We must address glaring disparities in treatment [PODCAST]

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“It is not enough to say we are anti-racist; we have to modify our systems to recognize that we have placed individuals of color at risk of poorer outcomes.  Lack of insurance, lack of finances, or even the presence of certain diagnoses may reflect less about the person and more about our society, our infrastructure, and our systems. As members of smaller communities and a larger society, we must make adjustments in our attitudes and knowledge as well as the services we provide to individuals who have experienced harm by insidious but ever-present racist structures.

Glaring disparities in treatment aren’t only happening in protests.  They are happening in all of society, and in our hospitals.  Only when we address systemic racism will we be able to realize the ethical imperatives of safe and equitable health care for all.”

Jane Gagliardi is an internal medicine physician and a psychiatrist.

She shares her story and discusses her KevinMD article, “It is not enough to say we are anti-racist. We must address glaring disparities in treatment.”

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today on the show, we have Jane Gagliardi. She is an internal medicine physician and psychiatrist, and she wrote the KevinMD article “It is not enough to say we are anti-racist. We must address glaring disparities in treatment.” Jane, welcome to the show.

Jane Gagliardi: Thanks so much for having me. I really appreciate it.

Kevin Pho: We’ll get into the article a little bit, but first off, can you share your story and your journey to where you are today?

Jane Gagliardi: Sure. I grew up in Massachusetts in a really nonmedical family. My father dedicated his career to nonprofit agencies directed at helping individuals secure decent, affordable housing regardless of their income. My mother was a teacher of English and humanities, and I’m really the only person who pursued any sort of scientific inquiry. My younger sister is an art historian specializing in the arts of Africa and some of the impacts of colonization and geographical distinctions, and my older sister works at the Central European University, previously in Budapest, now in Vienna.

I arrived at Duke, which is in Durham, North Carolina, in 1994 as a medical student, and I’ve stayed ever since. I completed medical school, my combined training in internal medicine and psychiatry, and my master’s degree in health services with clinical research as a focus. Interestingly, it wasn’t until three years into my residency at Duke that I learned anything about systemic or structural racism or the history of Durham and Duke as a community and health system partnership. In more recent years, that history has actually been more clearly disseminated and taught, which I think is an important advancement.

I’ve always gravitated toward roles that permit me to participate in education and also in advocating for excellence in clinical care, because I strongly believe you can’t have high-quality medical education unless it’s predicated on outstanding clinical services. So for 10 years, I was the clerkship director for internal medicine. For the last two years of that, I was also the associate program director for the psychiatry residency. Subsequent to that, I was for six years the psychiatry residency director, and I’m now the medicine-psychiatry residency director, all at Duke.

During my time in medical student education, I really worked to promote evidence-based medicine not just as a theoretical application but as an actual clinical tool, and I continue to co-teach that course. Then, during my time as the psychiatry residency director, I started, and continue to teach, evidence-based medicine and quality improvement, with a focus on having the residents identify small, low-hanging fruit in their area of work that seem like, if they could just be changed, there would be a large impact on patient care. Throughout all this time, I’ve also worked to incorporate morbidity and mortality conferences in the Department of Psychiatry and Behavioral Sciences, and I’ve worked to try to highlight a lot of the systemic inequities that we see on a daily basis when we’re taking care of patients, particularly in behavioral health, but also where I round on our combined internal medicine-psychiatry service.

So clinically, I provide care to inpatients on general medicine, inpatient psychiatry, and our inpatient med-psych service. I also do some consultation-liaison psychiatry, both at Duke University Hospital and our Raleigh community affiliates, and I do some emergency psychiatry.

Kevin Pho: So tell me, just through your lens in both internal medicine and psychiatry, how has the pandemic affected what you’re seeing? If you could paint us a picture, that’d be great.

Jane Gagliardi: Yeah, so the pandemic. I know early on in the pandemic, there was a lot of concern that patients had hesitancy to show up in the hospital because they might get sick. I remember rounding on our inpatient general medicine service in May, which was about six to eight weeks into the heart of what we thought was going to be a big first wave, and realizing that there was not only that hesitancy but also some diagnostic anchoring bias.

For instance, we had a patient who came to our hospital and turned out to be in diabetic ketoacidosis, but the shortness of breath associated with that diabetic ketoacidosis was, not once but twice, mistaken by the health care providers he called for advice as possible symptoms of COVID. So both of the first two times, he actually went to get a COVID test. It was negative, and the physicians or health care providers on the phone were like, “OK, good, you don’t have COVID,” and didn’t really think about what might be causing those symptoms. And so by the time he came to our service, I think he’d been in low-grade diabetic ketoacidosis for probably, I don’t know, eight or 10 days with his first episode of diabetes.

We also saw quite an impact on medical students in the institution, where they were really entrenched in clinical services, and then they were taken away from clinical service and had to really pivot to remote and online learning. I think that prompted them, really admirably, to come up with ways that they could support and help. I’m aware of students across the country doing similar things: volunteering to donate their scrubs, figuring out how to provide support to the physicians on the front lines, and really doing whatever they could to be useful, both to the community and also to the community of health care providers.

