Rishi Manchanda, MD, MPH: [00:32] One of the important things about this conversation is not just the topic, but who's in the room. And today, one of the things that I'm excited about is that the reframing, the understanding, and the possibility for alignment is now different because we also have—many of you have invited and I think we have several folks who are involved in—community benefits, community health investments, social determinants work, overseeing or directly running programs or system level kind of strategies to address social determinants in the community and/or social needs for patients. And those sometimes are very different colleagues, right, that are...as opposed to quality and safety folks who are thinking about harm in different ways, who's in the room always—and this is going to be true today, as well—always changes the possibilities of what it means to potentially reframe our understanding of things. And that's what's going to be exciting about today.
[01:23] With that in mind, let's talk a little bit about structural, social and structural drivers, and in the context actually, of harm, you know, understanding this context. To do that, right, if we go the next slide, you know, I've been listening avidly to this conversation in this peer network since the beginning of this, and it's been a real privilege to actually learn and listen and observe. And one of the things I've learned and have had a chance to reflect on based on my own experience—working in large health systems like the VA as well as smaller health systems, like community health centers—is that our in a quality and safety frame of reference, much of what is happening, if you just click one more, just to advance, there you go perfect... Much of what occupies a lot of time, for those who are in quality and safety and risk prevention is, of course, trying to identify harm, and then to be able to, of course, address it, if not prevent it in the future. The yellow... so I'm using soccer here as a way to at least kind of define this a little bit. And so this is the work, right? Is this a fair kind of....it's obviously a very rough broad brush here, but does this make sense, this kind of attempt to use soccer and the ways in which we use yellow cards, orange, or even red cards to identify near miss or serious safety events? Much of our work is occupied around that. Great, in a quality safety space. Let's go the next slide.
[02:46] And so you know, staying with soccer, a lot of what it is, is not just about identifying one harm event, but to then identify if that harm event is indicative of a trend or a pattern, particularly using a systems thinking model, right, the iceberg model approach. And so you can see here in the context of soccer, especially in identifying whether there was a pattern or trend of inequity, specifically racial inequity, the Major League, soccer MLS, did its own rough analysis. And it'd be interesting sidebar conversation, perhaps with the folks in soccer to talk about their methodology, the strength of their analysis, but point is, they started to identify whether there were inequities in even in terms of how harm was being identified, between those who received yellow cards and red cards, and whether the players who were given those cards were Black versus not. Similarly—and this is a screenshot of a dashboard, right of ways in which quality and safety folks and much of what has been, I think, a really important discussion in these peer network calls—to what extent are you identifying whether the harm events that you're...the adverse events or harm events you've seen, are now indicative of a trend? And are there racial inequities in those patterns? That's the bulk of what I would say we're doing. Does that that track so far, right? So far, so good? Kind of making sense? All right, let's go the next slide.
[04:06] Still others within our large kind of complex, you know, systems within health care, are thinking about goals—the goals that we're trying to achieve, not just for being able to identify and prevent harm, but now to advance health more broadly and health outcomes for discrete populations of patients, whether that's through a fee-for-service model, or value-based care model. And again, population health management dashboards and tools and entire teams exist for that purpose, right? To be able to identify goals and to measure our progress towards them using our dashboards. Fair?
Manchanda: [04:41] So, so far, I've just...this is just looking at quality and safety, events, reporting trends, and then population health management in similar kind of ways using kind of soccer as our frame of reference here. If we go the next slide here, one of the things that we don't do often is to then zoom out and wonder if the entire exercise—the process itself, right—is based on a foundation that is wholly inequitable. To what extent are we in quality and safety, are we in population health management, are we in community health designing the systems, designing the software that we use to be able to track events, and then creating the spaces, designing the spaces to be able to come together, and to recognize whether there are structural drivers that are causing harm? I'll pause here just to actually just look for other head nods, furrowed brows, or even receive some rotten tomatoes, if, if this makes sense. This is just one way to be able to frame or help to reframe what we're talking about today, at least in introducing this topic of a structural lens. So I'm looking for at least some head nods. And maybe you know, if you're off camera, feel free to use the chat to tell me if this kind of resonates. Yea or nay? Are you with me?
