December 2022 - Pillar Round Table: System Transformation (members only)
The COVID‐19 pandemic has exposed the complex interconnected dilemmas of health equity, economic insecurity, environmental justice, and collective trauma, severely impacting marginalized communities and people of color in the United States. The disproportionate number of COVID-19 deaths among racial and ethnic minority groups exposes the systemic and lethal barriers to care. Nevertheless, inequalities in health care have existed far longer than in the most recent crisis and are deeply entrenched in the existing systems. Without active conversations and actions, we are not going to be able to disrupt the status quo. In this round table discussion on December 7, industry and community expert Dr. Ron Wyatt discussed his research, work, and personal experiences to challenge the system to address racial bias in health care.
Dr. Ron Wyatt
The recording and slide deck are available to HC3 members by emailing Meghan@HC3.Health / Details will be distributed in the December 16 HC3 Weekly Email.
Dr. Wyatt has practiced internal medicine for over 20 years and currently practices in St. Louis (MO), Missouri, and Alabama. In his capacity as a doctor and as a person of color growing up in the South, he has seen first-hand the disparities and inequities that exist in health care.
Dr. Wyatt recalled that when he was 15 years old, growing up in Alabama, there was a mother in a nearby town who took their child to a general practitioner for a laceration. The practitioner sutured the laceration, and when the mother couldn’t pay, the doctor took the sutures out. She ended up taking the child to a veterinarian who provided the sutures and did not charge.
Defining and creating a system of inequities
Dr. Wyatt’s personal definition of health inequity is the difference in outcomes between groups within a population. “Health inequity” denotes differences in health outcomes that are systematic, avoidable, and unjust.
To consider inequities and disparities, it is necessary to consider how the system was designed. Historically, structures and systems have been put in place to maintain white supremacy. This led to the post-emancipation, where those structures were further institutionalized to maintain white privilege. This resulted in the Jim Crow era, driving mass incarceration, redlining, and concentrated poverty. Social drivers of health and “weathering” or toxic stress cause poverty and circumstances that lead to preventable chronic diseases and premature death.
Myths about physical racial differences were used to justify slavery. For example, a Louisiana physician said that a slave who ran away must have a mental health issue that could only be cured by having the devil whipped out of them. W.E.B DuBois’ 1899 book “The Philadelphia Negro” discusses the social conditions of black people in Philadelphia and describes a peculiar indifference to their suffering, and that indifference plays out in health care.
Inequity in health care today
A patient survey of over 500 people indicated that patients experienced discrimination, disparate care, and racist interactions within the system. Additionally, there is a great deal of research and literature that also points out the negative impact of race and ethnicity in health care.
Factors contributing to system inequities include system-related factors, provider-related factors, and patient-related factors. Dr. Wyatt’s work has focused on patient safety and how inequities can create unsafe conditions. He firmly believes that no one should be harmed when they interface with the health care system.
Root causes of inequities in health and health care
Bias: Bias is a friend or foe response, a natural tendency, particularly during stress or duress, to feel comfortable with people who are like us. There are integrative frameworks being developed to combat implicit bias by creating awareness and incorporating best practices into health care professional education. The hope is that this will eliminate implicit bias in health care and ultimately change outcomes, and improve patient safety.
Racism: Racism is a vector that leads to preventable death. The Emergency Care Research Institute (ECRI), a patient safety organization, found that in 2022 bias and racism was the third highest patient safety concern out of the top 10.
Race-based medicine: We need to eliminate race-based medicine because it does harm patients. There need to be structural shifts to confront the realities of inequity and move towards improvements.
Anti-racism actions: Some examples of “anti-racist” actions include:
Divesting from racial inequities
Desegregating the workforce
Mandating and measuring equity outcomes
Protecting and serving
Making “mastering the health effects of structural racism” a professional medical competency
Trust and Discrimination: In a survey, Black respondents were twice as likely to have experienced discrimination and don’t trust the system. To rebuild trust, actions to take include:
Listening and asking “what matters”
Sharing the decision-making process, including “do[ing] nothing to me without me”
Having structural humility and competency
Dismantling structural and institutional racism
Structural determinants of health: When an individual engages in the health care system, they bring their history – their social, political, and economic life – with them. Drivers of health include:
Health disparities that are outcomes driven by those drivers include:
Changing the system
It is important to implement structural competency actions in clinical settings to meet the needs of patients to the best of our abilities. Servant leadership is necessary to eliminate inequities. Having skin in the game with aligned incentives and anticipation of “black swan” events promote accountability. Leaders must manage risk with a “buyer beware” mentality, vetting the people that come to their organization saying that they can solve Diversity, Equity, and Inclusion (DEI) issues. Leaders should be wary of “profit and non-profiteers” trying to capitalize on this moment and be willing to look past the standard way of doing business that put people in harm's way.
