 Hello everyone, and welcome to today's session of the Harvard Medical School Organizational Ethics Consortium. I'm Kelsey Berry. I'm one of the co-chairs of the consortium along with Charlotte Harrison and Jim Saban. And today I have the honor to be your moderator as we hear from three experts on the ethics of pursuing racially concordant care as an organizational strategy to reduce health disparities. So first a quick note about this series. We are in our first consortium of 2021. So we first have to welcome everyone to this bright new year. This consortium is now in its seventh year hosted by Harvard Center for BioEthics. And it really aims to build a learning community of practitioners and scholars around the topic of organizational ethics in healthcare. So our programs this season to date have examined the role and responsibilities of various health system players in laying a foundation for health and flourishing in our communities as well as the very challenging work of building equity directly into organizational practice with as always a constant eye to the ethical questions that frame these issues. How do we analyze, advocate for, act upon and ultimately hold ourselves accountable for our value based commitments? Particularly when there is often legitimate disagreement over values. And how do we make good on our value based commitments within the organizational reality of limited resources, systemic constraints and uncertainty? We hope that you'll all consider yourselves a part of this dialogue and community and join us again for upcoming programs which I'll describe towards the end of the session today. But back to today. Racial disparities in care are one of the most pressing and persistent injustices of our time. Prompting many healthcare organizations to ask what they can do in their own house that will yield substantive health gains for black patients in particular. But how should managers translate an evidence base into organizational action on health disparities? As we turn to that issue, we'll be guided by three experts in management, ethics and history to the evidence for racially concordant care and then together scope out the moral and ethical terrain that shapes the actions a manager might take in response. So a word to the audience about your own participation in today's program. There are two major opportunities to participate today. So one, you can submit questions for our panelists at any time using the Q&A feature. Selected questions will be discussed at the end of the discussion today. And then second, we'll have a fairly robust discussion part way through the program today and during that case discussion portion, you can use the chat box to share your thoughts or we particularly encourage you to use the hand raise function to signal that you'd like to speak and then you'll be called upon to unmute yourself and you can share your comment and thoughts verbally. If you run into technical difficulties or questions about that, just shoot a note in the chat box and our staff and we will make sure that you have the opportunity to participate. So I have the privilege now of introducing our panelists. We first welcome Osase Udabala. Osase is a fourth year medical student at NYU. He is a thinker, an engineer and physician in training whose work lies at the intersection of healthcare, management and innovation. A graduate of Cooper Union and MIT Sloan School, Osase's professional background includes management consulting, early stage drug discovery, business development and venture capital. We also welcome Lauren Taylor. Lauren is a postdoctoral fellow at NYU Grossman School of Medicine in the Department of Population Health. Lauren's current work explores the ethical challenges associated with managing healthcare organizations and markets. Her research has been published in academic journals such as Health Affairs, Hastings Center Report and Kennedy Institute of Ethics Journal, as well as news outlets such as the New York Times and The New Yorker. She trained as an oncology chaplain at Massachusetts General Hospital and in the Office of Ethics at Boston Children's Hospital. And finally, we're welcoming Adam Biggs. Adam is an instructor in African-American studies and U.S. history at the University of South Carolina Lancaster and he also recently defended his Ph.D. dissertation in American Studies here at Harvard. Those research explores the roles that Black doctors played in the desegregation of Harlem Hospital and examines their efforts to use professional medicine as a tool to advocate for racial improvement in the first half of the 20th century. We're so thrilled to have the three of you with us. So with that, I will turn it over to Lauren and Osase to get us started. Thanks so much, Kelsey. It's fun to be back at the Organizational Ethics Consortium and I'm thrilled with this turnout. I have to say because I'm just going to share my screen here. Oh, yeah, I really shared my screen where Ashley just walked us through this. I'm so, oh, let me re-share so that you don't have to see all of my emails pop up. I was just going to say I'm so thrilled to see the folks who are joining. I just took a quick scroll through the participant list. And my goodness, we certainly have experts on the line. So I really hope our goal today is to make this as interactive as humanly possible in spite of it being over Zoom. And so I really do hope that you'll kind of use your voice, use the chat box, and chime in because this is not designed to be a lecture. It's meant to be kind of a cooperative endeavor where we explore the complexity of this question. And that takes kind of a little bit of effort on everybody's part. So we've tried to think hard about how to set the stage, but we really, really do invite you to please speak up, raise your hand, use the chat box, and engage with us whenever and wherever you can. So my goal here is just to kind of set the stage a little bit. As Kelsey previewed, the way that I thought we would use our time together is I'm not going to do an in-depth literature review of what we know about the research on racial concordance. That would take certainly the full 90 minutes, if not more. Instead, I'm going to try and give you a taste of that literature. So Spotlight, three fairly recent papers, just in case you're coming to this with an interest in racial disparities or health equity, but you might come and have no idea what literature we're talking about. So I'm going to try and set the stage. Then, as Kelsey previewed, we're going to set up a case. And both Osase and I were trained at business schools. So this is kind of a common pedagogical tool there where we'll outline kind of the contours of a dilemma. And this is where we're really going to be looking to you to jump in and participate. Tell us how you would see the case, what you think you would do. That's going to last about 20 minutes. Then we're going to invite Adam, who is our true expert on the panel, into the conversation. He's going to bring this fabulous historical perspective that I think, frankly, is often missing from the bioethics discussion. And we really want to kind of learn from him. And then we will kind of towards the end have an open forum Q&A where we won't try and pin you into the case study parameters quite so much. Instead, we can let that conversation drift and kind of travel where it will. So that's a rough outline of how we'll use the time. As for this literature, I said I'm just going to give you a taste. So this is the paper that first sparked certainly my attention to this question of like, oh, okay, what are the implications? It was a paper published in the Proceedings of National Academy of Science. So incredibly prestigious, high flying journal. It just came out in 2020 in the spring. And the question that the researchers asked was as follows, does physician-patient racial concordance improve infant mortality outcomes? This was a retrospective analysis. Again, I don't want to go too deep into the specific methodologies and design, but it is worth noting it was retrospective rather than kind of a randomized control trial that would be prospective. They considered the assignment of physicians to infants or newborns to be quasi-random. Very big data set. And here's kind of top-line findings. Findings were that newborn physician racial concordance, meaning when you had a black baby born to a physician who was themselves black, that was associated with a significant mortality improvement for those black infants. There did not seem to be a statistically significant improvement in kind of the mother's health or the mother's outcomes. And the authors note that the benefits here were especially kind of observable when you had what they considered to be complicated births in hospitals. So they were able to look at a little bit of information about the type of admission and the types of things that had gone on in the hospital and where the case was more complicated, the concordance between the race of the baby and the race of the physician seemed more salient. I should also just note there may be people on the line who are actually authors on some of these studies. And if you are an author on one of them, I especially invite you to speak up in the chat or when we're doing the Q&A, we would love to hear any additional kind of caveats or nuance you want to add here. But that's a snapshot of this Greenwood paper. It received a tremendous amount of crash. CBS News picked it up, CNN picked it up. And the kind of headline that people took from this was that when black babies in particular have black physicians, they do better, period. And so this was used to kind of motivate a discussion just like the one we're having