[05:56] All right, a structural lens. What does that mean? Let's go the next slide here. Let's apply a structural lens, actually to a very common harm event. A man walks in hungry. We have long standing cultural beliefs, right, that to address that particular need, whether it's manifest in a clinic, or in a soup kitchen, or in a community in a church, that what we should be doing is not just to give a man a fish to feed him for that day, but teach them how to fish and feed him for a lifetime. This is a worldview, a paradigm, a mental model using systems thinking words that are deeply ingrained. Does this make sense, that we know this, right, that we know this to be true? It doesn't make sense just to give a man a fish and feed him for a day. It means teach a man to fish, feed him for a lifetime.
[06:47] What I would argue is that this, if we use a structural lens, may not be sufficient. Why not teach women to fish? One more on? What if the pond close to home is polluted? And extended even further, what if their family and neighbors have been historically denied access to the resources to fish, like rods or tackles or permits due to poverty, racism, sexism, homophobia, xenophobia? And yeah, Scott, exactly. What if he is fishing in a polluted canal, right? In other words, a structural lens requires us to actually not just think differently, but to recognize that the way we think the mental models that inform our perceptions of the structures, which of course in systems thinking then influence the trends and patterns and ultimately, the ways in which harm shows up as inequity. These things really fundamentally matter. And I would argue that this gap between the kind of "give a man a fish, teach a man to fish" type of worldview, and the gap to actually extend that further and realize that that ancient kind of adage is incomplete because it lacks a structural analysis. Exactly Karthik, yeah. Now we start..now we're starting to go, right? And what we're just focusing...now we're getting started into social analysis. What you had, all rightly kind of identified is that we are at 1 or 2 when it comes at a scale of 5or 10, wherever it is, in terms of structural analysis, and part of it starts with what we're doing today, which is a reframing of this.
[08:13] So let's take the reframing and continue this forward the next slide. And now look back at the central question of harm. Quality and safety, folks, as you, Caitlin and Alan, kind of talked about, squarely focused on this question of harm. But a structural lens requires us to think differently. And some of the folks who've been thinking about this for some time have been thinking about structural analysis in the context of structural violence, a term that many of you may become familiar with, because of the work of late Paul Farmer, who was for myself, and some of you on the line here, a mentor, whose presence is missed. The term structural violence that he helped to popularize in an article in 2006, was actually built on a term introduced in the late 60s by a P scholar named Johan Galtung, who built this concept out and then many sociologists and medical anthropologists like Paul and others then started to build upon this huge body of research, using this frame of structural violence. As Paul described it, along with other colleagues in 2006, the term structural violence is one way of describing social arrangements that put individuals and populations in harm's way. It's the arrangements are structural because they're embedded in the political and economic organization of our social world, and they are violent, because they cause injury to people.
Manchanda: [09:35] What I'm inviting us to kind of think about a little bit is now thinking about harm, not just as something that may or may not be what Caitlin and Anna mentioned may or may not show up as harm in a quality and safety context, but it's showing up as harm in our hospitals and health systems. And to what extent is that harm actually perpetuated if not caused by structural violence? If you go the next slide here. Let's actually use this kind of lens and reevaluate even some of the common terms that we're that we're talking about in health care these days when it comes to social factors. So for example, you're familiar with social risk factors or social needs more these days than not. Many of your health systems, if not all of your health systems as we've learned, are in some ways either screening for or even actively addressing social needs of individuals. Social needs are really the social risk factors that individuals, like patients, identify and prioritize. Those social needs themselves are shaped by social determinants of health, if we're using that term properly. We have not done that properly in health care; we've co-opted the term talking about individual phenomenon, but public health teaches us that social determinants is really a community level phenomenon. Social determinants of health are really the underlying community conditions that themselves shape, the distribution, the chronicity, the severity of individual social needs. Why some populations, some people experience disproportionately some social needs and others. So for example, a food desert is a term that some of you, I'm sure all of you are hearing and familiar with, some of your working to address. Those food deserts then, of course, are associated with higher prevalence of individuals with unmet social needs of food insecurity. But those food deserts are not there by accident. They're there because of structural determinants of health equity. Supermarket redlining, for example, or what some food justice advocates describe as food apartheid.
