 Monica Peake. Monica is a general internist. She's an associate director of the McLean Center, and she's the faculty member at the McLean Center that's in charge of research and helping the fellows with their research. Monica is the world expert on improving shared decision-making between African-Americans with diabetes and their clinicians, and she has a really rare ability to basically bridge the worlds of academia, clicklnessum, and the African-American communities in a seamless way, sort of beloved by all these different communities. And so, Monica is going to be talking about the ethical responsibility of physicians to address health disparities. She's also a Greenwell fellow. Good morning. I am delighted to be here. I will not be talking about shared decision-making. I will not be talking about the grocery stores or our interventions. I actually did it at the last conference. I think it was the last conference. But what I am going to be talking about is the ethical responsibility of physicians to address health disparities. And I think about these conferences because it's a lot of us who come back every year as an ongoing conversation between myself and the group about some of the things that I'm interested in. So some of the slides you'll see are sort of repeated to welcome those that are new in the audience to this conversation that I consider myself having with all of you. All right. There we go. I'd like to just acknowledge the various places on campus that I sit, including the McLean Center, the Bucksbomb Institute, obviously the university, our diabetes center, and I'm currently funded through the Greenwell Foundation, one of the major bioethics foundations in the country. So part of the work that I'll be presenting today reflects my work as a Greenwell fellow. So for today, I'm going to talk a bit about health disparities, definitions and conceptual frameworks, some normative physician standards, the changing healthcare landscape, and then use two examples of studies of physicians, one of the physician organizations, and one that's currently being funded by the Greenwell Foundation that's underway. So I'll be presenting pilot data that's not yet been published about our ability as clinicians to try and address health disparities. All right. So health disparities in general, there are two kinds, disparities in the care that we deliver within hospital settings or healthcare settings, and disparities ultimately in the health that people have. These are obviously related. So one can lead to the other, but if we want to think about addressing the healthcare status in general, we have to think about both. This is just a reminder to us, and I'll come back to this in a second, that health care within this country is not equally distributed. And so there are different ways of thinking about disparities, and it's sort of, there are three different sort of buckets in which we think about differences. Two of those comprise how we think about disparities, disparities being sort of the bad version of a difference, either things that are happening within the healthcare system itself or things that are happening between people in healthcare settings. And so for interested in changing the health of people, a real people, then we need to think about changes in the healthcare system as well as changes outside of the healthcare system. And so last year, when I was here, I talked a fair bit about what's happening outside of the healthcare system in grocery stores and farmers markets and the work that we're doing to try and make bridges between what we're doing in care and what we're doing outside of care. And I had previously talked about shared decision making, particularly with the lens of what it means to have a marginalized social status, the race, sexual orientation, gender identity, any of those things, you know, those social identities that are marginalized, particularly if you have multiple of those identities and how that impacts, how patients and providers see each other, their communication, their ability to have common ground about making treatment decisions and ultimately health behaviors and health outcomes. I'm not talking about that today. So today, I'm going to be talking about healthcare systems and sort of broader macro level factors, and then particularly what we as physicians and all for the purposes of people in this room define physicians broadly. We can all be physicians today. If you're a healthcare provider, if you just sort of think about if you like to play one on TV, let's say. All right. I think I used this slide last time. I'm not sure, but just a reminder about the importance of distributive justice and what that means for existing disparities. And the tooth take home messages from Norm Daniels and Rawls are that disease and disability shouldn't impact our ability to live our lives and impact the range of opportunity that we have. And that the existing disease burden is disproportionately borne by marginalized populations. So some groups have disparities in healthcare and outcomes compared to others. And this is often the result of unequal distribution of societal resources. So it's not an accident that marginalized populations have worse healthcare and health outcomes. And so part of our job is to remedy the situation is to rethink how we are distributing resources and doing so in a way that's more just in order to ultimately address, reduce, and eliminate existing health disparities in our country. So as we're thinking about normative beliefs around physicians, so essentially what we should be doing as physicians to address health disparities, this is a paper that I like to read and reference periodically that had Mark Stegler as a key author. And they described several components of medical professionalism. And the one that I highlight in Maroon is the idea that part of being a professional clinician is to support policies to decrease health disparities. It's not just enough to take care of people that are marginalized, but we also work as individual physicians and as physician organizations to try and decrease the disparities that we see in healthcare and outcomes. This is normative. This is sort of the ideal. And this is a paper that was