here about the diversity of the physician workforce. But also I think, as we'll get to today, maybe some more difficult questions about, well, in the short term, when we've not yet solved the pipeline issue, what do we make of this research finding and what should we do with it? A second, just again, taste of a paper was this kind of Aslan paper. It's only about two years old. I guess now we're in 2021. So three, this was an NBR working paper, but incredibly rigorous methods. And here the question was again about racial concordance, but a different patient population. So here the question was, do black male patients, apologies, this should be capitalized, randomized to black male doctors actually wind up following through asking for it and taking up additional preventive care. This was out of Oakland. Here you actually did have a randomized control trial design. So that makes it different. And someone say a stronger design from the previous paper we talked about. It was based in Oakland, California. And the big kind of outcome measure here again was uptake and preventive services. The key finding was that black males who were matched with black physicians were more likely to select preventative services after consultation with black physician. And so the big kind of when they modeled this out and they said, okay, well, what could this do on a population basis? The takeaway was that black doctors could reduce black, white male gap in cardiovascular mortality by something in order of 19%. So you get these like huge implications when you take the study findings and you kind of blow them out to a population basis. And then finally just one other taste. This is the paper by Andrew Hill and colleagues again from 2018. And the question here was, so now in a hospital setting, so this inpatient whereas the previous study I just showed you was outpatient, does doctor patient race match impact patient mortality? This was not an RCT, it was a retrospective analysis using I believe the same dataset from Florida as the first study. And the key finding was that the kind of racial concordance here substantially reduced the likelihood of in-hospital mortality on the order of 15%. So another like pretty eye-popping finding in my mind. And here, as in other cases, the findings were driven by black physician-patient race matching. So I just wanted to again give you a taste and we could go deep deep into a methodological analysis, but I just wanted to give you a sense for what are we talking about when we even raise the question, like what are the implications of this literature? These are the kinds of studies that populate this literature. And I would just say on the whole, I think there's an informal count if my nosing around is right of somewhere in the order of 15 to 20 papers that take up similar kinds of questions about the benefits or the potential benefits of racial concordance. They take up that question in different parts of the health system, inpatient, outpatient, community settings, clinical settings, and they take it up with a fairly vast array of patient populations. So you saw infants delivering moms, African American men, you know, you can slice and dice the population in a bunch of different ways and ask a lot of different questions. And there's not uniformity on that front at all. But the emphasis is when you think about racial concordance, we could of course be thinking about any race of people, but the emphasis on this literature is on black patients. There's a range of outcome studies. So some think about behavioral stuff like the second study where they're asking about uptake of preventative services, and others are really focused on outcome outcomes like mortality. And that's not standard, but both have been looked at. And the methodologies are variable. So most are retrospective, a handful use prospective randomization, but I just want to note that. And then the effect sizes, of course, are also variable. Some are quite substantial. And I would say just in the kind of name of transparency, there are some findings that show no effect. That it doesn't matter what the racial concordance is between a physician and patient. It doesn't seem to matter. Black patients do justice well with white or other race doctors, as they do with black doctors. But I haven't yet seen a paper that shows any kind of harm. And I think that's important as we move into the study, just to keep in mind. So bottom line here, I would say, I think this literature is like far from ironclad in the sense that there's a little bit of a scattershot quality to it. But generally, if you kind of squint and just say, okay, holistically, what should we take from it, it does appear that racially concordant care for black patients appears to be beneficial. There's lots of things that we can and will, I hope, explore about why that might be. There might be some publication bias. There might be other things that are driving these effects. Wet your palate before we move into the case study, which we're going to do right now. So I'm going to hand it over to us, Asi. Thanks, Lauren. Just as a quick backdrop, Lauren and I have been thought partners in preparing for this symposium. It's been an absolute pleasure to be working together and also to benefit from Adam's expert historical counsel. As Kelsey mentioned, as Lauren also alluded to, and as I passionately believe, this is a very timely topic. So I'm glad that all of you who are attending are here and able to participate in the discussion. I hope it's helpful and at least thought-provoking. So if you wouldn't mind, Lauren, starting with the first part. So here is a case set up. Please put yourself in Dr. Pollock's seat and thank, please, you know, as we, as we, as I continue to give information, just think about how you feel. And when we, when we ask you a question, there's going to be a poll at the end. Don't think too much about, about your reaction. We really want to get your sort of like knee jerk gut reaction first, and then we'll have a little bit of a discussion about, you know, where that knee jerk reaction comes from. Okay. So this is Dr. Pollock. She is the chief medical officer of just healthcare, a delivery organization that holds financial risk for 200,000 plus patients. She's very committed to using organizational policy to pursue health equity. So Dr. Pollock has reviewed the literature, the literature that we just discussed and, you know, many other, you know, studies that have been, that have taken place on racial concordance and its benefits or, or risks. And it's considering rolling out a new program to try and match the organization's black physicians to black patients more deliberately. A few points to, to elaborate here. Number one, the program would rely on racial self-identification. Number two, the program would be opt-in for both patients and physicians. So there's no coercion here. And number three, the program would begin in an outpatient setting. So, so with all this in mind, also Dr. Pollock recognizes that black patients have commonly sought out in the past, rationally connected to cordon care, through informal referral networks, in hopes that a program like this would lessen the required leg work for those patients who opt-in. Dr. Pollock also believes that the literature is strongest with respect to black patient outcomes and the moral urgency to improve black, white disparities in healthcare, and particularly justifies an initial focus on this patient population. So with that said, thank you for opening up the poll. Ashley, the question is, if you were Dr. Pollock, would you support the implementation of a race-based, race-based physician-patient matching system? Like I was mentioning, you know, whatever your knee-drick reaction is, please, please enter it now. We'll have people not necessarily defend, but just sort of elaborate, you know, the different dimensions along which this type of consideration might take place. Super. And let's give, yeah, we'll give it another maybe 30 seconds or so for folks to give us a reaction. And then, oh, this is so interesting. Are you able to see this Osaze? Yeah, I'm looking at it too. That is great. Yeah, I know. Okay. I can't wait to share them back with you. All right, people, get your, get your voices ready. A few more seconds. Great. All right, so you should be seeing the results now, and I'm, I'm frankly a little bit surprised and delighted. If you were Dr. Pollock, would you support the implementation? Yes, we got 82% of you to go in on yes, and no, we've got just under 20%. So 18%. First thing Osaze, we're going to kind of co-moderate this, folks, but Osaze, surprise? Me personally, based on that. Yeah. Yeah, I mean, let's, let's definitely get some, some thoughts first. I think I was surprised personally, personally. We'll see how people feel at the end. So question number one, feel free to either, you know, raise your hand or type something in the chat box. You know, what were, what were, you know, considerations that you had here? What were you trying to sort of optimize? What were you most concerned about? I see Susan Parker's hand up, so I'm going to allow you to talk, Susan, and chime in, get us started here. I, as a clinical geneticist, do not know what that program would mean by race. I don't know what race is. It sounds to me like the program would be moving toward the Hopkins Colored Clinic from the years past that ended up with the Henrietta Lacks problem. And it sounds discriminatory, it worries me, and, and it frightens me as a concept. I agree that if people whose skin is darker than some other people feel more comfortable being cared for by people whose skin is darker, then that would be a noble effort. But if people