11. Reducing Disparities & Preventive Medicine’s Impact on COVID-19 (Part 1 of 2)

. I’ve been in practice for about 10 years, and I am honored to also have two fellow esteemed colleagues with me for this discussion, so I want to give them a moment to introduce themselves too. We’ll start with Dr. Christina Wells.

Christina Wells, MD, MPH, FAAFP:

Good afternoon, everyone. My name is Christina Wells and I’m a family medicine physician. I work for an FQHC that is connected to the University of Illinois called Mile Square Health Center, and I’ve been working there for almost 13 years. I am also an assistant professor of clinical family medicine, and I am a course director for the medical colloquial course at the University of Illinois College of Medicine. So I’m excited about the conversation we’re going to have today.

Carl Earl Lambert, Jr., MD, FAAFP:

All right. Thanks so much for being here with us. And then I’m going to turn it over also to Dr. Marian Sassetti,

Marian R. Sassetti, MD, FAAFP:

Hello. It’s a real honor to be part of this group. I’m the old one in the group. I’ve been practicing medicine for 31 years now. I’m in a private, independent practice just west of the city in Oak Park called Lake Street Family Physicians. I’m also an assistant professor at Rush, and do some teaching in the family medicine department.

Carl Earl Lambert, Jr., MD, FAAFP:

All right. Like I said, it is wonderful to have you both here for this conversation. Whoever’s listening, I hope that you are inspired, you’re educated, and that you hear a little bit about our real life experiences, and challenges, and troubleshooting with what I would consider to be very hefty topics. We’ll do our best to engage you and to treat these topics with care. So, let me just start with really an unsettling statistics. So, we’re about two years plus into the COVID-19 pandemic, and the first half of this discussion is really about disparities. And if you look at the data, there’s certainly disparities there that alarmed me. If you look at, say, for example, the proportion of deaths due to COVID-19, or severe hospitalizations for, say, black and Hispanic populations in the US, although they are a lower proportion of the US population, they’re accounting for five times the amount of deaths compared to our white counterparts in the US.

So, again, I think that does highlight the power that disparities can have. So, as a physician of color, and then as a family doctor that cares for patients of diverse backgrounds, that made me a little sorrowful, made me think that, hey, those are my patients. Those are patients that look like me, that are really bearing the brunt of what COVID-19 can do.

We are aware that there are different risk factors and different things that led those disparities to be. They didn’t just happen on accident, but rather, as we’re probably going to discuss, there’s systems at play that tends to harm populations that might be marginalized, or historically aren’t getting the things that they need. And certainly, as primary care doctors, we care very deeply about that. So, my first question really for my colleagues is, how do you feel about that data that I just shared with you?

Christina Wells, MD, MPH, FAAFP:

Well, I think that data is startling. This has unveiled the disparities among communities of color that continue to exist, and that maybe have challenged us, but that we have not necessarily addressed. When you think about being able to get COVID vaccines, especially in the beginning, there was a lot of misinformation out there. And I think because of lack of trust, there was a greater acceptance of misinformation. And when there’s misinformation, it’s also going to perpetuate the disparities that exist. And so, it is imperative that we think about how do we build trust and get a step closer to being able to reduce the disparities that exist? Because a lot of it may be due to things like misinformation and health and literacy.

Carl Earl Lambert, Jr., MD, FAAFP:

Yeah. I love that. There’s a progression. There are steps that were taken decades ago that got us to this point, and we’re going to have to take some pretty bold and courageous, intentional steps to undo the harm that’s been done historically. But I love everything that you said. Dr. Sassetti, do you have anything to add to that?