written by an ethics working group that had some people who have been trained here and have worked here at the McLean Center thinking specifically about ethics in practice, but there is a part of this that has specifically to do with health disparities. And this paper that was published in Annals in 2004, and they're talking about a number of factors. This paper was signed off on by a number of different national organizations of physicians. This is just a small listing of them. Oops. But what they said was that clinicians should advocate just as vigorously for the needs of their most vulnerable and disadvantaged as they do for their most articulate patients. So again, we have two examples where we are, we step forth our ideal goals of what we should be doing as physicians and as a profession to try and make sure that we are thinking about those who have the least resources and have the worst health outcomes among us and advocating just as vigorously for them and addressing these issues of disparities. So now I'm going to transition. And so talking about a paper that was written as part of a Disparities Task Force for the Society of General Internal Medicine. And what we did was try to, well, what we did was identify all national physician organizations. I had no idea there were so many. I probably wouldn't have undertaken the project had I know. But we identified them all and went and administered surveys to all of their organizational leaders. We checked out their websites. And we did as much reconnaissance as we could to try and really figure out what these organizations were doing to address disparities. And then we categorized them and looked at the overall numbers and did some predictive modeling to figure out which ones were more likely as physician organizations to be trying to do work to address health disparities. And so this figure is just our taxonomy that we came up both on we differentiated by organizational type. So what kinds of things people are doing as organizations. So we providing education, clinical care, advocacy, data monitoring, research, mentorship. And then the different kind of thematic domains. Are we specifically thinking about health disparities or things that impact health disparities like access to care, communication, health literacy, perceived discrimination, those kinds of things. So this is our taxonomy that we created to help sort of catalog all the various activities that we are identifying. And what we found is that the number of activities per organization range from zero to 22. About half 53 of the organizations fell into the zero or one category. So most organizations were not doing anything. And so we found 167 and half are basically doing little to nothing to try and reduce disparities. What we did find is that primary care organizations were more likely, although not statistically so, because the number was so small, there were only nine. But 89% is compared to 67% to have more than one activity. So two more activities to address health disparities. And we had to cut off at two or more because there were so few in general. So we looked at distribution curves and that's where the cut off sort of naturally lie. Large organizations, so that makes sense once they have more resources, both infrastructure, monetary resources, the ability to advocate, those were more likely to participate in, to have activities to address health disparities. Minority physician organizations, so the National Medical Association, Hispanic Medical Association, other organizations that were primarily comprised of underrepresented minorities were more likely to. And then organizations like my own, again this was a project from the Disparities Task Force of the Society of General Internal Medicine. So if an organization had a health disparities committee, that committee was probably doing something. And the doing something would be to try and address disparities. So that was a bit of a no-brainer that those organizations were much more likely, 95% of those are likely to have more than two or more activities to address disparities. So the conclusion that we came to from this one study was that we have a national priority to eliminate health disparities. Yet more than half of national physician organizations are doing little, if anything, to address this problem. That primary care and minority physician organizations and those with disparities committees can provide leadership and vision to the rest of us in thinking about how to try and from an organizational infrastructure and member organization perspective, think about trying to address some of these pernicious disparities. It's not enough for us to, I would submit, to think about the work that we can do individually or the work that we can do in small collectives at the University of Chicago. But we also need to band together and use our collective force in numbers, particularly in large physician organizations, like American College of Physicians, to really try and push a national agenda to try and really get towards equity. So that was one of the studies I'm going to talk about. And the other is sort of this reminder to just put this in context. So why am I talking about health disparities? That's because what I do, that's the focus of my research, but also to put that in the larger context of currently a current health policy implication. So Marshall had mentioned some, certainly Albert had talked a lot about healthcare policy, the long arc of health policy, and how challenging and difficult it is to actually make policy changes that have real impacts on people's lives. But one of the things that we're seeing as part of the Affordable Care Act is a shift in how organizations and physicians are being paid with a bigger priority on primary care and prevention, a bigger priority on care coordination, and on managing the health of a population. So population health management. And so what that encourages us to do is to think about not just those patients who have the wherewithal, and there are a number of reasons why they may or may not have that wherewithal, to find their way into my office and see me. We're actually thinking about all the patients in a giving population. And there's a little bit