would feel that something will be wrong with the care that will be received because it will be somehow lesser quality, that scares me. So you could call it Brown and Black Clinic, but that also has very negative flavor. And with the amount of what we're learning of Black resistance to vaccination based on Tuskegee and all of the discriminations that's already gone on, I would think this could end up feeling highly discriminatory and worrisome. It would have to be extremely well managed and thought through for terminology. Great. Thanks for getting us started, Susan. There was a lot there and I'm going to just bring in a couple more voices to respond before either Osaze and I start responding. So I see Bob Trugue, Keisha Ray, and Tomiojo. So I'm going to go in that order. So Bob, you should be unmuted now. I'm assuming I'm unmuted. Yeah, I can hear you. So it doesn't seem that complicated to me. It seems that people self-select their friends, their business partners, their doctors. I don't know that I've ever really done this intentionally, but every primary care physician I've had has been male and roughly about my same age. So what's driving this seems to be ubiquitous and to make it a little bit more simple. I mean, you said that they're self-identified. It's not that we're assigning people to particular races that in a way that would be discriminatory. I mean, these are how people have self-identified and it seems to just be facilitating a process that goes on all the time. Great. Thanks so much, Bob. I'm going to go to Tommy next. Hi. So I'm Tommy. I'm a fourth year. No, that's okay. Fourth year med students also at the HKS, getting my MPP. And this is really interesting to me because I think a lot about Black women when I hear wanting to have a Black OBGYN, given everything we hear about racial disparities and maternal mortality. And so in my mind, when I read this, I thought, wow, it would be awesome that health systems have a way to make this easier for them to do. I think similarly to what was just being said is that we also already kind of naturally select this. But at times, but because there are less Black physicians, it would actually be really helpful to give people a resource, I think, to make their care racially concordant if they want to. And if there are physicians as well who say, I don't, all of my patients don't necessarily need to have the same race as me. But if there are people who feel more comfortable because of who I am in my background and experiences, potentially, why not make that available to patients and physicians? Thanks, Tommy. Keisha. Keisha, it looks like in order for me to allow you to talk because you're using an older version of Zoom, I have to promote you to panelists. So I'm going to check in with our tech folks. Ashley, could you give me a heads up on what the best thing to do here? Looks like she's in. Oh, perfect. Is it okay? Yeah, fire away. Okay, sorry about that. So really what I was basing this on is whenever I give presentations on racial disparities in health and Black health, there's always people in the audience who talk about how their life changed once they had a Black physician. And I have my own personal story. My life changed when I finally got a Black dermatologist after decades of mistreatment, basically. So when I looked at this, what I ultimately cared about were patient outcomes. I think it's okay in this instance to use self-identifying information. We're not forcing it on people and saying you are strictly into these racial groups. It's self-identified. And sometimes, even in this audience, I'll see that there are white patients who prefer Black caregivers for various reasons. So I think it's really just, it's really increasing these freedom of choices and allowing patients to seek out the best outcomes, just like we would for any person that wants a particular doctor for whatever reason. Thanks so much, Keisha. Everyone should know Keisha is a bioethicist in her own right and a real expert on this as well. So we're grateful to have you here, Keisha. Beverly, I see your name next, so I'm going to hit allow to talk. And why don't you chime in? Oh, for one moment before Dr. Wilson chimes in. I was hoping that after those comments, we could pop over to the chat because there have been plenty of discourse in the chat and then stop to sort of summarize some of what we've been hearing thematically. This is why there's two of us. So that's a perfect, let's let really chime in and then we'll go over to the chat. That's the right idea. Well, first of all, thank you both and all of you actually for putting forward this program is highly timely. Of course, healthcare outcomes, that's everyone's goal to get the best care to those who are seeking it. It bothers me only a little in terms of that people have to be selected out. However, the overall goal of getting people to be free to voice their concerns, having practiced medicine 30 years, persons reveal more when they feel more comfortable. When you identify with your caregiver, whatever that reason might be, be it race, socioeconomic status, where you live, where you're providing your business, whatever it is that they identify with that level of comfort makes them more likely to give more information to you provide better care. So simply making that available. I don't think it lessens the care that we're going to give. I hope that it won't be perceived as being discriminatory in a reverse manner because ultimately everyone's goal should be the same, improving healthcare for all persons. And of course, people who are brown, people who are black, people who are white, whatever their color, they're all part of the human race. So that's what we're here to promote. So this is just one more method of getting that accomplished. So hats off to everyone on the panel. Thanks, Pamela. Oh, sorry, do you want to go over the chat? Yeah. Okay, let's see. So Lachlan Foro, I hope that's appropriate pronunciation says, I voted no. I think it's possible to design systems that make it much easier for patients to choose colonitions based on their, you know, clinical matching, matching preferences that are not explicitly race-based. So steering away from race-based choice systems. Catherine Saylor says, Optin and self-designated racial category made me more willing to vote yes. So I'll come back to that too because I'm hearing a lot of that. Dr. David Neal Sontag says, we have evidence that we could improve care for a particular population without detrimentally affecting the care of others. Why would we not use it? This is only self-reported, or this is self-reported race identification. My only hesitation is that the perpetuation that race matters, which it does, given our current situation, but arguably shouldn't, which is a great point that we'll also come back to. Donald Pathoff says, you know, a very good point while I've articulated colorist question mark promotion as part of the framing of the question issue. So again, this color piece of sort of reinforcing race-based differences. So we're hearing a lot of that. Ms. Christine Mitchell says, I think the case that, what setup is Dr. Pollock's preference, but in my own view would be to leave more control about whether slash when slash how to race match should remain with the patient, maybe with a soft nudge through information. So some grappling there with patient autonomy, whether it's explicit or sort of implicit. Nikki Tenerman says, since both physician and patient would opt in, I wonder if the program would draw those who are motivated slash interested in thinking about how racial importance impacts care. It might end up with self-selected patients and physicians who care about matching preferences. So there's something there to speak to selection and the consequences of selection, how that might impact care as well. So I wanted to maybe take the prerogative, just because I know both Laughlin Farrell, who is an ethicist, and Bob Trug, who is an ethicist. And I feel like I hear them saying slightly different things and I wonder if either of them would chime in again. I feel like Bob said to us earlier, I don't see any problem here. As you said, Lauren and Osasi, people do this naturally and informally. So we're just making something more formal and maybe easier for people to navigate than it already is. But this kind of quest for racial concordance is already happening. So kind of shrug, what's the big deal? Maybe I'm overstating it, Bob, but a little bit of that. And then I heard Laughlin saying, oh, I would really like, I'm happy with people doing these things informally, but I really don't like the idea of going to an explicitly race-based kind of matching or concordance system. And this is something that I think you and I have really grappled with is, to some extent, we use the example of if you're a manager in an oncology clinic and you kind of hear that a bunch of your patients are seeking out Reiki care or whatever it is, right, as some kind of complementary therapy or what have you. And then I think most people think good management is saying, oh, well, if there's an evidence base for that, I should bring that forward as kind of an entitlement of being part of my patient practice. Like, I should make that a formal thing that they can access so they don't have to do the live work to go out and do it themselves. And I guess the question that I would just put back to both of you, Bob and Laughlin is like, is this different? Is it different as a manager to formalize something around kind of the quest for racial concordance than it is to formalize other kinds of services or, yeah, kind of amenities for a patient population. And we're either either of you may be swayed by the