Marian R. Sassetti, MD, FAAFP:

I do. The way I think about it as a white physician is that this is a crisis, and a crisis that we can’t turn away from. We can’t pretend we don’t see these statistics. They’re right in front of us. So, we have this crisis of COVID, the illness itself. And then within that crisis is the unimaginable suffering of people who don’t have access to care, or suffer at greater levels. Again, as the older person here, I really want to encourage those of us who recognize that crises are opportunities, opportunities to get this right. This will be behind us at some point. And I think if this is the final thing that brings the medical community to understand that we have to, we cannot talk about our successes with a large percentage of our patients suffering so astonishingly more than our white patients, we cannot consider ourselves successful until we have really wrapped our arms around this kind of phenomenon.

And I just want to encourage all of us. I know we’re tired, but for those of us who hold that vision, that this crisis is an opportunity to really dig in and get this right. I’m excited to be part of this panel. None of us have all the answers, but for us to begin to want to be curious about what is our participation in this, and how we each bring our own gifts and talents to this population that needs more than they’ve been given.

Carl Earl Lambert, Jr., MD, FAAFP:

Absolutely. Beautifully said. So, you all raised some pretty important points that I want to hone in on a little bit. The first one is, as far as how did we get here? What are the factors that brought the curtain down? And when I think about my own patients, I know that a lot of my patients, they have chronic diseases, such as hypertension, Type 2 diabetes, asthma, things that we know that are risk factors for having those poor outcomes with COVID-19.

But when I think about social determinants of health, or just different strategies, or things that got us to this point, you think upstream. I think of, well, were these patients getting access to quality care, since culturally sensitive care, on time care, to make sure that those different conditions are treating adequately, so they wouldn’t end up being in the hospital? That’s one factor that I think of, but are there any other factors that you all can think of that we need to discuss right now?

Christina Wells, MD, MPH, FAAFP:

I think when you speak about social determinants of health, you think about things like the built environment. One disturbing thing that I see is that when you go into communities of color, you don’t have to go far to find things like liquor stores, or corner convenience stores, where people will get processed and unhealthy things, and not have access to fresh fruits and vegetables, and be able to eat nutritious foods. So, part of the issue with disparities is the way that environments have been designed and set up. And then when you think about COVID-19 vaccines, thinking about access, and again, going back to that misinformation. When my health literacy is poor, or I just haven’t been told, or there’s some mistrust, when something new comes out and I haven’t built that trust, I may be more willing to accept information from family and friends or social media, versus being able to talk with my doctor about this subject.

Carl Earl Lambert, Jr., MD, FAAFP:

Absolutely. Where a patient works, lives, eats, learns, and plays, plays a huge part in terms of their health outcomes, and most certainly, we’ve seen that with COVID-19. And we have to be aware of that moving forward, because God forbid this may not be the last pandemic that we see in our lifetime or even our trainees lifetime, so they need to be prepared and understand the nuances of that. And then you also brought up trust.

Some of trust is really being honest about where we are in the middle of the pandemic and saying, “Hey, here’s what we know so far. And as we get more information,” it’s an iterative process. So, as we get that, the better and better that we can keep you informed. But certainly being honest about that helps to facilitate trust, opens opportunities to engage in conversations to make sure that patients are understanding us. And it’s not from a paternal standpoint, but it’s really from a shared decision making and a poise of respect and dignity for where that patient is coming from too. So, I love all of that. Dr. Sassetti, I’m turning it over to you now. Anything else?

Marian R. Sassetti, MD, FAAFP:

Well, I really believe that one of the tools we have is our own curiosity. And how is it that this patient in front of me that has this whole entire life, and ancestry, and everything else is presenting to me? And I think way too often, just speaking for myself, I make assumptions. When I make assumptions, nobody wins. When I’m curious, I get data points and all kinds of information that I can gather. Early in my career, I learned right away, especially doing a well child, says who makes the decisions? Usually that’s a matriarch in the family, and I better not contradict that matriarch, because that young mom is not going to listen to me. So, being curious about the people who are important. And Dr. Wells, you were talking about misinformation.