As a requirement for health care accreditation, The Joint Commission has introduced health equity standards. Dr. Wyatt wrote the standards and emphasized that it is important for health care leaders to understand these standards.
A new Centers for Medicare & Medicaid Services (CMS) rule increased payments for acute care hospitals to advance opportunities for health equity and maternal health. Effective January 1, 2023, hospitals will need to show commitment to establishing a culture of equity. They are required to have an equity-centered strategic plan, a data collection plan around disparities, as well as leadership engagement. Health systems will also have to demonstrate a risk assessment for health-related social needs.
Eight states have filed lawsuits objecting to this new rule, saying it is not the role of CMS to mandate anti-racism plans.
Dr. Wyatt encouraged participants to read “Achieving Health Equity: A Guide for Health Care Organizations,” a paper published in 2016 that provides a comprehensive framework to pursue equity.
Dr. Wyatt concluded his presentation by pointing out that the conditions that COVID-19 exposed preexisted and that he is committed to ensuring that these issues are brought to light and don’t remain a moment and fuel the movement.
Answer Highlights from the Q&A
In Dr. Wyatt’s entire career, the only time a black patient wouldn’t allow them to provide for them was in St. Louis. The analogy for this is “the white man’s ice is colder.”
Dr. Wyatt also shared a patient intervention he had in Alabama with a diabetic patient. She was crying because a white physician previously told her that no matter what she did, her blood sugar would never be normal. Dr. Wyatt was the first person to tell her she could have normal blood sugars and that it wasn’t hopeless. That experience was then internalized by this patient, and trust was brought into question for the patient with the health care system.
There is more money going to the prison system than to education in the state of Alabama. And there is a strong need to deconstruct those systems.
Physician diversity has not changed since the mid-century, and the system perpetuates this. Black students continue to experience blatant racism from the people teaching them in medical schools, and more needs to be done to support them.
About Dr. Wyatt: Dr. Ronald Wyatt was most recently the Vice-President and Patient Safety Officer for MCIC Vermont, a major risk retention group based, and is a Senior Fellow at the Institute for Healthcare Improvement (IHI).
Prior to joining MCIC Vermont, Dr. Wyatt was formerly the Chief Quality and Patient Safety Officer at Cook County Health in Chicago, Illinois, and the former Chief of Patient Safety and quality for the Hamad Medical Corporation in Qatar.
Dr. Wyatt was the first Patient Safety Officer at the Joint Commission. He served as Medical Director in the Patient Safety Analysis Center Defense Health Agency/Military Health System Defense Health Agency, Falls Church, Virginia.
He is the former co-chair of the Institute for Healthcare Improvement (IHI) Equity Advisory Group and is faculty for the IHI Pursuing Equity Initiative.
Dr. Wyatt is a facilitator for the ACGME Equity Matters Collaborative and serves as faculty for the IHI Pursuing Equity Initiative.
Dr. Wyatt is a credentialed course instructor in the School of Health Professions at the University of Alabama Birmingham. He is the co-course director Keystone Program at the Northwestern University School of Medicine Master’s Degree in Patient Safety Chicago, Illinois.
Dr. Wyatt holds an honorary Doctor of Medical Sciences from the Morehouse School of Medicine and is a graduate of the University of Alabama Birmingham School of Medicine.
While a resident in training at St. Louis University Group of Hospitals, he served as the first African American Chief Medical Resident from 1987-1988.
He is a board-certified Internist and practiced medicine for over twenty years in St. Louis, Missouri, and Huntsville, Alabama. He earned a master’s (executive program) in health administration degree from the University of Alabama Birmingham School of Health Professions.