Addressing Health Care Inequities
Racial disparities observed during the COVID-19 pandemic drew renewed attention to health care inequities in the United States and the world. The pandemic spurred an infusion of energy into Stanford’s established commitment to furthering equity in health care.
Presence. The Art and Science of Human Connection is an interdisciplinary center within the Department of Medicine whose founding goal is to produce measurable and meaningful change in health care. Under the Presence Center, the Department of Medicine built on existing programs focusing on diversity, equity, inclusion, and justice. Here are three such initiatives under the Presence for Racial Justice Lab effort, spearheaded by Presence leaders Abraham Verghese, MD, vice chair of education for the Department of Medicine and the Linda R. Meier and Joan F. Lane Provostial Professor of Medicine, and Sonoo Thadaney Israni, MBA, executive director for Presence and for the Program in Bedside Medicine.
The Meharry-Stanford Summer Research Program
What started in 2017 as a summer program for five visiting medical students has now transformed the lives of more than 30.
The idea for the Meharry-Stanford Summer Research Program was planted in Verghese’s mind when he visited Meharry Medical College in Nashville, Tennessee. There he met with a former mentee, Stephanie McClure, MD, now senior associate dean of student academic affairs. Meharry is one of the historically Black colleges and universities (HBCUs) in the United States.
Part of the Meharry curriculum includes a summer placement at a campus of another medical school, where students explore new approaches to research and medicine. Most of the placements had been at campuses close to Nashville.
When Verghese learned about this opportunity for students, his immediate reaction was, “Why not at Stanford?” Not only would students be exposed to the unique depth of research and practice available at Stanford, but also they would experience a different environment, far from home, that could help open their minds to a wider world.
With the support and sponsorship of Department of Medicine chair Robert Harrington, MD, and vice chair of finance and administration Cathy Garzio, Presence and the Department of Medicine designed a program to engage Meharry students in current research at Stanford and to build a strong connection between the two institutions.
Verghese recalls that it was a mentor he had when he was a student who saw something in him that he didn’t see in himself. That support was what motivated him to go further in his studies. “That was a powerful lesson, and one I try to fulfill with our Meharry students: to help students understand what they can become.”
“Long-term, some Meharry students may join us in the future as residents or faculty,” says Verghese. “But even if they don’t, my hope is that their experience here will transform their lives in some way.” He notes that many Meharry students have come a long distance to make it through the ever-narrowing pipeline that brought them to medical school. “I’m in awe of them,” he says. “They have a lot to teach us, and getting to know them has been a humbling experience.”
In 2017, the program began in the Department of Medicine. With the collaborative leadership of Israni; Florette K. Gray Hazard, MD, associate professor of pathology and of pediatrics; and Payam Massaband, MD, clinical associate professor of radiology, it now includes the departments of radiology and pathology. And though the COVID-19 pandemic has forced the 2021 session to take place virtually, it offered placements for 23 students.
Two Meharry-Stanford Program Alums Pursue Their Dreams
Edna Idan, MD
Passionate about serving the underserved
Former Meharry student Edna Idan, MD, attended the Meharry-Stanford Summer Research Program in 2018. She graduated from Meharry in 2021 and began her residency in emergency medicine at Vanderbilt University that year.
“The people I met at Stanford embodied the phrase ‘anything is possible’—a concept I learned from my parents,” she recalls. Idan is the first person in her family to have become a physician.
She had always wanted to become a doctor and take care of the underserved. But her experience at Stanford opened her eyes to just how wide the health care disparities gap is. “My research that summer made me even more passionate about the subject,” she says. “The experience changed how I communicate with patients, as I came to understand that just because I’m a doctor doesn’t mean a patient will automatically trust me.”
“The people I met at Stanford embodied the phrase ‘anything is possible’—a concept I learned from my parents
Working under the direction of Marcella Alsan, MD, a former associate professor of medicine at Stanford, Idan carried out research for the Oakland Men’s Health Disparities Study. She analyzed data about Black men’s distrust of the health care system.
A big takeaway from Idan’s summer at Stanford was her understanding of the importance of mentors. “I made it through high school and college fine, but things started getting difficult as I transitioned from college to medical school,” she says. “I didn’t have anyone guiding or advising me on how to study, how to get into medical school, how to stay on track—it was all new to me.” Once she found the right mentors—including Al’ai Alvarez, MD, clinical assistant professor of emergency medicine at Stanford—she moved ahead and tapped into her network for advice and support in her residency application process.
Sara Tesfatsion, MD
Confident that she can contribute
Sara Tesfatsion, MD, spent the summer of 2017 at Stanford. The program helped her solidify her desire to work in primary care and preventive medicine. She graduated from Meharry in 2020 and began her residency in internal medicine at the Medical College of Wisconsin that year.
Tesfatsion remembers “an openness from everyone I encountered at Stanford.” The program also broadened her perspective on practicing medicine. “My medical education at Meharry was geared towards underserved populations. At Stanford, we had numerous discussions about access and care for different communities, ranging from the physical exam to available health resources.”
During her two months at Stanford, Tesfatsion worked in an endocrinology clinic with Sun Kim, MD, assistant professor of endocrinology. She helped the psychology department run a study in the Mind and Body Lab. And she shadowed doctors such as Maja Artandi, MD, clinical associate professor of primary care and population health.