For us to say to ourselves, “Okay, clearly our message isn’t working. So, how can I be curious about what messages are? And why are those messages working? And how can I be in solidarity with my patients, instead of telling them the book smarts and the science behind things? How can I align with them, be curious about what’s happening in their lives 15 miles from my office? What are the predictors of what they will listen to or not listen to what is available to them?” And too, Dr. Lambert incurs our medical students to begin that right away, to really access those really important morsels of information about our patient’s lives. And make no assumptions. It’s dangerous territory to make assumptions.

Carl Earl Lambert, Jr., MD, FAAFP:

And with that misinformation piece, I think we need to talk more. It’s so important. I have to share this quick story. Near the beginning of the pandemic, my family, some of them see physicians, some of them don’t. They had created a Facebook group, a family group, where they were spreading misinformation. Someone accidentally invited me to this group. And when I saw it, yeah, I said, “Oh, my goodness. I need to have a family meeting. I need to have a family meeting right away to discuss this.” Because misinformation tends to travel quicker than the truth. And it’s just really fascinating that if this is happening in my family, it’s certainly happening in the minds of my families that I’m seeing in the clinic. And even when I have those discussions, never do I insert shame. There might be some credence to that. Because again, when we talk about disparities, we have to think about the historical context. For example, experimentation of marginalized groups, where as a medical community, we’ve lost some of that trust.

And really this phase that we’re in with the COVID-19 pandemic, I think it’s been an opportunity for us to step up and gain some of that trust back. And as you all mentioned, it’s an opportunity to really say, “Hey, we really have your best interest at heart. Trust us. We’re going to be transparent with you. We do not want to harm you. In fact, we take an oath.” I think even in the Hippocratic Oath it says prevention is preferable. So, I just wanted to just say that. Any other thoughts around the misinformation piece? Any other stories or narratives that you all wanted to share, and how you’ve connected to your patients when that comes up?

Christina Wells, MD, MPH, FAAFP:

Yeah. I wanted to share something because I thought you made some powerful points. And I think trust is a big issue. And maybe thinking about how we approach trust in a different way, and more so as a partnership, versus I tell you this and you ought to do this. But what I found in my practice, I had a patient who actually got a vaccine and then got COVID, and asked me whether or not they should get the second vaccine. And I told them that they should, and I explained why they should. They were able to listen to what I had to say because I was honest. I didn’t make it seem like I knew everything. Where there were areas where I was lacking in information, I was completely honest about that to say, “This is new for us. This is something that we’re trying to understand, and we don’t always have all the answers. But as we get them, we will share them.”

And because I was honest with her, because I shared my own experiences, then the patient was willing to go ahead and get the second shot. And so, I think the relationships, the honesty, the humbleness, the really trying to meet people where they are, will really go a long way to building relationships. When a patient trusts that their provider, their primary whoever’s taking care of them has their best interest at heart, then they’re going to be willing to take the advice and suggestions of that provider.

Carl Earl Lambert, Jr., MD, FAAFP:

That’s a mic drop moment, I would say. That’s a mic drop right there. So, we will come back to that in a little, bit about the power that a preventative, or PCP, has in terms of relationship, and even positively influencing their patients. But Dr. Sassetti, anything on your end you want to share with that?

Marian R. Sassetti, MD, FAAFP:

I agree. I think what Dr. Wells said is so beautiful, and I like the word humility. I’m old enough that I get to enjoy the luxury of these very long term relationships. And one young woman I’ve taken care of over 20 years now, I hadn’t seen her for a while and we called her to get her in for routine. And we started the conversation about COVID and she said, just flat up, “Look, I didn’t want anybody telling me what I have to do.” So, I was able to use one of my favorite lines, which is, that makes sense. You’re a good advocate for your body. That makes really good sense. And then I’ll often say, “Look, some really horrible things have happened in medicine.” We have to own that. And those were huge mistakes. And right now, I want to point out the good things that have happened.