[11:20] In other words, as we think about the social needs, or social determinants and even structural determinants, what does it mean to actually use a harm frame to understand that all of these are mechanisms by which social arrangements perpetuate harm? And the question is either, are we by understanding social needs, by understanding social determinants and understanding structural determinants, are we either perpetuating, or are we counteracting arrangements that cause harm? Let's go to the next slide here, and let's talk about this. Now, this is a particularly...this is an element that has come up a little bit in some of the prior peer network calls that I've assessed, and I think your own self-assessment of the field in the, in the rapid fire poll that we did at the top, I think validates this that this is not for any personal failing, perhaps, but because of a systemic blind spot that we've had in health care. We are not as professionals in quality and safety, in particular, and I think population health and in general, you know, many forms of health care, were not trained to actually apply a structural analysis. Formally, as part of our training, think about it going back to whatever your your professional training was, and is—with the exception of social work and a few other professions—there was very limited exposure to micro, meso, macro kind of influences on health including structural kind of factors.
Manchanda: [12:43] So it's, it's important for us to start to become familiar with this. And again, this is where who is in the room really does change our efficacy to start to talk about structural factors. In other words, it's one thing for us, for a group of people who are relatively inexperienced talking about structural violence and forms of it—like the ones you see on the right, whether it's food apartheid, or hyper incarceration, disenfranchisement—it's one thing for those of us who are less comfortable with the literature, less comfortable with the facts, less comfortable with the history, to start talking about it. What usually happens in those contexts is that we end up either feeling overwhelmed by it, and therefore reinforce the sense that therefore we can do nothing about it, it's somebody else's job, it's not my lane, etc, etc. We've seen this pattern time and again. Or we've seen the difference when people who actually have experience with the history, the facts, and the work—for example, those in community organizations, advocacy coalitions, lawyers, and others, right, who often familiar with this—are able to come into that conversation. So today, actually, we're going to try a little bit of that and see, and to what extent this group is able to talk a little bit more about these mechanisms, these common forms of structural violence.
[13:56] One example of wealth extraction, just to drive it home, and to really drive home our institutional complicity is the form of medical debt. In 2021...two things, one medical debt as many of you know and health care expenses writ large has continued to be one of the, if not the major, either number one or number two driver of new poverty in America for many years. From 2016 to about 2018, anywhere from 11 million Americans every year who were not in poverty were driven into poverty, not because of student debt, or credit card debt, but because of medical debt and health care expenses. A 2021 study demonstrated that of the top 100 hospitals ranked in the US using a common ranking system, 57 of those hospitals had actually driven...were charging more than 5 times the amount to patients and to their insurers. indirectly for the costs compared to the cost of delivering care. In other words, the chargemaster rates, super high. And similarly, a third of hospitals in that same kind of grouping, out of the top hospitals in America, over a third of those hospitals were in some ways participating in lawsuits or aggressive debt collection practices against patients. it's a form of wealth extraction. It's a form of perpetuating generational poverty. I don't know if we've had many conversations in health care systems and hospitals about that, right? About the ways in which our financial practices may or may not be perpetuating social violence. But it's an example of how in which health care, we are part of this, this web of these structures right now by which social violence can be perpetuated. And we're not alone. Researchers have identified that there are anywhere from 843 on up state laws, that—state laws right in the past 10 years—that have been identified to disproportionately discriminate against marginalized racial and ethnic groups. Let's hear a little bit more about the ways in which structural inequities might be showing up whether it's in clinical care outcomes, patient experience, quality and safety, and then come back to this kind of point that a shared approach with a structural lens might actually allow us to better make visible what is often invisible here.
Manchanda: [16:20] So let's go the next slide here and say, you know, as we look at, as we hear these conversations, we'll come back to this notion of what it's like to look at the events using a systems thinking approach, the ways in which harm is showing up in these different ways, not just for our quality and safety, folks, but our community health and population health folks and clinical care. And then finally, you know, how are we doing in terms of being able to work in order across departments to review the structural drivers of health equity? A lot, I just laid on the table here, but more importantly, let's actually hear about the work that you guys are doing. So if we go to the next slide. This is the time now for some conversation, voices, not mine. I am pleased actually to kind of open the floor up if we go the next slide here and start hearing some perspectives, to hear from if we have folks from Ochsner, VUMC. Here I'm looking around to see on the screen if you want to unmute and just voice, voice over. Good morning. Wonderful.
Teresa Arrington: [17:23] This is Teresa Arrington.
Manchanda: [17:25] Hi, Teresa. Thank you.