other's concern or lack thereof. Laughlin, I see your hand. I'm gonna unmute you here or allow you to talk. I guess I put in a bunch of other comments. And I don't know, Bob, and I disagree. But often when we do, I think he's probably right. But my highest level concern is that we need to do things that as urgently quickly as possible, improve race-based disparities in care, but in ways that will bring us closer to where we really want to be. And my concern is that this can leap out to Dr. Pollak as, oh, now I fixed something. And now I contribute to a culture where black, black concordance in patient providers is like, that's a good thing. And then when it's not happening, we worry, oh, maybe it should be happening more. And then we've deepened the race-based identities that are part of the disease we're trying to cure. And as I said in the chat, my last comment is, I think the single most important step that Dr. Pollak needs to take, and all of us do, is to not think we're so smart, we've got scientific literature, we're going to fix the problem for these other people, but to invite the people who are experiencing disparities as partners and figure out what's most helpful. They'll have lots of other ideas. They aren't specific to black patients. And I think things may grow from that. And it might be that you come out of designing that, that from them, they want to have the ability to specifically match by their identified race, not just for black patients, but Latinx and others. But in that conversation that's deeper, we'll be learning about the pros and cons, including the Spanish-speaking providers in our primary care practice who have disproportionate numbers of Latinx patients. And that not only means that they have fewer of lots of other patients that they actually would like to take care of, but they also know their colleagues are not learning about Latinx culture and all of those things. And it is not getting as close to where we want to go. So, you know, as people in Nome know obsessively, I think there's a both and and and path here that we have grossly oversimplified by saying, oh, we've got this data, now we're going to match by race, Kumbaya. Thanks, Laughlin. Bob, do you want to chime in briefly and then I'm going to turn it over to Adam to join the conversation next. Sure. Just really briefly, I think there's a tension here between us always saying that race doesn't matter. We don't want to reify race, we're removing race from all these metrics in medicine. There's a tension between that and the reality that race does matter, as shown in the evidence that you presented at the beginning. And to the extent that we already permit people to choose their providers in so many ways, why would we say that race is the one thing that we're going to exclude? I mean, it seems to be sort of saying, oh, you know, all these other things can matter, but you can't let race matter. And that just seems illogical to me. Yeah. Great. Thanks, Kumb. Osaze, any last comments on what we've heard so far before I turn it over to Adam? In the interest of time, let's definitely turn it over to Adam. There's plenty more that's super valuable in the chat, but yeah, let's give some space for Adam to react. Great. Adam, tell us what you think based on what you heard and all that you know. I just want to say I really appreciate you guys setting this up, and I love the richness of this conversation. And this is really fascinating to me in a lot of different ways, thinking about this from a historical perspective. And I guess one of the things that I have to ask is that when we see numbers that high, 82% of people in favor of this, are we sort of underestimating the role that white supremacy still sort of maintains within our patient population? Because when I'm hearing this conversation, I mean, I'm sitting in Lancaster, South Carolina, and I realize a lot of folks here are in Cambridge. And I can tell you, those are two very different places. And also, who's in this room is actually sort of a very different sort of group of people. And I think we may very well feel like there are more folks who have certain levels of racial enlightenment, if we want to call it that, who kind of challenge whether or not race is actually a meaningful kind of intervention. I wonder if that doesn't put black doctors out of business, right? Like if you say that we are going to match in that particular type of way, do you allow white patients to make those same decisions? And if you do, are you effectively limiting what kind of opportunities black practitioners have to practice medicine? And Laflan sort of mentioned this, I think, is what he was kind of getting at here. I think it's a very kind of interesting kind of dilemma to actually sort of to raise with this. I wonder if we were talking about surgery, if people would feel about it the same way, you know, when we're talking about general practitioners, when people are dealing with chronic diseases or coughs and headaches and that sort of thing, if we are more comfortable with the idea of assigning black doctors into these roles, would we allow patients who needed surgery, thoracic surgery or other sort of complicated procedures where there are disproportionate numbers of black patients in those positions? But also, those are things that surgeons and residents sort of compete for is the opportunity to get these types of procedures. What kind of tensions, sort of class tensions within medicine would sort of present themselves there? When I think about this historically, I think part of this is interesting because when we talk about, I mean, my work looks at the desegregation of Harlem Hospital in the early part of the 20th century. And so one of the things that happens here, this happens in the 19, starts in 1919 and ends in 1935. And in the wake of World War I, one of the things that happens is that with the influx of African Americans into Harlem, there is a push to bring more black practitioners onto Harlem Hospital staff, right? Black communities are getting a larger voice in Harlem because their numbers are growing. And there is a push for really about a 10-year period to integrate the Harlem Hospital staff. This is an epic battle that kind of takes place within Harlem and within the medical community in Harlem, between black practitioners and white practitioners on staff over how to integrate this process, how to integrate the institution, and who among Harlem's black medical community should be sort of integrated and added into the institution. There is a major reorganization of the hospital governing system in 1930, one that brings a slew of black practitioners onto the staff and actually oust several of the white practitioners who had been there for a long time. This does not end the conflict. After this, that moment takes place, there is a conflict that emerges within the black practitioners of Harlem about who should gain access to the staff, whether those who are trained at institutions like Harvard and UPenn, whether they should, these elite institutions, whether they should be given priority to serve at these institutions, or whether practitioners from Mahary and Howard should be given priority to serve at these institutions. And it is very much a question about what type of institution Harlem Hospital is going to become. Is it going to become a cutting-edge research institution, or is it going to become an integrated cutting-edge research institution, because there are a lot of black patients who come in that need surgical kind of interventions, there are a lot of different types of medical research that can be done at Harlem because of the population they're serving. Or is it going to become at institutions that is dedicated to the training of black medical personnel? This goes on until a riot breaks out in 1935, and the discussion about who gets into this hospital changes. But what also changes is the perception that patients in Harlem have about the hospital itself. Once it becomes a black institution, patients aren't as enthusiastic about going there. And a lot of them, when they have the opportunity, they will go to other institutions in New York to get medical care. This is sort of a condition that runs throughout the better part of the 20th century. I think it was 1967 when Martin Luther King is stabbed in Harlem, and they are looking for a place to treat his wounds. And there is a debate, because he's in Harlem and they take him to Harlem Hospital, but before they actually treat him, there is an ongoing, I mean, a rather vigorous debate about whether or not they should treat him at the black hospital. And it takes the chief of surgery, Aubrey Nard, he has to go and convince the kings on to Raj and the mayor and other local political leaders who are there sort of debating this about, he has to convince them that the doctors at Harlem Hospital can actually care adequately for King. They treat his wound, he comes out just fine. And at the end of this, one of Kings on to Raj comes up to him and said, you know, I thought Aubrey Nard was a fancy white doctor. I think we want to be careful. And I think the results of the studies that Lauren shared, I think they are meaningful. I think they tell us some things that we do want to be conscientious about and considerate about. But I think we also don't want to overestimate the extent to which black patients actually want black practitioners. And part of that I'm going to share my screen with you. This is a quote from the autobiography of Damon Tweedy. Some of you might be familiar with this already. Some maybe not. And let's see. Is that coming through, guys? Okay. Things are kind of moving strangely. We could see your screen. It was just end