Can we talk about it? I think asking permission and being humble enough to hear a patient who says, “No, you need to hear what I have to say.” These are the same conversations I have with my smokers. I’ll say, “Okay, I’ve heard you. I’m going to honor that, but can I bring it up again? Because I think this is one of the biggest health risks for you.” And I’ll say something like, “We’ve been a good team so far. You and I have made really good decisions. Your health has improved. You’ve done some wonderful things. I want to stay on that track. Is that something that we can do?”

And I think that ability to partner, be humble with, be on a journey instead of the, I’m in charge, and you have to do what I’m saying, for me to listen and say, “Can I bring it up again?” Happily, I chose this story, of course, because the happy ending is, of course, she got the COVID vaccine after thinking about it. I don’t think it had a whole lot to do with me, but I can guarantee you if I had said, “Yeah, I’m going to give it to you or take a hike,” I’m guessing she wouldn’t have kept coming. So, I’m an advocate of humility, curiosity, partnering with. I like the term being in solidarity with our patients. What’s their experience? What’s their fear? Acknowledging it, and they have a right to it.

Christina Wells, MD, MPH, FAAFP:

Right. And if I can add something to that too, I think that’s so great that you said. I think why this is important for reducing disparities for COVID-19 vaccines is because I think that over time, and you can tell me whether or not you guys agree, that we’ve done a better job of improving access. But although we’ve done a better job of improving access, there still may be some hesitancy in persons of color to still want to be able to get the vaccine. And in order to be able to reduce the disparities that we see in people of color getting vaccines versus other groups of people, then there needs to be some other issue that we need to address. Maybe the issue more is the lack of trust, the misinformation that’s out there, and delving into why that exists, we’ll be able to get over that bridge, over that hump, of why people of color are not getting vaccinated, even though there may be increased access to vaccines.

Marian R. Sassetti, MD, FAAFP:

I had read a story a while ago that if you ask a marginalized population to take a survey, there’s an enormous return on that, because there’s very little opportunity to have a voice. And sometimes I’ll capitalize on that and just say, “I really want to understand this. You and I have agreed on so much. It’s really important for me to understand that. Not only that, but lots of my patients are saying the same thing you are, so can you help me understand this? I want to understand how to deal with this.”

Sometimes I’ll actually use the word ambassador. “I’d like you to be my ambassador out in the community. I have all this knowledge, but somehow people aren’t coming and getting these vaccines, so help me understand this. Let’s be a team, at least on you teaching me this.” Even if I can’t convince them to get the COVID vaccine that day, empowering them that they know they have a voice and that this is so important, I want to learn about it. I don’t want to dismiss it. I want to learn about it. Help me understand is one of my favorite lines. Help me understand your thinking around this really important topic, because lots of people are thinking you are.

Carl Earl Lambert, Jr., MD, FAAFP:

This is brilliant. Like I said at the top, I’d probably be talking the least because these are some wonderful docs talking right now. So, the only thing that I think I might add, what I’m hearing is, we have to think about interpersonal relationships, and the power and the influence that we have to flex that. And then we also have to think upstream as far as systems that are at play. So, one thing I wanted to just ask, and we’ve talked about it, and I think I won’t even put a disclaimer for our listeners. I think sometimes this is a topic that may be uncomfortable for even physicians or providers to talk about, but we have to name it. Oftentimes, we have to name things or injustices. So, one thing that came up as far as broader issues is biases. If you have a bias towards a certain people group, you may not try as hard.

If they say, “No, I don’t want to do that,” you may say, “Yeah, okay.” The conversation ends there. So, that may be related to a bias that you have towards a certain people group, whether you know it or not. And we know that biases can kill. They can lend to disparities that we see, similarly to how systems around patients and access to resources and different things for their own health can contribute to outcomes as well. So, any thoughts as far as biases? Do we have biases? And again, any other thoughts towards that before we move forward to other questions that I may have for us?

