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A Healing ARC for Hospital Inequities

Learning Objectives:
1. Describe the three components of the Healing ARC framework
2. Describe an example of how the Healing ARC framework can be used to eliminate race-based algorithms in health care
0.5 Credit CME

This video is an excerpt from the AMA Advancing Equity Through Quality & Safety Peer Network session on A Healing ARC for Hospital Inequities. This section describes the Healing ARC framework and how it can be utilized to challenge outdated and harmful race- based algorithms.

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Video Transcript

Karthik Sivashanker, MD: [00:33] All right, so I'm going to turn it over to Drs Morse and Wispelway.

Bram Wispelway, MD, MPH: [00:39] Great. Thanks so much Karthik. Really a pleasure to be here and excited to go through this. I want to really do a little bit of the background of how we sort of got to Healing ARC, which I hope I hope people are interested in. And please, please ask questions. Before turning it over to Dr Morse...go ahead to the next slide. So just briefly, heart failure patients at Brigham and Women's Hospital can go two places, ultimately, with...if they're decided to be meeting requirements for admission to General Medicine where they'll see a hospitalist like me, or to our specialist cardiology service, where they will be on a team that's headed by a cardiologist, and has a number of other distinctions which we'll talk about shortly. This is a photo for those who are familiar with the old tower as those probably close to 50 years old, at Brigham and Women's Hospital, where the general medicine patients are in shared rooms, for example, or semi-private rooms.

[01:35] Next slide. Here you can see the differences...certainly offer differences for patient experience. These are the solo rooms in our Cardiology Center, the Shapiro building, where patients are treated when admitted there, and how they have specialty trained nursing, specialty pharmacy, and discharge planning. These are obviously larger rooms, more natural light, have a lot of perks, right. Historically, about two thirds of our heart failure, patients would go to Shapiro in the Cardiology Center, while a third will go to General Medicine.

[02:08] Next slide. This patient experience isn't just at that more superficial level in terms of what the rooms are like, right? We know that patients treated by cardiologists, with inpatient heart failure, have better outcomes. So there's observational data from around the country and also around the world showing when treated by a cardiologist compared to general internist, that patients have reduced mortality, lower readmission rates, better cardiology clinic follow-up. We found pretty similar results at our institution. We weren't really powered to detect mortality differences, but we saw better follow-up and lower readmissions for patients who were treated on our cardiology service, all other things being equal and controlled for.

[02:51] Next slide. So, you know, one of the things...and I'll talk about the study we went into in terms of what spawned this study...is that, I mentioned that two-thirds of our patients go to cardiology and one-third of medicine, didn't seem like that was happening randomly. So some of us as residents actually worked on both of these services. Whereas as attendings, we're really only on one or the other. You're either a general medicine doctor, a hospitalist, or a cardiologist. But the residents, the interns, would be on both. And what we're noticing anecdotally, it seemed like patients of color were more likely when they had heart failure, even with low ejection fraction, even if they were pretty sick, sometimes they were being seen on general medicine, right? It seemed like maybe they weren't getting the best care. And that was more systematic. And so we wanted to study this. And we ultimately published this in Circulation of Heart Failure in 2019. I'll talk about the results shortly. But first, I'm going to do a detour into how we really approach this question and approach this problem. So first, I'll just mention that...and this comes from our methodology...that the study was guided by public health critical race practice. This is an approach utilized by researchers to really not only study but also intervene on, really, ameliorate, examples of institutional structural racism. It comes out of a multidisciplinary or interdisciplinary framework called critical race theory, which I'll talk more about. What's really important and first and foremost to mention is that we, when we thought about race and ethnicity in this study, and we used data from our EMR that's largely self-reported, although it's not not perfect, is that we're thinking about race as a social construct, not one that's biological or genetically based, and therefore any differences really are reflective of social processes, structural processes, as opposed to any innate biological differences between patients. So we're really upfront with that in the methodology so that we could appropriately interpret the results of this study.

[04:49] Next slide. So this is a definition I like from Kamar Jones, really about structural racism. So what is racism? It's structuring opportunity and assigned value based on how one looks based on historical interpretations that unfairly disadvantages some, unfairly advantages others, and causes a sapping of strength of all of society. This is bad generally. Not just for people of color or for minoritized groups.