As time has gone on, and I’m sure you’re well aware of this yourself, a lot of what we thought was going to be acute stress has kind of turned into that same kind of chronic slog. I think it’s been especially hard to navigate how to advocate for science without getting too political, and that’s been a big challenge both with patients and with learners: how to make sure that people stay safe without mandating their behavior. And over time, seeing things that really seem like they don’t match up with best practices, maintaining optimism, I think, has been a struggle for many. And so those are, I guess, the main themes that I’ve observed pandemic-wise.

In probably, yeah, the end of May, with the death of George Floyd at the hands of police in a widely publicized and tragic video, I became aware that our viral pandemic, while acute, really doesn’t hold a candle to the long-standing racial injustices and the pandemic of systemic bias that many individuals in our country have faced. It was in thinking about that pandemic, and how people are supposed to navigate society when things are so polarized and unfair, that ultimately contributed to my desire to write the piece I wrote.

Kevin Pho: So let’s get right into that piece. It’s titled “It is not enough to say we are anti-racist. We must address glaring disparities in treatment.” Now, for those who didn’t read that article, can you just walk my audience through it and share the story of why you decided to share it?

Jane Gagliardi: It’s something that’s been on my mind for six or seven years now, starting in 2014, when I mentored a group of residents in our very first quality improvement project. We were trying to figure out how to decrease rates of violence by patients in the psychiatry emergency department, and what we really wanted to do was to implement an evidence-based, validated, nurse-rated scale called the Broset Violence Checklist to predict 24-hour behavior and whether patients were or were not at risk.

During the period of time that we collected data, it became clear to me that the triage method for patients in our health system’s emergency department, as to whether they’d go to the regular part of the hospital or the locked psychiatry area, which has fewer beds than we usually have psychiatry patients, had to do with gestalt. It was a red, yellow, green system where, if the person initially evaluating the patient kind of felt nervous, they could put them in the locked psychiatry area. And then subsequently, when we collected data, I noticed that we had a disproportionate number of Black individuals who were thus triaged to that locked psychiatric area. At the time, the Durham County demographic was 38 percent Black, and in our locked psychiatry area, we had 52 percent Black patients.

In 2015, for a different reason, I gained access to other information regarding all patients who got a psychiatric consult in the Duke emergency department, and I noticed that all comers who got a psych consult matched the Durham County demographic, and that of patients we kept on our inpatient psychiatry service, 36 percent were Black. Then, worried about this disparity, I reached out to our local state mental health institution to find out about the proportion of patients we triage to that state mental institution, and at the time, it was 72 percent Black patients that we were triaging to the state mental institution.

I’m relatively blunt, and I have endeavored to find ways to amplify this concern. I think some of the concerns are being addressed in a new behavioral health addition that’s being built on the Duke community affiliate campus associated with our institution, to provide easier access to care and better, expanded services. At the same time, in light of disparities in diagnosis that are well documented, it would be super tempting for somebody to say, “Well, actually, these Black patients have lower insurance and higher rates of schizophrenia, which we don’t treat in our health system.” It’s possible to say that, but actually, there’s quite a bit of data that shows that if my white husband and my Black colleague had exactly the same symptoms that I might call bipolar disorder, it’s much more likely that my Black colleague would be diagnosed with schizophrenia. And so the underlying premise that I was trying to highlight in the article that I wrote was that we are creating systems of inequity, and then we are perpetuating them with the way our health care systems act and treat patients.

During the events of January 6, watching how the police response did not seem to be as robust as what I recalled from over the summer during Black Lives Matter protests, and then, kind of riveted to news coverage and different accounts of how that had come to pass, which at the time was not as well known as it is now, with ongoing investigations and maybe a commission that will be developed, it really struck me that there are clear parallels in the way that the system in the country treats people and the way that our medical system treats people in terms of injustices and disparities. So I think, in a nutshell, that’s what I was endeavoring to highlight in my article.

Kevin Pho: So let’s talk about that triage study that you had previously mentioned. What were some of the reactions that were garnered after you brought up the results of these studies, and what are some of the potential proposed solutions to fix some of those results?

Jane Gagliardi: The initial inquiry that I did was really a quality improvement study, and it has not been published. I raised it to the attention of various leaders, and, you know, it was only three weeks of data, so maybe it wasn’t statistically significant. And I think what we’re seeing resonating even more now is that people don’t really like it if you call them racist. And so I got a little bit of defensiveness.

In May of this year, after George Floyd’s death, I kind of dusted off that analysis I had written in 2015-16, tried to decrease whatever might be inflammatory in terms of language, and brought it back up. And so I’ve been working to amplify the message. I don’t think it’s an individual person’s fault, and at the same time, I think if we continue to accept that capitalism is the only method in which medical practice can thrive, we will continue to perpetuate some of these inequities.