of debate about how we're defining population. I would argue that we should be defining it based on geographic area. Currently, for the most part, it's being defined based on payer mix. So you have patients that have a certain kind of insurance, and that insurance plan will consider themselves to be doing sort of management for that population of patients. The obvious downside for that is that when I see patients, it doesn't really matter to me what insurance they have. And I don't treat them differently. I don't look at their insurance card before I see them. And so we really need to be thinking about changing entire health systems and not just stratifying care within a given system based on payer mix. But the bigger picture is still one that we're thinking about entire populations of patients and that we're doing risk stratification. And so that we're thinking about those who are in greatest health need based on medical or social needs as a way of identifying resource allocation. So this gets back to my previous slide about distributive justice and the decisions, the tough decisions that we have to make around our limited healthcare dollars. And so part and parcel of population health management is thinking about these broader issues of inequities and providing additional resources to vulnerable populations, not less. And so it really encourages us to think about the underlying causes of health, because we're trying to save money by keeping people healthy. And the biggest driver of health is not actually what we do in healthcare systems. It's what's happening when people are living in our communities outside of healthcare systems, these social determinants of health. And so there is an increased interest currently in thinking about how can we wrap our hands around these social determinants as healthcare organizations, either because we think it's the right and moral thing to do like me or because we're trying to save money like many others. But for whatever reason, we are trying now as a country to figure out how to do this. And so it makes these issues of equity and the operationalization, I haven't had them actually, much more important currently. And so then again, so I've been talking about the reorganizing the delivery of healthcare, but it also has implications for individual clinicians and that we're thinking about more team based care and care that for me is great. That means that the onus isn't on me to remember all of those vaccinations and if there's a whole team behind me who can sort of do some of these things, it is less physician centric, which I think is the way that life should be. But that does mean that there's less power, that physicians are going to be giving some of our turf away to others to try and deliver better care for patients. So are we ready for that? Who knows? I hope to find out with the survey that I'm doing. So that then brings us to this very busy slide, which I'm just going to walk us through a little bit. And so we asked, so this is a result of one, two, three, six questions that we asked on a Likert scale for physicians to comment on. Item C has to do, or let's take item D, sort of start in the middle. It's unfair in principle for patients to have a different quality in healthcare for the same medical condition. And purple and green are basically agree, red and blue or disagree. And so for question D, almost everyone strongly agree that it's unfair that health disparities exist. Now, when it comes to E and F, who should be addressing those issues, should it be healthcare systems or should it be physicians? These are physicians who responded. They were more likely to say that it should be the healthcare systems responsibility rather than our individual physician responsibilities to address these disparities. But they did say that we should be partially responsible. And some of this issue around how we choose to make these choices in the clinical encounter comes down to what's more important. The patient that's sitting in front of me or all the patients that I'm taking care of or all the patients that are part of this population. And so we asked about some of that tension between the individual versus the community of patients. And so that's sort of what A, B, and C are about. So a physician's main responsibility is to his or her individual patients more so than the overall patient population. Most physicians said, yes, I'm here for this patient. And then for population health and thinking about that tension, so item C, population health management versus individual patient care, we'll see that there's a little more of a tempering of that effect so that we can understand the importance of balance between these two constructs, but we still as physicians are leaning towards taking care of the very person that I'm looking at in the room at that time, which makes sense. And then last, that clinicians should make, we should consider how the allocation of resources when making clinical decisions. And most physicians did agree to some degree with that. The next slide is also very busy. That's my last one, almost my last one. And it's about addressing non-healthcare needs within the healthcare systems. And so the first two, the top two slides have to do with screening and addressing social needs, such as safety and family support. And the second asks physicians about who is doing and who should be doing screening for material needs like food and housing. And what physicians largely said is that, so in the maroon, that they are 40% of the time screening for social needs. And a quarter of the time screening for material needs. And that, but when you combine them together, someone in the clinical practice, either themselves or a non-physician, is screening for medical and social needs. We just know that that's not true. That's not happening. And so that for me is, I think that's an important sort of reality check for us as clinicians. The other has to do with addressing a social needs and who should be doing that. And what physicians are saying is that I'm doing a fair bit of this screening and addressing, but I really wish someone else would be doing that. I really rather task shift more of that to non-physicians. And so we have not looked