[05:17] Next slide. So what is critical race theory? I think these quotes are pretty helpful. The first one from Delgado and Stefancic, is that critical race theory, it's a collection activist and scholar [sic] interested in not only studying but transforming the relationship between race racism and power. And Kimberly Crenshaw, one of the founders calls it a practice, a way of seeing how the fiction of race...we talked about that sociopolitical historical construct...has been transformed into concrete, racial inequities. So it may have been ultimately socially made up right, how groups are being, you know, put into different racial buckets. But that still has a lot of impacts on health, and other inequities.

Wispelway (cont): [05:59] Next slide. The key tenants, I'm just going to focus on the green ones, because they're the most relevant to our work. But that first and foremost, and most important here is that racism is really ordinary in society, it's not the exception, it's not the bad actors, it's embedded into our systems, through a historical process of racializing certain populations, for their exploitation. And justifying it sort of pushing people into different racial groups as part of justification of horrible treatment. And of course, we're thinking about things like enslavement, or the taking of indigenous land and things like this. Race is socially constructed, we talked about that we'll talk a little bit more, and it serves an interest, it serves the material and psychic interests of the dominant group, which is this, again, socially constructed identity of whiteness, which is also historically relatively new.

[06:49] Next slide. So what does socially constructed really mean? I think this term gets thrown around a lot. But I didn't understand it for a very long time. But, but I think this from Patrick Wolfe, an anthropologist, really helped me, which is that races are better understood as traces of history, since racialization, acts to reflect to justify and reproduce into the present the unequal relationships engendered by historical processes of colonization and domination. So racism might actually be redundant since race already is an ism. This was...races were created to create a hierarchy in society, instead of keeping people on an even plane. And so the very process of racializing people over time is one that that speaks to oppression in and of itself. So you can almost think of those as collapsible.

[07:38] Next slide. This, I'll go through very briefly. But the big mistake in medicine that's been sort of ingrained in us through our training is this racial essentialism that these racial categories rather than the reality that I just mentioned, about what they entailed, in fact, were taught in many ways that they reflect inherent biological differences. And this comes up, we'll talk more about it in terms of the algorithms for race adjustment, for kidneys, and other things.

[08:07] And go ahead to the next slide. So there's both a moral and an intellectual mistake, because essentially, what we're doing is we're conflating two things. this oppressive socio-political fabrication of race that I just talked about, we're conflating that with ancestry, which is, which is an understanding of genetic diversity and population distribution of alleles. By putting those things two [sic] together, as if they map onto each other, this is the big mistake, historically, in medicine that sort of infiltrated a lot of our thinking.

Wispelway (cont): [08:37] Next slide. And this has a number of consequences that have been studied, actually exacerbates learner's empathy. You know, it reduces empathy. And it contributes not just to interpersonal bias, but systemic biases in terms of how we care for patients, right. This has infiltrated all aspects of medicine.

[08:56] Next slide. So I mentioned at the beginning that we use public health critical race practices for our study. This has really four faux SCI about it, but I just want to mention one in particular, which is that public health critical race praxis, when you develop a study, you should already be thinking that there needs to be an action component at the end, and this is really going to lead into the part Michelle is going to discuss.

[09:18] Next slide. So finally, I'll just briefly touch on the data that our study found. Sure enough, we found that you can see here on the left the raw data, two thirds of white patients and about half of Black and LatinX patients were admitted to cardiology. So there was a difference. This difference persisted even when we controlled for many other things like comorbidities, insurance status. We looked at area deprivation index, so markers of poverty and neighborhood indices, type of heart failure, etc. And so even when we control for other aspects that are deeply impacted by structural racism, we still as an institution had differences by self-described race and ethnicity, so there were elements that we were responsible for on top of structural barriers to accessing care. And it mattered. We can see here on the bottom left that we had different outcomes, lower readmission rates for cardiology and increased follow up for patients who are admitted to cardiology.

[10:21] Next slide. So we did a follow up study by surveying providers, and we found that white patients are perceived to advocate for specialty care more often and more strenuously, and that providers were responsive to this, when patients asked. Also found a little bit of a difference in terms of outpatient providers calling, or sorry, emergency providers calling outpatient providers more often for white patients. So you [sic] some of the mechanisms potentially at play here. But obviously, we couldn't get to the full story of all the different things that are contributing to these outcomes.

[10:56] Next slide. So finally, and this is where I'm going to turn it over to Dr Morris. So what do we do about it? This was the big question. What are the different approaches that are out there? We were sort of underwhelmed by what we found, right, mostly, which were race-blind or color-blind sort of interventions. And so we really wanted to think deeply about what was the action approach from public-health critical race practices that we could take here. I'm going to turn it over to Michelle.