One of the, I think, low-hanging fruits, which is one of the things I like about quality improvement, that would help address some of the disparities would be having access to care for serious and persistent mental illness, not just, you know, the kind of mental illness that will pay for transcranial magnetic stimulation or electroconvulsive therapy. So, you know, the things that aren’t particularly sexy but are important, like having long-acting injectables available for people who are suffering from schizophrenia.

I’ve heard that in other institutions, there are some clinics that are really dedicated to clarifying diagnosis, understanding that disparities in diagnosis may sort of haunt people forever, and that if you really listen to the story, you might realize, because this is the other part that goes into what I was writing, that sometimes we’re prone to thinking somebody’s paranoid when in fact they’re just expressing long-standing, legitimate mistrust of the system that has treated them disparately.

So I think there are a variety of ways to raise attention to that. I’ve been working in our Department of Medicine’s Championing Civility program. We’ve adopted UVA’s Stepping In for Respect training programs, and I’ve been fortunate to be trained as a facilitator for those. A group of really outstanding social workers led by Melissa Gordon-Pitts in my organization has created a six-week series called “A Deeper Dive into Anti-Racism: Conversations with Colleagues,” and I’ve been able to co-facilitate one of, like, the Wednesday noontime series of those. We’ve just kicked off our second session of the six-week series.

And then there are a few other opportunities in terms of, you know, one of the patients I highlighted in that piece. He was a young Black male who had been incarcerated for 12 years, and I really worry that he was probably incarcerated for things he did while he was manic, and his bipolar disorder was never recognized. Then, during a hospitalization, there were multiple opportunities to discharge against medical advice or to offer different care. And, you know, nobody wants the nurses or the doctors to get hurt, and if you treat mania, somebody who appears to be aggressive and agitated may well become not aggressive and agitated, which is what we saw with that individual.

So I raised his situation, with all sorts of details that I wouldn’t be able to share on a podcast, in a departmental morbidity and mortality, to really discuss issues of redlining, criminalization, stigma, mistrust, and implicit and explicit bias as areas in need of improved education and recognition. So I think multipronged approaches are probably necessary.

Kevin Pho: We’re talking to Jane Gagliardi. She is an internal medicine physician and a psychiatrist. She wrote the KevinMD article “It is not enough to say we are anti-racist. We must address glaring disparities in treatment.” Jane, one of the issues that you mentioned previously about implicit bias and systemic racism is that individuals themselves may not be aware that they’re racist, or they may not be aware that they are biased. So what are some actionable tips that you could share to help address this issue?

Jane Gagliardi: So I think if there’s an elephant in the room, it can be really useful to address it. Different people have different demeanors with their patients. Especially in light of the racism pandemic that came to the forefront in the spring, I have started asking even the patients in the psychiatry emergency department how the pandemic is affecting them, and I specify that I mean both the viral pandemic and the pandemic of racism that’s been increasingly highlighted in the news media. They may or may not trust me to totally give me an answer, but I think asking the question and being nondefensive in the responses that I get helps them to understand that I’m there to help and there to listen, and not there to prematurely judge or prematurely close my diagnosis.

I think it’s also important to recognize, and I’ve got a whole other line of interest in how the electronic medical record is kind of shaping the way that we do or do not really dive into stories, that the thing we have as medical professionals is that curiosity and the compassion, really, not to take things at that snapshot face value that our medical record systems want us to take them at, but really to understand where somebody comes from and what their story is. And instead of just thinking, “Huh, they don’t take their medications because they’re noncompliant,” really trying to understand: What are the barriers?

Sometimes it’s a barrier, and we’re finding this with COVID vaccines, where they can’t actually get to a pharmacy. Or maybe it’s a barrier where they don’t have the $2 copay, even though they have Medicaid. Or perhaps it’s a barrier where, and I’ve seen this quite a bit with, say, individuals who have family members that have died from sickle cell disease or other hereditary conditions, they really don’t think the doctors understood what was going on, and they’re not trusting that it’s the right treatment for them. And so whatever we can do to fully understand who that patient is that we’re taking care of, in order to best align with them, their values and preferences, and our understanding of the best scientifically based evidence with respect to their situation, I think will promote better trust and better patient outcomes.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Jane Gagliardi: Oh, so many take-home messages. But I think the main take-home message I was hoping to convey is that disparities in evaluation, diagnosis, and treatment have been documented for decades in our medical literature. Unequal access to nutritious food, greenery, and health care isn’t necessarily the fault of the individual who is experiencing it, and we need to stop falling back on excuses like insurance status and really work to try to address disadvantages that individuals in our country are facing in health care. So in medicine, as in society, we need to actively seek ways to confront and rectify disparities in the care we provide to our patients, which also comes in society.

Kevin Pho: Jane, thank you so much for being on the show, and thank you for sharing your time and insight.

Jane Gagliardi: Thank you. I really appreciate the opportunity.

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