57Because I have I'm lucky enough
47:00to have the resources I use them
47:02to advocate for my for my patients
47:05and and and then it's follow up.
47:07So it's not just making those
47:10appointments it was. Letting the mother know.
47:15I know every time you come here you
47:17see a different provider because that
47:19that's the reality that happens, right.
47:21We're not in private practice
47:22and with a solo practitioner,
47:24but making the connecting,
47:26making the connection and making
47:29the commitment.
47:30So I asked her if it was OK for
47:33me to have her,
47:34her Direct Line and I told her
47:36I'm not in clinic tomorrow,
47:38but I will call you tomorrow because
47:40I want to know did they call you
47:43to give you the appointment and.
47:45And and and using that and then
47:47you know you can't be the one
47:50following up with every appointment,
47:52but then relaying the message to
47:54those involved trying to work as a
47:57team and sending messages through
47:59the electronic medical record or
48:00one-on-one to those who I knew
48:02would see him and say.
48:06Follow up is important.
48:07If the patient doesn't show up, I want
48:10to know and and you and you let me know.
48:12It's difficult.
48:16Because so much more of our
48:20communication is electronic and you know,
48:23work hours with the work hour
48:25limitations especially in in.
48:27Training institutions where residents
48:29can't be on for long periods of time,
48:33then there's a lot of turnover
48:36and we need to, I think,
48:38work harder to ensure that the
48:40sign out contains some of these.
48:43You know, the.
48:45The message is that we want to
48:47relay not only what medication
48:48this patient should have,
48:49but please make sure that this
48:51patient is not lost to follow up.
48:58Thank you so much. Any other last questions?
49:07Alright. Well,
49:08thank you very much Dean Vasquez.
49:11We really appreciate your time
49:13and sharing this incredible story
49:15and I hope everybody has a great
49:17rest of your day. Thank you.