of slideshow. So I think if you just go kind of click on the slide and reshare, it'll be good to go. Sorry. I have no worries. Is that up now? Nope. Not yet. There we go. Okay. So Damon Tweedy, who is a practitioner at Duke now, right? This is from his autobiography in 2015. And he is not the only black practitioner who mentions moments like this. Ben Carson mentions this in his autobiography. And several other autobiographies of black physicians that I've read. I mean, almost two a person mentioned incidents like this. But he was treating a patient who had sickle cell anemia. And when he came in, this is the reaction that the patient had for him. I'm going to read it out to you to just give you a sense of some of what his encounter was. He says, come on, man. We both know what the deal here is. I'm sure you did good in school and everything, but they're passing you off on me. And they think I won't care because I'm supposed to be a dumb nigger. Go tell your boss I don't want no black doctor. I didn't come all the way to Duke to see no black doctor unless he's some kind of expert. I could have stayed home if I wanted to see a country as doctor. I ain't going to be no guinea pig. And what I think, like I said, what he is articulating there is not in any way kind of unique. And the evidence I'm kind of bringing you, bringing to you with this is fairly anecdotal. But I think it makes the case, I mean, that there is a range of attitudes that black communities hold toward black physicians. And I think when we talk about how we are going to make these kind of decisions, I think this is something that we should consider and continue to sort of take into account. It's not clear to me that, I mean, these attitudes, I have disappeared in the last 20 years all of a sudden. I think it actually is kind of like absurd to kind of make that assertion. But if we want to sort of promote this idea, then I think it really does require almost sort of a granular level of sort of analysis and interpretation to think about how we can apply it. And I'm wondering, should I just kind of stop right there for now and we can kind of. Thank you, Adam. Yes, we're, so I wanted to thank the three of you and all of those who shared in the chat box and also verbally for starting to scope out this moral terrain, which is clearly many varied. And also for thinking about how we, the core question here is not just what managers could do, right, but what they ought to do, what kind of an institution do they want their institution to become as Adam forced us to think about. So for those who joined late in the event, let me and for everyone, let me encourage you to start sharing your questions using the Q&A function. We're going to come to those a little bit later on. And before we do that, though, I did want to give Lauren and Osaze and Adam a chance to reflect on what they've shared so far and maybe ask a question of one another if they'd like to do that. You know, I'll just call out right now the conversation that's going on in the chat right now. I'm finding incredibly rich. You know, we, before this symposium started, we said that there was a risk that we wouldn't be able to fit everything in within the 90 minutes. Clearly, that's going to be the case. There is discussion about internalized racism. There's discussion about, you know, sort of backfiring. There's discussion about autonomy. Much of that was captured in Adam's comments, of course. You know, I just, I think for all the attendees, if you have a chance to sort of peruse through how people have, you know, looked at different angles of this question, I think it's incredibly rich. So again, I'm very glad that we're able to have this discussion. We have, you know, over 100 people who are here in attendance. So a wide variety of perspectives. I had a question for you based on your dissertation work. And I wonder if you could share with the group, you know, a lot of your work is about the integration of Harlem Hospital. But then if I'm remembering correctly, there was kind of a subsequent effort to say, we should now start kind of a black only hospital like a segregated hospital again. And can you, I only got as far as that was a live discussion. And I wonder if you could just fill us in, because in some ways, I think one of the critiques that most stops me in my tracks, when I start to think down this path of, oh, yeah, maybe you could do a racial matching program. And it would be opt in on both sides, is I've had some folks say to me, well, that's just ushering in a return of segregated medicine. And so you have kind of the background to kind of contextualize that for us. Where did that conversation go way back in the 1930s, 40s, and did that segregated hospital actually come to fruition after these huge efforts to do the integration of Harlem Hospital? Good, because I think what you're highlighting is that how intrinsically conflicted like this discussion is like there is no real clear answer to this one way or the other. Because at the same time that we see Harlem Hospital get integrated, there's also a call to say, well, maybe we can build a separate private black facility in Harlem as well. And then that will perhaps remedy some of the conflicts that we see going on between the black practitioners there. I think one of the things that maybe we need to kind of get comfortable with is I mean, the way that actual moment worked out is that there was enough resistance to that idea. It was the Julius Rosenwald Fund, which was a wealthy philanthropic group that had a lot to do with, I mean, made a lot of substantive contributions to black medical education and black medical schools. They had sort of proposed the idea of building a separate black hospital in Harlem. And the political environment at the time just didn't really a lot for it. But I think what you're actually laying out there is that one of the things I think sometimes these conversations sort of want us to get toward is a place where we can say, we'll get comfortable doing this one way or we'll get comfortable doing this another way. And I think one of the things that sort of intrinsically embedded in this is the conflict and the tension and the indecision. Like there is no right answer on how to do these, right? There's no and there certainly is no magic bullet for addressing the problem of race. And I think when we kind of start, I mean, there was no magic bullet in Harlem Hospital when black physicians were trying to integrate. Everybody had really good intentions, right? But that did not stop these really epic and vitriolic conflicts and interactions from taking place. Like it was not, I mean, there is, I mean, I think we could say also sort of a legacy of, I mean, there's a history of black hospitals that has been sort of known for a while. And Vanessa Gamble is one of the people who have been, she's a Scott historian who actually a lot of my work is in some ways, I mean, derivative from what she was doing, right? Where she talks about some of the tensions that came up, not just in Harlem, but really in other parts of the country that also were struggling to kind of build separate hospitals and debating about what the implications that, what implications that had for integration. I think, you know, one of the things that, I mean, we talk about dealing with issues of race, you kind of have to get comfortable being uncomfortable. Well, I mean, you just have to realize that you're going to be uncomfortable in some of these discussions and that that's never going to change. I think there's such a fundamental part of what we are talking about. It speaks to our moral sensibilities, it speaks to how we understand who we are, you know, what does it, what does it mean to have a segregated or even a concordant policy, you know, beyond just whether it's effective or not, does that signify something else? Do black people stop going to a place where they know they're only going to get concordant care? Or do they flock to it? I mean, I think those are, and at one point do they flock to it? And at another point, do they not? The idea that we can sort of pinpoint one black person or the black person who is going to, you know, patronize these types of medical services and suggest that that never changes over time is also something that I think, you know, history says, you know, that, you know, that way madness lies, right? Like, these are not sort of simple, one-off sort of issues. And I think there's a level of, I mean, complexity that we can only really hope to sort of understand on some levels. That being said, you know, everything simple is false and everything complex is useless. So on some level, we're going to be, you know, we have to make decisions about what we are going to do, right? What we think is most important and then essentially accept the consequences that come with that, right? There certainly will be moral shortcomings, right? There will be moral consequences, whatever decision we sort of, we make on that. And I think one of the things that, you know, at least in looking at this historically, one of the things I have come away with is that we have to get over the idea of being the good guy, right? That so many things that everything that we do has moral implications that aren't great, you know what I mean? That will raise, you know, raise real questions about our ethical standards. And we can defend them as much as we can, but that doesn't mean we are alleviated from the burden that comes with dealing with the problem of race. Like, there are very, I mean, I don't know if there's an answer to this question. I know there's not an answer to this question. And I know there's no easy way to remedy it or to address it. And so, I mean, it