Michelle Morse, MD, MPH: [11:24] Thanks, Bram. And thanks again, to the AMA, for having us and to all of you for trying to be both innovators and change agents in your respective spaces when it comes to health equity. I will say I suspect, just based on the numbers in the window, and based on what I'm guessing, may be true for a lot of your work, this is not easy. And a lot I think of how we get through this work of really trying to re-jigger the wheels of how our systems work, is building up your muscles for being able to handle and, I wouldn't just say handle, I would say engage in disagreement, and despite disagreements that you may have with people at your institutions, manage conflict in a way that is really productive. So I suspect that in the discussion, we'll get into what that looks like for all of you. And I'll certainly say, my muscles for productive conflict have certainly grown tremendously over the past decade or so of doing this kind of work. But with that in mind, as Bram was describing, from the beginning, our hope with this heart-failure project and program was, if we confirmed what we thought was happening, and the data bore it out, which of course it did, then our responsibility was really to actually make the changes that were necessary to end the inequities that we uncovered. And so one of the ways that we attempted to lay that out and make it clear is through really describing our experience over several years of developing the project of developing, research questions aligned with public health, critical race praxis. Also describing a bit of the history of how these inequities and racial injustices came about, and then really get into what does this mean for us? And how do we ensure that we're being held accountable for doing something not only studying the patterns and so this piece in the Boston Review, which several people probably have never heard of, and almost very few people probably read, honestly, is, where we were able to publish this article around an anti-racist agenda for medicine. And similar to what, what Bram described about Dr. Jones and her definition of racism, for those of you who have seen her speak, you may have seen her talk about walking against the kind of propelling pathway or walkway that you see in an airport, right? Like, you know, your first decision is to turn against it, and then walk in the other direction. And in many ways, that's kind of what we tried to outline in this paper.

[14:20] Next slide. And what we were really trying to say is, having uncovered this pattern of institutional racism and heart failure care, how do we actually intervene? What is the pathway for action? And how can it be grounded in the history of pathways for truth and reconciliation and reparative justice that have been used in many other disciplines outside of medicine? We, I think, rarely in medicine looked to...or all too rarely look to other social science fields for solutions, and in this case, that's exactly what we did in large part because of our past history of work in the realm of social medicine, and certainly with Paul Farmer being one of our one of our mentors. And so we look to economics actually, and many of you may be familiar with Professor Sandy Darity And Kirsten Mullan. Professor Darity is an economist. Kirsten Mullen is a cultural anthropologist and cultural change worker. And together they have worked on reparations for quite some time. And what we wanted to do was say, all right, these folks have been looking at this as a framework for action, for repair, for redress. How can we apply their frameworks and their learning and their actions to what we found as an example of institutional racism in medicine. And so their framework is around acknowledgement, redress, and closure. And if you have time, you should definitely check out their book, From Here to Equality. It just came out last year, and is a very thorough history of reparations. And I should just clarify that the definition of reparations that we're using is this is cash payments by the federal government, to Black American descendants of enslaved people. So reparations must be at the federal level, it can't be at the institutional level. However, what we're also saying is, even if reparations at the federal level were paid today, and they should be, there would still be institutional racism, there will still be patterns of institutional racism.

And so at the same time, we also need to be organizing and implementing and acting around anti-racism interventions at our institutions. And so that's kind of how we came up with the Healing ARC, building on their framework of acknowledgement, redress, and closure. So if you...sorry, can you go back? If you have developed or studied or found an example of institutional racism at your institution, organization, within your community, these are the steps that we suggest we take in to really actually intervene upon and fix, attempt to fix. It's a process, right? There is no silver bullet for any of this. But this is a pathway to attempt to fix and address some of those inequities. So acknowledgement begins with really actually being fully transparent and voicing responsibility for the injustice. Redress is the reparative action and compensatory action to address the harm that's been caused. And then closure is when the community that has been harmed, actually themselves say that the harm has been adequately redressed. And so it's not about what Bram and I think it is complete. It's really about the people who have been impacted by institutional racism in heart failure care. And this is all aligned again with the reparative justice approach, and certainly, hopefully something that you all feel is feasible in your respective realms.