Arrington: [17:26] From Ochsner Health in the...really throughout Louisiana and Mississippi. But we have two speakers I think that are interested in presenting. And I'll start out with Lindsey White, who's the director of our tobacco cessation program, but she actually helps to assist with the running of the Lyft program. And that is something to try to address the need of, you know, patients...they have to get to their appointments, and it's very difficult to do if you've got just transportation difficulties. And we were beginning to see, you know, some outcome fallouts in terms of people needing care for chronic conditions, things that we have programs for, like diabetes and whatnot. And also, I can't ignore the fact that we as an organization, we do want to reduce our no-show rates. So that is certainly a piece of the puzzle. But I'd like to turn it over to Lindsey now to tell the group a little bit more about the lift program at Ochsner.
Lindsey White: [18:23] Thank you so much, Teresa. I actually run the transportation...so we try not to say Lyft too often, because it gets people confused. So we actually have two separate programs going on. One is called branches, and that is exclusively Lyft. That means any department that feels that they need to give somebody a ride to or from their appointment can do so. The second department that's actually what I focus my energies on, we typically do this at the Community Care Centers, all the smoking cessation centers, OB and Peds will be up Q3 of this year. We had some car seat things that we had to work out. And so that program actually requires every person that scheduled an appointment within those centers to be asked if they need transportation. If they answer yes, then that goes to our work queue. We look at their current benefits. So if they have Medicaid, if they're disabled, Medicare, then we set up the appointments for them through whatever provider they have. We also will take care of all the prior authorizations because that's a very complicated process for a lot of people. So we take care of all the prior auths, especially around the disabled patients that we have currently. And then if they are not able to receive benefit, maybe they're uninsured or maybe they have a same day appointment, which Medicaid requires a three day lag period, then we will utilize Lyft to do so. We also worry about patient experience. So we just recently yesterday had a woman who was 38 weeks pregnant, had waited over an hour for her Medicaid bus to come pick her up. And so she requested a Lyft to be taken home because she had kids and she was worried about the babysitter leaving. So of course, we took care of that for her. So I think around patient experience, it's always beneficial. We are also working with national Lyft and Epic to create an integrated integration project so that we're not in two separate systems that will actually have real time data within Epic. And so that's kind of been a long-term project that we've been working on that hopefully within the next year, we'll have a resolution to that also.
Manchanda: [20:28] Thank you, Lindsay, is another colleague from Ochsner that...
Arrington: [20:32] There is. I'd like to introduce Steph Most and she's going to tell you about the Unite Us program.
Steph Most: [20:39] Hey y'all, thanks for having me. Rishi, thanks for inviting us. I'm Steph Most, I oversee Ochsner's strategy system wide for social determinants and, you know, how we're addressing them, as well as our community health workers, which is a big arm in how we're addressing them. So to kind of we'll talk to them and guide us. But for us a big part, of course, before we're putting in specific interventions and things in place and you know, Lindsay and her team have done an incredible job on the transportation arm, which we have known even without...even early on in our data collection, we knew was an issue. So we're grateful to have that program, in full effect as it is. But of course, a lot of...Emery, she and I have talked about this before, but a lot of our interventions, while some like transportation benefit from living within our four walls, for the most part, our interventions need to be living in the community, the same place where structural determinants and social determinants are taking place and, and causing issues and need for our patients. It's the same place where those solutions need to live.
[21:46] And so one of the backbone arms, kind of our intervention approach is the community resource referral platform Unite Us and what's great about unite us, there's a couple different perspectives it gives us. First of all, it's the first closed loop platform that we have access to. So we're able to see every step of the way, from the second we refer a patient to the second...you know, there's an outcome on the referral, whether it needs to be rerouted, it's rejected just because an organization is you know, out of funding, or it is accepted and there's a successful connection. We're able to see down really to the set like exact time, seconds wise, that the organization reaches out what happens. And the other kind of piece of that is what I just touched on is when referrals fail, it gives us a lot of great insight into where our community resources are lacking. You know, specifically, what domains or what neighborhoods, you know, those specifics so that that way when we are looking at community investment and looking at where we can really build capacity to make sure we have those solutions in our community, that platform and the data we're collecting by putting referrals and helps us see those gaps as well. So Unite Us has been really instrumental in helping us plan more of our intervention arms moving forward, but also giving us a backbone to make sure that no matter what, we always have some form of a way to refer patients and refer them in a way we never have in that closed loop information feed, which is really critical.