takes, I mean, when you talk about being humble, I mean, I think was dealing with these issues, you know, that's what we are doing. That's what we need to do at least. So I can't help myself though, before we turn back to Q&A, you know, you are a historian. So in some ways, you have the luxury of complexity. If I put you in Dr. Pollock's seat, just like right now today, and you can change your mind 60 seconds from now, but which way would you vote on this matching program? That's, I mean, I think if it was me, at this particular moment, I would make it like a shadow program. Like, I wouldn't actually say that's what I was doing, but de facto, I would do that and see what the outcomes were. And if it seemed like it was helping people, right, then I would maybe continue to do it. I would be reluctant to formalize it though, unless I got a real sense from, I mean, I would have to come from so many different directions. I mean, patients would have to say it, administrators would have to say it, contributors would have to say it, your political, I mean, depending, obviously there are a lot of different factors in there. But I think, you know, if the goal is improving Black health, right, which I think is fun. Like if we say that's the goal, then I think you do say, all right, let's see if we can make that work on some level, right. There have been policies that have been adopted in US history. The Hill Burton Act is one of these in the mid 1940s that embraced segregation, but still effectively provided increased resources to care for poor African-American communities in the South had meaningful implications, meaningful benefits for addressing racial health disparities, okay. So that, you know, you can improve health in a segregated or there was some evidence that you can improve health even in a segregated system, but it's still segregated, right. And there's still consequences that I think go with that as well. So that's, I mean, I think that's kind of how I do it. I wouldn't say I was doing it, but I would, I would try to see if I could make that work. Yeah, yeah. Osaje, any thoughts? Sorry, on what Adam said, I just wanted to give you a chance before we go to Q&A. No, I think that I personally, you know, really value what Adam just said as a response to your question. I think that I think that there are lots of different bits of backblower sort of consequences that that can come from the optics alone of instituting such a policy or program. So being able to sort of eliminate those sort of consequences by not being public about it at first, and then sort of create like a pilot program and see how that goes and see what the sort of smartest ways are to sort of expand that type of program, you know, resonates with me quite greatly as a strategy. So I'm largely in line with what Adam just said. And I wanted to give Adam a chance if you wanted to ask any questions of Lauren or Osaje. We do have a lot of audience questions, but I wanted to reserve a moment just in case you wanted to do that, Adam. I think I actually have a couple different questions, but I'm also kind of open to bringing the audience back in. Let's go ahead and do that. There are a lot of questions here. So Charlotte Harrison has been following the Q&A and I'll turn it over to you, Charlotte, to raise one of them to begin. Oh, Adam, I see you. I'd like to say this, you know, like one of the things like not all of the comments in the chat are going to all the everybody, all the attendees as well. There is just a, I mean, there is a rich discussion going on in here, folks. And I want to reach. Yeah. So I just want to say this is great. Great. Well, we are thrilled. Thank you, Kelsey. And thank you to the audience for the excellent questions that are coming in. So I want to start with Robin Pierce. Here's her question. This may be an acceptable short-term solution, but the more important question is why the outcomes are better in race concordia situations. To the extent that this is true, what seems to be important for long-term addressing is to identify the mechanisms. It seems to be an assumption that it's just comfort with people who are of the same race. Is there something else going on that can be addressed so that a long-term solution can be found? Yeah. Lauren, please take this home. I'll give a first pass answer. I think to address the first question, as I think was alluded to in the question, the benefit seems to really come from trust and comfort. And Lauren and I and Adam have spent a lot of time talking about why that is the case and why that's something that patients find valuable. So I'll leave that for later. In the second part on the long term, perhaps obviously, perhaps not obviously, I think has more to do with systemic racism and the broad, broad impacts of systemic racism on the delivery of care. Of course, there's no one easy solution that you can kind of snap your fingers and suddenly solve systemic racism. Racism is not a construct that occurred overnight and definitely is not something that will sunset overnight, which is why it makes more sense to think about that in the long term. But in the short term, there's definitely a way to or there's definitely something to racial concordance that provides benefit for selected groups of patients. And that really is the core of why we wanted to have this conversation. Lauren, would you like to add to that? I would just underscore, I think as you'll see, I've got three takeaways at the end of this and this idea that race seems to be proxying something in the literature and we're not quite sure what it's proxying is one of the big points that I've really come to in conversation with Osase and Adam. When you read the papers carefully, we know we have racial concordance and we know we have some set of outcomes, but we don't really know through what pathway the racial concordance appears to be increasing, say, hospital mortality. And as Osase started to say, the papers give various kind of, they float ideas. Maybe it's about trust. Maybe it's about communication. Saying maybe it's about trust is a whole black box unto itself about what goes into trust. I'm not sure that's really a mechanism, but maybe it's about communication. Maybe it's about patients' expectations when they walk into the room. If I'm a black patient, I walk into the room and I see a white patient I expect to be discriminated against, but if I'm a black patient and I walk into the room and see a black physician, I don't carry that expectation and therefore I enter the arrangement differently. It could also be kind of an expectation going the other way from provider to patient. And this has not been nailed down in the literature. That is something that I feel quite confident about. And so I think this is something that I'm so glad the question was asked because it really just, I think, reminds us to be, as Adam said, really humble in how we try and interpret and put this literature into practice because we don't really know what's kind of under the hood, if you will, of this racial concordance. And then on the short and long term, I think this is one of the other big ideas that we're still kind of wrestling with is certainly, I think almost everyone here would agree, over the long term, I don't think we would want to see anything like a matching program indoor forever. In the long term, what we want is a healthcare system where all patients walk in with equal confidence that no matter what provider is assigned to them or what provider they choose, they receive the same level of care and they respond with the same level of kind of enthusiasm about engaging with that position. The question is, what's the best way to get there? Do we kind of, or could we, should we, use something like a matching program to buy ourselves a little time to get to that place? Because we say, you know, clearly right now, from the literature, when a Black patient sees a white physician, they're not getting the same level of care. So let's, in some ways, buy ourselves some time, improve some health outcomes in the short term and be doing background work as Keisha and others have been saying in the chat to reform the system long term and then transition back to kind of a race blind assignment system. Or does that intram measure of creating some kind of racial concordant system have such detrimental optics, it sends such dangerous signals that we think it's not worth the social cost even in the short term. And that's kind of how I see that long short term trade off. And I think I would only add to that. I mean, when, I mean, one of the, when we talk about what sort of the mechanisms are, and we sort of talked a little bit about this before, I mean, one of the suspicions that I have, and I think the incident in that Damon Tweet quotes out of sort of plays out with this, is that, I mean, Black doctors, I think get very used to being challenged, right? They get very used to being questioned and they're having their legitimacy and their authority and they're sort of undermined in some ways. And I think to be successful, they also have to develop sort of a set of shadow skills, or maybe they refine their communication skills in a way that white practitioners aren't always required to do. And that being said, they may even when they encounter patients who doubt their abilities, right? Who question whether or not, you know, they're being put off on them because they think they're stupid, right? Whether they're just being used to handle Black patients through the administrative structure of the hospital. They're able, I mean, Tweetie goes on and he says, you know, he goes through a very sort of like patient process, I mean, a deliberate process with the patient, where he