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A champion of health care fairness

Medicine@Yale, 2018 - June July


Uncovering inequalities and striving to improve both care and education

Medicine permeated the youth of Marcella Nunez-Smith, MD, MHS ’06, associate professor of medicine (general medicine) and of epidemiology (chronic diseases/social and behavioral sciences). Her godfather, a surgeon, practiced it. Her mother, a nursing professor, taught community health. Etched in family lore, and recorded somewhere, is Nunez-Smith’s confident declaration, at age 6, of her plans to become a reproductive endocrinologist. Her devotion to medicine has never wavered.

At 16, she matriculated at Swarthmore College in Pennsylvania, and double-majored in biological anthropology and psychology. She took a year after graduation to help care for her ailing grandmother, and teach at her former high school in St. Thomas, U.S. Virgin Islands, and then began medical school at Thomas Jefferson University Medical College in Philadelphia in 1997.

Eventually, internal medicine would supplant reproductive endocrinology as her primary interest. It became the focus of her residency at Brigham and Women’s Hospital in Boston. One day, a close colleague mentioned a fellowship program that provided skills and resources for physicians to affect the health of whole populations, rather than one patient at a time. “I immediately thought—I want to do that!” Nunez-Smith says. She applied to what was then the Robert Wood Johnson Foundation Clinical Scholars Program at Yale, and learned of her acceptance from Harlan M. Krumholz, MD, Harold H. Hines, Jr. Professor of Medicine (Cardiology) and professor of investigative medicine and of public health (health policy), who would be her program director.

Inspired by the work of one of her mentors, JudyAnn Bigby, MD, former secretary of Massachusetts’ Executive Office of Health and Human Services, Nunez-Smith knew she would pursue fellowship research on health disparities and inequities. Her first project grew out of her own residency experience as a woman of color. “We had a very supportive environment there,” Nunez-Smith says. “We also had some medical staff who, for the length of the residency, confused me with another resident, who is 6 feet tall, and many shades darker than myself. We laughed it off at the time, but I began to think, ‘What does it look like for our profession to support diversity?’ ”

“People of color in hospitals and practices are often invisible and must deal with climate and culture issues all the time,” says Nunez-Smith. “For example, patients might refuse to accept that a person of color is a physician, even with data they have—like seeing a stethoscope.”

She led a group that approached Krumholz and her fellowship program advisor, Elizabeth H. Bradley, PhD, now president of Vassar College, with a plan to investigate workforce diversity in health care—a topic so nascent that neither had heard of it. That qualitative research would lead to work on patient health care inequity, and, with pilot data supported through a Yale Center for Clinical Investigation (YCCI) Scholar Project Award in 2006, Nunez-Smith became principal investigator of a National Institutes of Health (NIH)-funded grant to develop a Patient-Reported Experiences of Discrimination in Care Tool (PreDict). She became assistant professor of medicine at Yale a year later.

Nunez-Smith would soon develop the Eastern Caribbean Health Outcomes Research Network (ECHORN), a collaborative, multimillion dollar research study funded by the National Institute for Minority Health Disparities. Among other NIH and foundation-funded projects, she would found the Equity Research and Innovation Center (ERIC), which turns five this year. All ongoing projects at ERIC—from population migration, to cardiovascular disease, to pediatric obesity—are examined through a health-equity lens, she explains.

During her 14 years in the field, Nunez-Smith has found that a participatory research approach is the most important tool she has in translating health equity research to tangible results. “At its core, participatory research means that researchers cede some power to community members who have the expertise necessary for the scientific success of a project,” she says. In 2016, Nunez-Smith and colleagues were awarded nearly $10 million in funding over five years to launch the Yale Transdisciplinary Collaborative Center for health disparities research (Yale-TCC), within ERIC, which aims to improve early identification of individuals at risk for hypertension and type 2 diabetes.

No matter which research project Nunez-Smith works on, the immense impact she felt during her initial Yale fellowship, now called the National Clinical Scholars Program (NCSP), is never far from her mind. “I learned to take risks. Build good teams. To not take ‘no’ easily,” she says. Now, as a core NCSP faculty member, she impresses these lessons on the next generation of clinician-scholars.

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