Manchanda: [23:26] Thank you, and Lindsey and Teresa, thank you as well. There's a question here that I'm going to ask you to consider and we're going to... I want to turn the baton to our friends from VUMC as well to continue kind of just hearing about the incredible work you guys are doing to address social needs, social determinants. But as we go over to VUMC, to hear from their experience, I invite you guys to think on the answers to the second question on the screen here: how are unmet social needs that you're addressing, the social determinants as well, contributing to perhaps in showing up as harm events. It's a question for you guys, as well as for your peers and your colleagues in the quality safeties space. So thank you, VUMC. Anybody from VUMC here today with us?
Elisa Friedman, MS: [24:01] Yeah. Hi, Rishi, it's Elisa. And excited to be here this morning, really inspired by what you've shared, Rishi and want to echo the gratefulness and, you know, thanks to the AMA and to you. And I think also bringing Paul Farmer's name into the space also always inspires, so thank you. I'm going to speak probably a little bit more generally, and—and unfortunately, some of our colleagues that are doing work at the individual program level weren't able to be here—but we'll speak a little bit more generally. So I'm the Associate Vice President for Community Health and Health Equity in the Office of Health Equity, and I'm the community and population health lead for this project. I'd say just falling on my sword that we have a lot of work to do in terms of looking at harm from the lens of structural violence. But I wanted to...I think there's a lot of have assets that are kind of floating around the system that can be brought together, we've started really working closely with our quality and safety team, which is fantastic. They have a new team, not a new team member, but a team member whose role has recently switched to focus entirely on health equity. And she's here today, Kelly Morin. We spent a lot of time together. So I think that's a good sign in terms of weaving our work in community and population health into our work around harm events.
[25:29] But I wanted to share some quick, quick examples. One is really more thinking about the the assets that we bring in terms of our work and community population health and the assets we bring to work that's really looking at embedding racial equity, and understanding of institutional and structural level factors into harm events. And, you know, some of those are our equity lens, which, you know...I feel like we're constantly talking about institutional and structural levers, but really having the opportunity to weave that into our work across the enterprise. Some of our work around anti-racism, which, you know, obviously, in that space, our focus is all about dismantling systems and thinking about inequities at institutional structural level. similar sort of equity, what Rishi shared. I think, really key around this social driver space and developing community partnerships is, you know, the center of much of our work is community engagement, the currency of trust, and mutual benefit and transparency. And so, as far as these kind of pieces coming together, I feel like that's an asset that we bring as a partner to this work around quality and safety and harm events, specifically, advocacy. I don't know that I'm sharing anything particularly new for you all, but a lot of our community partners in our community investments that we make are with organizations that are working on advocacy issues, whether related to housing, transportation, food insecurity, and a lot of the social drivers that you all are aware of. So we have those partnerships, we're making those investments, I would love to see those investments be more aligned with the work that we're doing around quality and safety and harm events, and so I think there's a lot of opportunity for, for alignment.
[27:15] The other just two quick examples, I wanted to share is some of our individual level programs. And I really appreciate the distinguished...distinction that reaches made between those sort of those individual programs, and then thinking at those other levels, about social drivers of health. And so, you know, we have a program that's focused on increasing access to healthy food for low wage earners, our employee workforce who are also our patients. So developing a partnership with a lot of, some of our local farms and providing food boxes at low cost. We are doing a lot, I would say in pediatrics more than the adult enterprise around screening for social drivers. The barrier—and we've done some research within our own institution is, I'm sure the barrier of that you all have confronted—which is implementation. So we can screen but then how do we implement? And again, I feel that that's where community and population health can be an asset. And then just the last thing is around, we have a program, a few programs focused on transportation, one is a transportation program focused on individuals with complex chronic conditions, and getting them to, into the health system. And we've definitely learned a lot through that project. It's, you know, one of our challenges was some of these transportation providers won't go into the neighborhoods where we need them to go to, go into. Or there aren't drivers available in those neighborhoods like Uber, we found one of the challenges. And so we had ended up looking at, like a taxi service to be able to solve that problem. So, so anyway, I feel like there's a lot of opportunity to align a lot of the assets we have in our system.
Manchanda: [27:41] If we go to the next slide, Ryan, one of the things that I think Elisa what you just kind of voiced over as VUMC's, is some of the programs right that are represented in the, in the slides that the VUMC had shared with AMA and similarly Ochsner had done the same and we have Ochsner's slides here—each of your systems in this whole peer network have contributed to that. One of the things and we did this a little bit with a prep call we had just a couple days ago with VUMC—and we'll do this with Ochsner and with all of you in a second—if you go the next slide, is to think now about these robust social needs and social determinants programs as an opportunity to, from a different perspective, from quality and safety, typically, to think about what kinds of harm are showing up or showing up but not being recognized by your health system?