goes about sort of earning his trust. And then at the end of it, the patient is very, I mean, he all but apologizes, you know, he's like, I'm sorry, you know, that stuff I said before, don't, you know, I'd be happy to have you as my doctor next time I come. And so I think, you know, that's sort of worthwhile to think about, but the other part of this is that we don't want to, you know, I mean, a lot of times people like to talk about Tuskegee as though it's in the past tense, we like to talk about Henrietta Lacks as though it's in the past tense, we like to talk about Jay Marion Sims as though it's in the past tense as though different forms of structural discrimination still don't take place in professional medicine, you know, and the dialogue that went on, it has been going on, even about how the COVID vaccine is tested, right? If you don't have research that incorporates Black subjects, then there are doubts that people have about whether or not it's effective, whether the medical interventions that are being used are going to be effective with Black patients. And I think this concern about being exploited is not something that, I mean, it's not just an image problem, I think with professional medicine, but it is something that modern practitioners need to be cognizant of, right? This is, I mean, in many ways the doubts that patients have about Black practitioners often correlate with their doubts about professional medicine as a whole. And so, yeah, I think those are just, yeah, when we talk about the mechanisms and how this works, I think those are certainly, when we say we're in a race being a proxy, sometimes it's the, the doubts about the institution that are being amplified that you see playing out. Thanks, Adam. Thanks for those answers. Given the time, I'm going to combine some threads of questions and let the panel choose which ones to pick up on. Awesome, thank you. That would be good. So we have a question from Jeff Flyer about the adequacy of the evidence base when you're making a decision that's got, you know, major trade-offs either way. Do you feel the adequacy of the evidence base is there to support a program like this? There's a related question about just the ethics of this is a long-term pipeline question, but as we talk about short-term and long-term approaches to the problem, the question is what about the ethics of making hiring decisions based upon race? And finally, the question of, in the meantime, what's being done to educate the Black population on what to look for in a clinician? And, you know, could that be a way of supporting movement, you know, relying on the autonomy of the patient to make choices? They're all great questions. So I'm going to cherry pick and start with the first question. You know, so the question was, you know, is there a sufficient evidence base to definitively make a decision one way or another based on, you know, what we have as a society have sort of collected as data to date? You know, I would counter that with the second question that Lauren, Adam and I have bounced on a lot, which is, you know, we, this is an era in which we very much value evidence-based medicine, but this may be a scenario where maybe following the evidence isn't necessarily the way to go. I'm not confident that any amount of evidence constructed any particular type of way would really be sufficient to inform a decision here one way or another, which is difficult. And we did sort of lead people down a certain path because we put them in the position of a fictional character who was, you know, considering the decision based on an evidence base. But who's to say that, you know, an evidence base is really the foundation upon which one should be primarily making this decision? So I'll stop there and leave it to Lauren and Adam for additional comments. Yeah, I feel, Jeff's question about is the evidence-based sufficient, I think is kind of him cutting to the bottom line, like, okay, so what would you do? And it's a fair question. I don't find the evidence base without a clear understanding of the mechanism. I don't find the evidence base so overwhelmingly compelling that it would feel to me negligent not to do it. At the same time, I feel like if I were running an organization in this moment, it is important to be saying, like, are there new things that we can try? Are there potentially radical steps that things that feel radical and feel uncomfortable that we should be going to try because we've known that we have these health disparities persisting for decades, maybe someone say centuries, and they don't seem to be getting better. So just continually kicking the can down the road and saying, it's a pipeline problem, it's a pipeline problem doesn't really seem to be a robust enough response. So that's the like rock in a hard place that I still continue to sit in. I think if you said to me like right now you've got to do something, you're in the manager's seat, what would you do? I think I would probably first talk a lot, maybe survey staff about what they would think about such a program since they're a key piece and you need some sufficient number to kind of opt in in order for this to even be a meaningful quote unquote program. And then if I were to do it, I think I would be very clear with myself and with patients that this was a time bound effort. So we're going to try this for six months or we're going to try this for one year. And then kind of hold your feet to the fire that at the one year mark, our hope is that we no longer need to do any kind of matching because you will be able to walk into this organization and be confident that no matter what physician you're matched with, you're going to receive the same kind of care. And if you have to re-up the program, you re-up it at one year, right? You try it for one year, maybe the outcomes still aren't the same. So you do it for another year but really force yourself as a management team to continually revisit this and always keep in mind that this is not a permanent solution and therefore the policy should not appear on the books as if it's a permanent solution. It is always an intermittent effort to tide you over to kind of a better world. I think one of the questions, and I maybe started to allude to this a little bit earlier, one of the questions that I wonder if we don't need to consider a little, I mean carefully as we talk about, you know, I mean even when we talk about this in sort of the notion of the pipeline, you know, if we begin to adopt these programs, are they only programs, would they only be adopted when we are dealing with, for example, practitioners or in specialties that had a relatively lower level of status within the medical profession, right? And part of the reason that sort of signifies to me is because that's also the same role that Abraham Flexner ascribed to black physicians in the early part of the 20th century, right? When he initiated this major set of reforms that really implemented the standards that we, many of the standards that we use today to train medical practitioners, right? The idea was that black doctors would be created just to serve black patients, right? And he said, we can have it now. 80% of the hospitals that were directed toward, that were black hospitals closed as a result of the reforms that Flexner and the AMA and the Carnegie Foundation initiated, right? And the words that he used was that they would effectively, I mean, he didn't put them this way, but they've been looked at, he assigned a place where they would be effectively glorified sanitarians, right? The question that I have, like the things that inhibit the pipeline growth, right, are still very much in place in the medical profession. And a lot of those are very much educational. Integrating hospitals in the 1960s did not expand the number of black practitioners in the field, right? It was 2%. In 1968, it was 2%. I think in 1998, I think it's maybe 6% today around that, right? Six or 7%. There is a lot of critical soul searching that we would really need to do to say, we are going to bring more black practitioners, black doctors in to serve in professional medicine, some of the fundamental notions that we have surrounding ideas like merit and good medicine would have to be interrogated much more thoroughly than I think we are generally comfortable doing, right? But that being said, I mean, if it is about outcomes, right, then there may also be, you know, room for elevating the role of the nurse practitioner in this, right? Where we might say, you know, if we don't necessarily have to speak only about trained MDs, but what about sort of elevating the allied professions in ways that would also be more likely that it don't require as much of an investment of time and effort and money and resources to actually complete, but would perhaps allow us a means to bring more black practitioners into the practice of medicine. And while they might not be certified MDs, they might very well be capable of providing the type of interventions and care that would stand to improve black health. Thank you, panel. Thank you, each of you. And I think that although we've reached the point where we have to turn to the next part of the program, I want to just share a point made in one of the questions that I imagine the panel would endorse what I want to comment on if we had more time, which is that while it's important to focus on the clinician relationship and the specific example that's given here, this doesn't address biases across the institution, the infrastructure, the policies and so forth, the climate of an institution that could affect the way care is delivered by all practitioners. And that is just a topic that needs further discussion. And