Christina Wells, MD, MPH, FAAFP:

I think we all have biases. And I think once we acknowledge that, that will get us a step closer to understand what those biases are. Overcoming and acknowledging those biases is important, but also just making an intentional effort to say, “Although I may have biases, I’m going to look at every patient the same. I’m going to treat this person as if this were my brother and my sister, my mother and my father.” And I think if we could be more relational to people, that would help us, but I think we all have to understand that we have some sort of biases. I know that we’ve had to do training on implicit and explicit biases. We’ve all probably dealt with that. And that can definitely help us to uncover biases that we never knew existed within us. And those may be some first steps, but understanding that no matter what you may think, every single person has some sort of bias.

Carl Earl Lambert, Jr., MD, FAAFP:

Yeah.

Marian R. Sassetti, MD, FAAFP:

Yeah, of course. I’m going to say, of course we have biases. I think the most challenging bias is I don’t have a bias. “Hey, I’m not racist. Hey, I’m not classist. Hey, I’m not elitist, and please don’t call me that because it’s offensive.” If we could get underneath that and just say, how did I come wired, hardwired, and otherwise, into this practice? What are my gifts, but what are my challenges? And is a challenge that I have getting in the way? And again, the curiosity is just one of my favorite words. So, what I teach the medical students, if you hear yourself using the phrase they, they like it, they don’t do this, they do this, be really careful, and just wonder where that’s coming from. Don’t call it bias, call it a challenge, an internal challenge that you have. So, just being aware of the way we talk can help us come over it.

Are we using they way too often? And then just I’d say be gentle with ourselves and each other. We aren’t going to help the situation that we’re put upon. Instead, we’re chosen. I know that sounds very melodramatic, but those of us who took this oath gave up so much of our time and training, I do believe this is our moment. We were chosen to take this head on. We could put our heads in the sand and move to our next crisis, or we can actually say, “This is our moment. We have the data in front of us. How do I contribute? How does my practice contribute? And what can I give that counteracts this?” I just think it’s a philosophic change internally for us. We don’t have to fight. We can just be in solidarity with each other. And if we start to feel put upon, it’s something else is bubbling up, and it’s not curiosity.

Carl Earl Lambert, Jr., MD, FAAFP:

Like I said, just brilliant. Everything you’re saying is so brilliant. I feel like I need to take notes as I am talking and contributing to the discussion. So, one thing that came to mind is the quote, “Physician, heal thyself,” but from hearing you all speak, “Physician, know yourself.” We need to know our weaknesses. We need to know our blind spots. And again, having biases in and of themselves is not bad, but not being aware of them or how they play out in day-to-day interactions is. And then I want to actually punt this over to Dr. Wells, because I think you had mentioned that when we talk about discussions like this, it may be easy to talk about race. Okay. Black patients, white doctors. But do you think that this applies to different combinations other than race? Do you think that’s something that our listeners need to be aware of too?

Christina Wells, MD, MPH, FAAFP:

I think that when we think of biases, we always think that it’s a black, white issue. I think that has some undertones to it, to be completely honest. But I think that because of a longstanding black, white issue, now we do have issues that exist that are intra-racial if that’s the correct word, where it’s people of the same color who may be dealing with biases that have been implanted and carried on because of living in an environment where people are looked at differently.

And so, you may have where there is a physician of color, and maybe still mistreating a person of color based on learned biases. And then there may be challenges that we experience looking at people based on their socioeconomic status. Even though we may be of the same race, we may look down at people who have different socioeconomic status. We look at people differently based on their sexual orientation, based on their religious affiliation. And so, like someone said earlier, that failure to recognize that we all have biases and how they have come into play, in order for me to have an effective impact on this person, I need to be able to look to them as I would my family member, my mother, my father, my brother, my sister, and help me to be able to overcome the stereotypes that I may be carrying.

Carl Earl Lambert, Jr., MD, FAAFP:

You’re absolutely right. I love that you touched on internalized racism. We don’t talk about that part enough. And I agree, and I resonate with what you said. To the listeners, you might be thinking, “Oh, my goodness. We’re talking a lot about the disparities and the bad things, but has the tide changed?” I do want to ask fellow colleagues, do you feel like the tide has changed? And if so, how and how have you seen that?