“The fact that someone could recognize my potential and future contribution to the field of medicine was encouraging”
The highlights of the program for Tesfatsion were her experience with Artandi and hearing Verghese speak about what “presence” means in a hospital setting for the patient-physician relationship.
“I still think about Dr. Verghese and his approach to the physical exam,” she says. “This has already influenced how I practice medicine: I try to take the time to sit back and give my patient my undivided attention. I will continue to champion the importance of bedside medicine.
“The fact that someone could recognize my potential and future contribution to the field of medicine was encouraging,” she recalls. She says her experience at Stanford “opened doors for me in my pursuit of a medical career, and I’m eternally grateful for that.”
The 5-Minute Moment for Racial Justice
The 5-Minute Moment for Racial Justice is a new curriculum that promotes racial justice and health equity during patient bedside interactions. It is built and being investigated as a set of modules to be implemented during teaching rounds.
“The United States has deep history around race and racism,” comments Samantha Wang, MD, clinical assistant professor of hospital medicine and the leader of this effort. “Many of my colleagues reached a tipping point in 2020, when we started having conversations in what I call ‘brave spaces’ and spending time sitting with discomfort,” Wang says. “We may have been aware that health care was not necessarily equitable or fair, but we hadn’t stopped to understand how we might have been contributing to these disparities or consider what we could do to prevent them from continuing.”
Samantha Wang, MD (center) is the leader of the 5-Minute Moment for Racial Justice program, designed to promote racial justice and health equity during interactions with patients. Residents Thomas Savage, MD (left) and Jaspreet Pannu, MD (right) worked with Dr. Wang on the program
The core philosophy of this teaching curriculum is that topics relating to racial justice in health care can be introduced routinely, effectively, and efficiently in the clinical environment, and that the teaching is enhanced through historical narratives.
This framework is applied across the pilot curriculum of 10 clinical scenarios, all of which have implications for diagnosis and treatment among people of color. Examples include increased maternal morbidity and mortality in Black women, provider unconscious biases in patient pain perception and treatment, and diagnosing melanocytic skin changes in patients with darker skin.
The 5-Minute Moment for Racial Justice centers around five steps, which are listed here using skin findings on dark skin as an example:
Does skin color have an impact on a finding such as a skin mole?
2 Current Standards
How do we currently evaluate skin findings in people with dark skin, and what are the limitations? Most medical textbooks feature light-colored skin when discussing skin conditions.
3 Historical Narrative
Describes a prominent scenario from the history of medicine, where a skin finding on a dark-skinned person was mistakenly dismissed as benign but later determined to have been a lethal form of cancer.
Why is the five-year survival rate for skin cancer 67% for Black people but over 90% for white people?
5 Steps to Equity
Wang notes that “to be effective, learners and educators need to recognize that medicine may not be as objective as they had thought. In our trials of this program, we’re finding that there is definitely an appetite for this kind of exploration and discussion.”
The current plan for disseminating the 5-Minute Moment for Racial Justice calls for training a core group of educators who will become champions for sharing the curriculum with learners.
Presence 5 for Racial Justice
In a time when medicine is dominated by technology—such as electronic health records, telemedicine, remote monitoring, and machine learning—is it any surprise that the sacred doctor-patient relationship is under duress? Doctor visits that were once central to clinical care are now at times perfunctory and mutually unsatisfying. Add racial bias to the mix—often unconscious but sometimes not—and you’re facing a problem that adversely affects a huge swath of our population.
Stanford aims to address this challenge by using communication tools that will help clinicians build trusting relationships with Black and other marginalized patient populations.
"Our goal is to identify specific communication strategies and practices that clinicians can use to address racism that affects their patients’ health and well-being"
Presence 5 for Racial Justice was developed by Verghese and Donna Zulman, MD, assistant professor of primary care and population health. It’s an adaptation of the 2020 Stanford Presence 5: a multiyear, evidence-based research study distilling five clinician practices to ensure presence and build trust. Presence 5 for Racial Justice adapts five core components of that original approach to address racism and promote health equity. They are:
1 Prepare with Intention
Consider how your identity could influence how you perceive your patient and how your patient might perceive you.
2 Listen intently and completely
Listen for your patient’s experiences with racism, bias, or mistreatment.
3 Agree on what matters most
When creating a shared agenda with your patient, check yourself for biases that might influence what you prioritize for the visit
4 Connect with the patient’s story
As you listen to your patient’s story, consider how anti-Black racism has influenced your patient’s experiences with his or her health and health care.
5 Explore emotional cues
Consider how racism trauma might influence your patient’s emotions.
Working with a team of diverse advisers from four community health care centers around the country, the group developed materials to help deploy these concepts across the medical training spectrum, from medical students through practicing clinicians at every level.
“Our goal is to identify specific communication strategies and practices that clinicians can use to address racism that affects their patients’ health and well-being,” says Zulman. “Whatever we learn will need to be implemented together with structural and systemic interventions.”
Zulman is the principal investigator for the umbrella Presence 5 for Racial Justice project. While she is pleased by the progress made so far, she recognizes that they are tackling “a very complicated problem with deep historical roots.” She does not think this research will offer the sole answer to the problem, but she is hopeful that her team’s findings will help foster conversations that ultimately lead to more equitable and racially just care.