at this in any detail, adjusting for various social demographic variables. This is sort of our first pass at our preliminary data. But the early conclusions that we have from that is our physicians believe that health disparities are unfair and that resource allocation considerations should be a factor in clinical decisions that our physicians and our sample anyway are prioritizing individual care over population health goals. The physicians may be overestimating the extent to which healthcare systems are addressing underlying causes of health disparities and systems meaning systems and themselves, that physicians believe that non-physicians as opposed to clinicians should be responsible for addressing health disparities. And they're more likely to support that healthcare systems more than individual physicians should be responsible for addressing health disparities. So in wrapping up, my final thoughts are that I think that physicians believe that health disparities are unfair, but we aren't really willing to sufficiently follow up with actions to address such disparities. And so that the goals of population health management and achieving health equity are at risk, these issues are not sufficiently addressed. So for me, this is a time to take a good long look in the mirror as a physician and at my colleagues nationally and think about what we can be doing to change systems and change hearts from our peers to try and sort of promote health equity. I'll end again with thanks to everyone who supports me and that makes my work possible. And also a picture of me and Paul Farmer last night where I did this ridiculous late last-minute party crash and he was so generous and hugged me like he knew me. And so I just wanted to say thank you and to, I always cry, this is so embarrassing, but just to say that he is the reason that I started on this work. That it's people like Paul Farmer and others that were like him that made me see that social justice is something that we should all be working for and something that I could actually do as well. So I just really wanted to express my excitement that he's winning this award and my delight that he hugged me like he knew me. And to say thank you and thank you all. I'll take this one of you. I know you're not looking. Hey Dr. Peake, how are you? Thank you. I'm Ben Brown. I'm one of the current Ethics Fellows and an OBGYN and a family planner here at UFC. And this question probably could have gone to really anybody in this block of talks, but I'm excited. I think it interfaces well with your talk about the ecology of the health system in particular. I wonder what you think about the challenge of addressing care for patients when the patient for whatever reason may be marginalized and the care itself may be marginalized or stigmatized. And so I think about trans care. I think about physician aid and dying. I think based on where I come from about abortion and birth control. And I think a really important growth in the discussion of intersectionality in caring for patients who continue to suffer historical marginalization. And so I wonder how you think that interfaces with when the care itself is not stigmatized or marginalized even within the health system? Yeah, no, that's a very important point that I've primarily been talking about social identity and how that can marginalize people. But even for people who are not otherwise marginalized or maybe they can be experiencing health conditions or medical treatments that will have that have socialist stigma attached to them. I think when any time you are at the intersection of marginalization, it's more than a doubling impact on that person in their health. And that makes them particularly vulnerable. And that it's our job as stewards of health care resources as clinicians to really try and be more empathetic to providing care for vulnerable patients no matter how they're being defined. And to make sure that they have the full range of access to care knowing that they have disproportionately been historically denied such access. And that's our job today and tomorrow and in perpetuity until we see equity to disproportionately reallocate resources until we see equal numbers in outcomes. Thank you. Hi, I'm Candice Hindley with the Blue Hat Foundation. And one of the things that I'm thank you so much about your slide for health care disparities because it's definitely with spot on. It's a lot of times that it's not addressed properly and it was I mean everything that you had on your side was spot on. One of the things I always like to ask doctors when they're prescribing treatments is to take the moment and look at your patient and ask themselves does the treatment match the life? Because a lot of times patients especially low income patients they don't have the opportunity to take off work. They don't have the opportunity to have treatments that may cause more harm than good. So is that something that you think would be feasible that can be added in the questions that were added in when doctors are evaluating patients or treatment? Does this treatment match the life and can they alter the treatment so the patient is still able to maintain a lifestyle that's not going to impair them? Absolutely. That's the other hat that I wear is thinking about this very thing how culture, race, class, socioeconomic position and social identities impact people's ability to share in treatment decisions. And for those communities or populations that have traditionally had less of a voice it's hard for them to articulate the reasons why it's more challenging for them to be adherent to a plan of care or to voice their preferences about plans of care that may reflect either personal preferences or lifestyle barriers. And so how can we as physicians and as health systems try and change ourselves to meet the needs of patients where they are? And certainly I'm thinking about those considerations is a core part of how we should be addressing marginalized populations in shared decision making and clinical care delivery. Absolutely. So this is the second year in a row that I've cried in front of this audience and so I just have to apologize. But thank you again for your patience and for your very engaging questions.