Marian R. Sassetti, MD, FAAFP:

You know what, Carl, can I go back for just a second?

Carl Earl Lambert, Jr., MD, FAAFP:

Oh, sure.

Marian R. Sassetti, MD, FAAFP:

There’s been a line that I’ve been using that has been so helpful for me, because I believe all marginalization is about power and control. Whatever you’re talking about, domestic violence, distribution of goods in society. And what I’ve taught myself to say to my patients is, “Look, you’re driving the ship.” It’s an acute line. I think it’s fun, but it reminds me the person in the room that’s in control is not me. And if we can share that power just very, very consciously, in each visit, I have to remind myself who’s in power.

Boy, would I love to have the power and control and run the world. But in that moment, with that patient, when it gets really difficult, I pull up that line because it calms me down, and it says, “You know what? You’re driving the ship. Okay. Let’s take it from there first. You’ve got the power and you’ve got the control, at least in this team.” I have founded it calms me down a lot when I’m feeling like the patient isn’t doing, quote, what I think they should. There’s the they word. But it might be a technique that our listeners can use too.

Carl Earl Lambert, Jr., MD, FAAFP:

I’m so glad you interrupted. That is such a thoughtful and needed contribution to the discussion, so I thank you for sharing that. And imagine if every single patient had that experience with their PCP, what a difference that would make moving forward. That would be a wonderful thing. Yeah. I’d say, have you all seen the tides change? With these interventions, with this thoughtful attitude as we interact with patients, with the mindfulness, as far as greater systems that are at play, have you seen any changes for the positive?

Christina Wells, MD, MPH, FAAFP:

I don’t know what the data shows. What I was reading was that about maybe 50% of African Americans have been vaccinated, and that’s just at least one vaccine in the United States. And so, we know that there’s still a lot of people of color who have not gotten fully vaccinated. And so, I think that we have started and maybe we’re tip toeing, but I think we’ve made some strides, but I think that we have quite a journey to go.

Carl Earl Lambert, Jr., MD, FAAFP:

Sure. I would agree with you. I can speak from just personal wins that I’ve had with patients that initially said, “No, I’m not doing that.” Or even I had an older black male patient say, “Dr. Lambert, are you trying to Tuskegee me?” So, that was the initial conversation. But as we build relationship and he saw how much I cared, eventually he did get vaccinated. My hope would be that, yeah, we’re moving in the right direction, but there’s so much more work to be done. And I think we’re going to talk about that more as we see into the power of preventative medicines impact on COVID-19 and changing these numbers. So, Dr. Sassetti, how about you?

Marian R. Sassetti, MD, FAAFP:

I don’t have the statistics. I’m grateful that you do, Dr. Wells. I personally definitely have seen over these last two years, and certainly well into the vaccine, so many of my families of color saying, “Okay, we’re ready. Okay. We believe you.” I have the luxury of a lot of well child care, so I can bring it up each time. And I think that positioning myself as somebody who really cares. Again, because I’m old, I have these very long term relationships. And at one point, I said, “So you really want to see me burst into tears? Please get this COVID vaccine.”

And she started laughing and she said, “Not today.” And I said, “Okay, but someday you’re going to do that, because you don’t want to see your old doc burst into tears.” And that stuff that helps me, again, where I’m just like, “Come on, it’s the end of the day. And I thought by now you take the vaccine, but you don’t.” Of course, those families, many of them, I don’t have my own statistics, but certainly many of them come back and say, “You’re right. I’m ready. I’m going to do it.”

Carl Earl Lambert, Jr., MD, FAAFP:

Wonderful. We are family physicians on the podcast, but I know we’re speaking to a broader audience of pediatricians, internists, primary care providers, who all likely understand how we play a part in terms of reducing disparities. So, I think we’re moving more towards the granular piece, maybe even action steps and just things to consider as we move forward.

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