[17:59] Next slide. So specifically, how did we do this, for our heart failure work at Brigham and Women's? One of the ways that we felt was a specific point of intervention. And again, this builds on what Bram was presenting earlier, around the survey of providers in the emergency department. So this best-practice alert is what was implemented at Brigham and Women's Hospital after many, many, many months of conversation about what kinds of interventions could really get at the drivers of this pattern of institutional racism in heart-failure care. And so the best-practice alert really describes, again, it's a step towards acknowledgement and redress. It describes when a patient who is Black or LatinX, with a primary diagnosis of heart failure is admitted or the click happens to admit that patient in the emergency room, a best-practice alert comes up and say this patient is from a group that has been historically excluded from cardiology specialty care. So really think again about where this patient should be admitted. And I think that, again, raising awareness amongst providers, it sounds like it should just happen, and we can just do it, and it's fine, and people will change their behavior. And as all of you know, is quality improvement and equity people [sic] that is absolutely not how it happens in real life. And so really using this reminder, and acknowledgement, again, about the wrongs that have been done is critically important.

[19:33] Next slide. And that this has just begun to be implemented at Brigham and Women's Hospital. We're tracking it very closely to see what impact it has on this pattern of exclusion of Black and Latin X patients from the cardiology service. And then the final step is around closure in the Healing ARC framework, and one of the ways that we've attempted to do that is through community wisdom councils and I think, Bram, and even I know I think I saw Reagan and Esteban who were also on and were involved in this, Karthik was involved in this, I think all of us would probably say that we wish we had involved the directly impacted community earlier in the process. So lesson to all of you who are thinking about using the Healing ARC framework, you know that involvement and engagement from the beginning is critical. But what we've been able to do over the past year and this is ongoing, this spring and summer is...actually have the Wisdom Councils are people from across Boston, and actually some of them outside of Boston, who have themselves been community leaders and activists and either them [sic] or family members have been directly impacted by examples of cardiovascular inequity and racism. And essentially, what they are doing is developing a framework themselves and a roadmap that can be used to really get to closure. And our belief is that this is going to be a really important piece of being able to say that acknowledgement, redress and closure have all been adequately addressed.

[21:03] Next slide. So, of course, it all sounds perfectly good, right, like you tie the bow and problem solved. But of course, there was quite significant backlash, unfortunately, against this work. We, unfortunately, were targeted on social media and in many right wing...I'm laughing at these pictures of us because they're pretty hilarious. But anyways, the right wing press, there were over 25 articles and right-wing press, calling us racist. There were threats to the institution, there are threats to us. And then a few months later, there were unfortunately neo-Nazi groups this winter who marched on the lawn of Brigham and Women's Hospital saying that we are racist, and that what we're trying to do is not fair to white people. So you can imagine our surprise, right? Again, like who reads the Boston Review? We certainly didn't think white supremacists were reading it. And yet there's been tremendous and quite consistent, now over a year later, ongoing backlash against this work, and against us personally.

[22:20] Next slide. And unfortunately, I think that that is a trend that many people who are working on racial justice, and health equity and challenging the system are experiencing this backlash as well. So it's certainly not just us. And we are still quite protected as doctors. So I think that's important to mention. Even though this backlash has been fierce, we have a lot of resources at our disposal, and there's a certain protection that our positionality and titles offer us. But this part of the reason for this backlash, in our opinion, is, of course, what W.E.B. Du Bois called the wages of whiteness. This is, Kumar Jones would probably describe it as like internalized racism for white people, it's this internalized feeling of superiority that white people have, because they've been told in our society in every way possible, that they are superior, right, and that the reason that Black people and other people of color are, quote, unquote, behind is because we're inferior. And that becomes internalized in lots of different ways.

[23:24] Such that, next slide, it even seems that efforts to improve racial equity are unfair to white people. That's how it has been interpreted by people, again, who believe themselves to be superior. And it all feeds into this great replacement theory idea that I'm sure many of you have heard about in the press over the past several years. It's kind of been growing in...I don't know...support, and certainly is racist, and the foundation of white supremacy in many ways, but essentially says that liberals, Jews, and others are essentially trying to replace white people as the dominant racial group. And that is, of course, unfair to white people. And there's a lot of support for this. This is one of those theories that used to be kind of a fringe white supremacist theory and now is, quite frankly, promoted on Fox News quite regularly. In fact, some recent research that just came out showed that a third of Americans and half of Republicans believe in the great replacement theory and that is scary.

