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The Intersection of Infection Prevention and Control and Health Equity

Learning Objectives
1. Identify infection prevention and control
2. Define how infection prevention intersects with health equity
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Audio Transcript

Stories of Care is a podcast, presented by the American Medical Association and CDC's Project Firstline, committed to deeply exploring equity and infection control challenges through the voices of health care professionals. The COVID-19 pandemic has highlighted long-standing gaps in infection control knowledge and practice. Stories of Care addresses the wider context behind these gaps, how they relate to health care equity, and how frontline personnel are rising to meet these challenges in health care settings.

Megan Srinivas, MD: [00:00:00] Welcome to Stories of Care. In this episode, I spoke with Dr Michael Bell, an expert in drug-resistant pathogens and hospital-acquired infections at the Centers for Disease Control and Prevention and Dr Karthik Sivashanker, Vice President of Equitable Health Systems & Innovation in the Center for Health Equity at the American Medical Association. Together we discussed how infection control and health care equity intersect and what our own experiences have taught us about the urgency and complexity of embedding health care equity into our work.

Thank you both for being here today to help start this conversation on the intersection between infection prevention and control and health care equity, two very important things that people don't often connect in our society right now. Dr Bell, I would love to start with you and ask you exactly what is infection prevention and control?

Michael Bell, MD: [00:00:21] Great question. I wish more people would ask it. Infection prevention control are two sort of circles on a diagram all related to patient safety, personal safety and the safety of our colleagues. The prevention side of it. When I think about IPC, the P is generally the protocols and practices we use to make an outcome better. So when you think about inserting a central vascular catheter, the fact that we use a checklist, that is a protocol that is intended to reduce contamination of the line, which reduces bloodstream infections, and so that's prevention, usually a very systematic thing. Infection control is a little bit broader. This is the idea that we need to recognize where infectious material might be or be coming from and do what we need to as appropriate to keep it from spreading. And that can be anything from recognizing that a crowded waiting room full of coughing people is a bad thing. Right. We've learned a lot about this past year or also recognizing that if somebody leaves a used needle out on a procedure tray, that is a hazard that needs to be addressed immediately. Those are all infection control issues. And as I said, they are very broadly applicable both to help our patients survive their stay or their treatment, but also to keep ourselves and our colleagues safe.

Srinivas: [00:01:47] It's so interesting that you talk about this from and how patients might interact and spread diseases to one another all within the same system, which then looking back at the year and a half that we've had thus far that you referenced, makes you wonder why within the same systems we're having such different outcomes between patients. Which brings me into your area of expertise, Dr Sivashanker, what exactly is health care equity and how does it tie into this whole IPC approach that Dr Bell was talking about?

Karthik Shivashanker, MD, MPH, CPPS: [00:02:18] It's a great question and a fundamental one. So maybe we'll start with health equity and we talk about health equity. We're talking about fair and just opportunities to be as healthy as possible. So that means removing obstacles to thriving like poverty, discrimination, powerlessness and lack of access to goods, fair pay, education, safe environments, criminal justice and, of course, health care. And so when we say health care equity, we're talking about that specific domain that contributes to the larger picture. And so that's everything from access to care, but not just any old care, high quality, safe, and equitable care. And that includes preventative care and specialty care treatments and so on, which is important to distinguish from a quality. And I think this is kind of getting at your question, which is the default approach we've always taken in health care has been the same for everyone or this sort of color and identity blind approach, which actually does not lead to high quality care and outcomes for populations. Just one example. If you're a person with a disability, it doesn't make sense to give you equal care. That might mean giving you the same documents in the same font size, but if you have low vision, that's not providing high quality care for you. So what we need to do is actually think about how do we design our systems or practices to provide exactly what each population needs to maximize their chances of thriving. And one other thing I mention getting into this is providing kind of the foundation for why things are the way they are and have not worked up till now, is that we've applied that equality concept very poorly, by the way, up until now, and how we design processes, systems, laws, policies. So we're not even getting to equality when we design. But that's been the driving principle. But that has ultimately ignored that historical legacy of disinvestment and deprivation in policies for historically marginalized minorities, communities. That's led us to a highly unequal society. So when we ask the question, why are there different outcomes? Why are different populations faring differently? It's because we exist currently in a highly unequal society and it's been designed that way. And we need to undesign it.