[29:44] So for example, I think it was one of your colleagues, Elisa, who had mentioned the story that thinking about the rideshare program work that you do, the transportation work that VUMC is doing. Look on the left here. One patient, one of Elisa's kind of colleagues shared the story of you know, how does the show up as harm? It's interesting. Well, one patient was showing up in the hospital every two weeks. The team was struggling to figure out ways to help. This patient lacked housing, access to insurance, was therefore having poor outcomes. It was a form of harm. To what extent does that harm actually showing up in an adverse event or not, is an important question. But the interventions, the social needs interventions, now becomes something I think slightly different if we started thinking about these as ways to at least reduce harm, right, by addressing social needs, and maybe an opportunity then for the kinds of conversations that exist. If we go to the next slide here to think about what additional strategies. Ochsner are had very similar kind of stories as Lindsey, you were sharing, and Teresa, you were sharing as well, and Steph, as you're sharing, right? There's a lot of incredible programs, right, addressing social drivers. To what extent is that showing up as harm and how more importantly, if we go the next slide here, does this serve as an opportunity for alignment? We're not going to go into all these questions right now. You're going to see this come up in a second, and we'll share it you know—these are your resources to share with you if it's helpful—to prompt conversations, you can, as you can see on the left, for quality, safety, risk prevention leaders, to discuss with community population health colleagues, and vice versa on the right. One of the things that we know, of course, is, as all of you have alluded to the power of the data and power the data that comes from quality and safety reporting systems, clinical registries, population health management software, and CHNA's and community area-based social risk and disease. There's a variety of different data sources to start thinking together, together, across departments, around answers to these questions as well to really to better interrogate underlying social structure drivers. So these are again, questions or prompts that allow your data analysis to now bring a structural lens to it.
Manchanda: [31:47] Next slide. Another resource is to also recognize that there are—as many of you are already demonstrating—this is being done. This is not a novel idea. It's an idea that actually is already, we're already seeing visions of the future in the present right now. Right? We're already seeing ways to now start to work together to align institutional action. Here's an example of ways to actually start redesigning care models informed by a structural lens that, by definition, has to be placed based, as Steph was talking about, a community-based perspective. I won't read through all of this example on the right here of how folks at Cincinnati Children's took a really specific marker of medication adherence for asthma, and then did a geo marker, as they called it, by looking at pharmacy data, data from pharmacies, and then geocoded that information to be able to generate a place based data perspective on a geo marker really of, of medication adherence, and then realize that there was actually inequities by place, which meant social and structural drivers were at play. And then use that insight to now deliver more effective and more equitable medication adherence interventions. A structural lens unlocks effectiveness, right, and more equitable kind of approaches in ways that can only happen when you start to work together.
[33:08] And the next slide here is we come to the top is this just key takeaways. It is time for us to I think really reinforce what many of you have acknowledged in prior conversations in this network, and that is that the inequities that are the center of this peer network and the center of many of your health systems kind of projects these days are not bugs, they're not byproducts, there are features, right? Because every system is perfectly designed to get the outcomes it gets, the inequities themselves must be the outcomes perfectly designed by our systems. So our systems—our systems, the structures that we occupy—are driving inequities. That's a very different, active and more fact-based kind of analysis, than "these inequities are happening and how do we better acknowledge them?" Another key takeaway is that those inequities themselves are driven by structural violence, and racism being one form of structural violence, that are causing disproportionate harm. And that harm can present in many different ways. Sometimes it may be showing up in your quality and safety data, perhaps not as Caitlyn and Anand were talking about at the top, and it also is showing up in other parts of your health system. You need to just look, right? And start looking for the harm in that kind of way. And lastly, it's important because health care is not, just like all systems, not neutral. We have to you know, take essentially what you know, Dr Ibram Kendi and others have talked about in terms of, you know, what it means to be anti-racist and recognize it's there's no middle space. It's either we, we are perpetuating structural inequities—he example of medical debt is just one I mentioned, but there's many others that you guys have shared as well—or we were reducing those structural inequities by leading where we can lead, partnering where we can partner, and supporting or we can support
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