[24:40] Next slide. So, at the same time, that is the case, the idea from our perspective, in terms of how to manage this backlash is really the best response to neo-Nazis marching on Brigham's, lawn and threats, and, critiques that we're somehow racist, the best response is for as many institutions, people, organizations as possible to take up this kind of work and use a Healing ARC framework to actually impact change and reduce the racial inequities that are found. And this is just one example of that. Our colleague Scott Heysell and Greg Townsend at UVA, published this article, really describing how UVA itself has actually undertaken this process. I think...they've probably been doing this work for about two years or so now, I think we've been in conversation with them. They have uncovered a similar pattern at UVA in care. And they are planning an implementation program around using the Healing ARC model to address the institutional racism that they also uncovered at UVA. And we want to see more of that. Again this is the best response to a backlash from white supremacists who have completely misinterpreted and misconstrued what we're trying to do, and who have also completely misinterpreted and misconstrued the true nature of the current social arrangement in the United States, which puts white people on top.

[26:09] Next slide. Similarly, the American Medical Association, they, in their strategic plan that came out just a couple of years ago, mentioned our work and our framework of acknowledgement, redressing closure. And also, of course, is hopefully one of the ways that even more institutions will take this framework up and use it.

[26:33] Next slide. So ultimately, the answer is, we are undeterred. This program at Brigham is moving forward, it has been implemented, we are measuring the impact. And we are doing our best to share the experience and the planning and the process of this work with as many people as possible so that more of all of us can get on board with not just studying racism, but ending the impact that racism has on health outcomes.

[27:06] Next slide. So yeah, this, I think this says it extremely clearly. Again, the work continues. You know, any neutrality essentially supports the status quo. And the whole point of anti-racism work is to interrupt the status quo, because that is a huge part of reconfiguring our systems to be more fair and equitable, and just, for people of color.

[27:33] Next slide. I think this may be the end. Yeah. So we have been so thankful for many of the people who have rallied to our side, including the global campaign Against Racism that Equal Health started four and a half years ago. That's one of the organizations I cofounded. And that campaign was really one of the first to come to our side. We also worked with the Massachusetts Coalition for Health Equity, and they were able to put together a pretty incredible petition, and multiple other friends and colleagues, advocacy for change, many others have come to our side really to support this work. And again, try to expand it.

[28:14] Next slide. I think there might be a little over time, but I think this is...I think only have one or two more slides here. But we did want to take a moment to mention another example of this kind of work. And this is work that I've been doing here in New York City, as one of the interventions and as an accelerator to really make sure that change in clinical algorithms and racism and clinical algorithms, and many of you, I think, have been a part of this battle and this wave of change for ending and de-implementing race adjustment and clinical algorithms. The reason that we launched this coalition in November of last year here in New York City is because number one, well, we've got, a massive city—biggest city and biggest health department in the country. And there were institutions like health and hospitals. And I know, Lou is going to speak to this in a moment that in New York City had already decided to de-implement race adjustment in EGFR, or in spirometry, or in vaginal birth after cesarean section. But it was a patchwork; there were these kind of exemplar institutions that did it. But it was not a part of the standard for the city by any means. And so the idea here...and we also fought this battle at Brigham, it was ugly, and it was not easy. But ultimately, it did also get to implemented at Brigham. And so with those experiences and knowing how fragmented our health care system is, in my role as Chief Medical Officer, we decided to launch this coalition to get as many of the biggest health systems across the city to join and decide collectively to de-implement race adjustment, number one. Number two, to measure the impact on racial inequities that are related to those various clinical algorithms, and we decided to focus on EGFR, spirometry, and VBAC. And then thirdly to develop and implement a patient engagement plan to make sure that patients whose care was delayed because of race adjustment actually got the care that they deserve. So I think in those three goals, you can probably see a lot of resonance with the Healing ARC model and acknowledgement redressing closure. But we ultimately had 12 institutions join the coalition are now nine months in, our inaugural report is going to be coming out very soon. And we'll make sure we share it with you all. And it describes not only the history of why these algorithms are racist, but it also describes all of the ways that the institutions, including the six largest health systems in New York City, why these institutions, what they're doing at their institution, what's facilitating and inhibiting change, and how they're moving forward with these three goals of the coalition.

[31:03] Next slide. So thank you to all of these fabulous people and many others who are not listed here. This has been truly a "teamwork makes the dream work" kind of an effort, and it's included every sector of the hospital and community in many very profound ways.

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