if I can just amplify that a little bit, if we are talking about money, nobody ever says, well, they had an intention to make some money, right? The business failed, but they had good intentions. But when we talk about race, all we talk about is intentions, right? They had good intentions instead of talking about outcomes. And so I think when we talk about the institutional inhibitions, right, the way that structural forms of discrimination continue to operate within the medical profession, it's not because there's some explicit policy that says black people can't do this or black people have to do this. It's because there are these larger structural systems that inhibit black health, but also inhibit the careers of black practitioners in many ways. I want to make sure that we get a chance to thank all of our panelists. But first, just spend a few minutes, if you'd like, the three of you to kind of bring us home if you had any concluding thoughts or points that you wanted to make before we thank you for the day. Well, Kelsey, we were hoping to repoll quickly and see if folks could give us a pulse check. Osaze, do you want to say a little more? Yeah, Ashley, you wouldn't mind bringing up the poll again. Now that we've had this extremely rich conversation, the audio of which only captures the tip of the iceberg to be completely honest. We want to know, again, same situation if you were Dr. Pollock, would you support the implementation of a race-based physician-patient matching system? The responses are already fascinating. So we'll give people a few more moments to consider between a rock and a hard place, choosing yes or no. Yes, I know it's not exactly a fair way to phrase the question, but I suppose that's sort of the point. The purpose isn't really the final decision, more so the thought process and the considerations. I'm going to ask also, if you're someone who changed their mind, meaning you were yes and you became no or vice versa, and you'd be willing to tell us just like 30 seconds of why, raise your hand because I would love to hear what arguments seem to sway, folks. All right, we've got yes still wins the day, carries the day, but it's a much closer poll. Does anyone want to share just 30 seconds if you changed your mind? Or if you didn't change your mind, we could hear that too. It does seem, it looks like we have one raised hand perhaps. It does seem that on the whole, there is a bit of a trend toward more, I don't want to call it ambivalence, just uncertainty about whether or not implementation of this type of system would be good on the whole. Yeah, Beverly, I just allowed you to talk. Would you tell us just briefly your thoughts? Yes, I still had, as I stated, the first initial reservation about the reverse racism being a concern, but more importantly, as Dr. Harrison mentioned at the beginning, the implicit and the explicit bias, it's difficult as a physician to understand how just one or two courses at the near end of someone's training would sway heavily against the bias that has been inculcated into them during a lifetime. And I think a more effective means would be really understanding. You pretty much learn most of the things you need to know by five years of age, but definitely through your primary and secondary years of education, more needs to be done to make persons less race conscious than they are presently encountering in schools so that by the time decisions are made to enter medicine, they already have a healthier mindset toward those who look different than themselves. And so I think that needs to be a part of the larger conversation in addition to making it possible for persons to choose people if they choose to do so, that look like them to provide their care. Thanks, Beverly. I'm not seeing any other hand. So I'm going to take the moment just to share a couple of final kind of, I hesitate to call them takeaways because they- Discussion points, I suppose. Yeah, yeah, thank you. So as I jump in here, but yeah, I called them takeaway challenges. You could see my ambivalence already. I just wanted to highlight three. One is something I mentioned before, but I think in the spirit of being epistemically humble in the face of this question, what do we do with this literature? I think just staying clear about the fact that we're not really sure what racial concordance is telling us, like what the mechanism is. We know that the race of the physician is serving as a proxy for something or I should say we think that it's serving as a proxy for something. And I think managing by proxy measure is always risky because you risk losing sight of the true outcome. Here, I think it's especially risky because managing by proxy, meaning setting up a racial matching program has some potentially substantive social costs as well, but I just wanted to leave you with this idea of a proxy and what is it proxying and kind of an appetite to continue to ask further questions and maybe yourself contribute to this literature about what's really under the hood of racial concordance. The second point is just that I think we need to be careful and again, humble when we think about being evidence-based managers. It's very tempting because there's so much fanfare and enthusiasm at Scenums for evidence-based management to let that drift into the practice of management and say I'm an evidence-based manager as if that absolves you of some kind of agency in making inevitably morally loaded choices. And I think that's somewhat dangerous because as we've seen, what would it even mean to be an evidence-based manager in the face of this literature? It's not necessarily clear and it's not as if looking at this evidence absolves you of the agency and making the tough moral calls. I'd also just call forward one comment. Vinay Prasad has spent a lot of time thinking about this racial concordance literature and he kind of cautions his listeners on a podcast to really be careful about saying that good things need an evidence base in order to do them. And what he means by that in relation to this issue of racial concordance is it can be enough to just say look the diversity of the physician workforce is a good unto itself. It is important to do for a whole host of reasons. We do not need to necessarily link the import of the diversity of the physician workforce to some kind of patient outcome in order to make that case. And when we cede kind of the moral argument to an empirical one and make it seem as if well it's only important to care about the diversity of the physician workforce if we can show 19% in hospital mortality reduction then we've really potentially lost something. We've certainly maybe lost ground in the argument and so I just wanted to raise that up. And then finally this last point has been coming through in people's discussion about short and long-term outcomes but one thing Osasi and I have really been wrestling with is this idea of there's contingency in how we pursue social change and because we're talking during Martin Luther King Junior week I thought it would be appropriate to bring this forward from his where do we go from here. He said the white liberal must affirm that absolute justice for the Negro simply means in the Aristotelian sense that the Negro must have his due. It is however important to understand that giving a man his due may often mean giving him special treatment and I think this really captures both a deep kind of insight and discomfort that we all share about this conversation but also the kind of managerial complexity in an organizational ethics consortium we should recognize that you can read this and say yeah man that's true but then it's left to the manager to decide the circumstances under which special treatment are warranted and what the design of that quote-unquote special treatment is that will further the goal of what he calls absolute justice or if I can borrow a term from my friend Matthew Riley who's on the line who is himself a king enthusiast you know what will further the goals of pursuing beloved community so I just wanted to frame those up as takeaways and with that I'll turn it back to you Kelsey thanks. Adam let me invite you I know you wanted to make a final comment if you wanted to jump in. Oh the only thing I had to say is just I really appreciate you guys including me in this discussion and I mean I can't see the audience folks but you know I really appreciate the level of engagement that you all have have taken part in this as well and I'm just glad to see that folks are interested and invested in exploring this topic more. I appreciate you all yeah inviting me to be a part of it. Thank you so much I think the overall comment that we can really make here from the perspective of what the organizational ethics consortium has committed itself to is just to thank the three of you for really kind of modeling for us what a learning community can look like and inviting everyone in to grapple with what is a difficult issue and to think carefully about not just health as a consideration but how do we find ways to encounter one another in relationships that are equal and that are less inhibited by some of the harmful distinctions that we have allowed to shape our reality for far too long. So I just wanted to thank each one of you and also to the audience for being so engaged. Our website shows upcoming programming we're going to transition to thinking a little bit about supply challenges during COVID-19 for organizations and some ethics consults around that in our coming program in February and we just encourage you to join us and I want to extend my deepest thanks to all of you to my co-chairs Jim and Charlotte and thank you so much be well and good afternoon. Thanks everybody.