Srinivas: [00:04:39] And that is such a good point. How do we undesign the systems that exist to make them more equitable? You're at the CDC, Dr Bell. That is a long-standing system. What are some of the things that you see that need to be changed, that have changed, that are moving us towards this direction of increased equity?

Bell: [00:05:01] So I am, first of all, super happy that we're having this conversation right now, but I am also extremely sobered by the reality that this is a first baby step. [00:05:11] We have so much to do. And I would love to say that there is all this stuff happening that is changing health care equity in our country right now. But I don't think we're quite there yet, quite honestly. I think I'm seeing right now early evidence pointing at, for example, from the COVID response, how different people perceive health care. We've done a lot of community outreach to understand why some people are or are not accessing care or vaccine. And when you look at the responses, a lot of it is couched in the sense of they will judge me, they will treat me differently or badly. I could even be harmed if I go in for this because of who I am or what I am. And that, to me, is such an existential crisis for health care, especially in a country as diverse as ours. [46.7s] I think this is both a huge task, but one that we are only starting to undertake. That said, I think that there are really great opportunities to do what you just heard Dr Shivashanker say in terms of create equitability, not equity, not equality, but equitability for simple minded people like me who like visuals. I saw a great slide about bicycle's equality as everyone gets the same ten speed, no matter how tall you are or what your needs are, equity is getting a bicycle. You can ride well. And that is something that we certainly focus on in my division at CDC to start thinking through what do these people need in order to do as well as they should. And if you take examples as concrete as, for example, hemodialysis, this is a population of individuals who are starting with a health issue that puts them at a major disadvantage, that are tied to a health system that is supposed to change out their blood, all of it three times a week, a major issue. And yet most of them are not high in terms of socioeconomic status. Many of them come from communities or backgrounds that are inherently disadvantaged because of racism or other inequities. And thinking about how we from the health care safety, infection control perspective can do more to raise both understanding and awareness. I think that's an important starting point, as well as impact and effectiveness of care for that population is one of the examples of areas where we're focusing.

Srinivas: [00:07:40] You both have tied into a lot of these longstanding socio-demographic issues that we really need to start paying more attention to. I love the fact that Dr Sivashanker, you haven't mentioned that too long. We've been colorblind as providers trying to pretend that everybody is equal when they're not. What are some of the factors that we have overlooked that we as health care system, as nurses, physicians, techs, whoever we are in that system, need to start looking at more carefully to ensure that we don't make that mistake any longer?

Shivashanker: [00:08:17] Yeah, and I want to offer a slight reframe in that I think we should value each other fundamentally as human beings equally, meaning we all have inherent value. But what we may need to thrive may not be equal. I think that's an important distinction. So going to where I'm sorry, can you say the question again? Because I got a little caught up in that part of it, but I do think that's important. You're asking about the opportunities are like where we need to be focusing our attention

Srinivas: [00:08:54] And what have we been overlooking when we look at patient care, when we look at our subset and the people involved in it, that we really need to start paying more attention to?

Shivashanker: [00:09:05] That's a hard one because the answer is everything. So I'm going to give you an example. [00:09:09]Some of my work has been has been really focused on this intersection of quality, safety, equity. And one of the first things we started doing was asking with every single Hahm event happening in the hospital, what is there an inequity associated? We hadn't done that before. And then if there was, at what level was it structural? Was it institutional or was it interpersonal? Was it implicit? And from there, applying our analysis to identify the contributing factors to actually lead to actions at a system level, what that did was it opened up a Pandora's box. So what we found was that in the year before we started doing that, out of all of our safety reports, all of our patient complaints, we had none related to equity. We had no inequities, apparently. And in the year after, we had hundreds of them, you know, hundreds and hundreds. So the point is that we're systematically blinding ourselves to these issues. The way we've been doing the work has been making it invisible. And when it is visible, we haven't taken cohesive, meaningful action. So what I'm really saying is pick an outcome, almost any outcome out there and look hard enough and you're going to find inequities. And the question is, what are we going to do about it? We don't need any more studies at this point. Identifying disparities across X or Y outcome. We need actual action supported by resources and infrastructure, focused on system redesign. So, so and when we talk about infection control, that that holds true as well. And COVID-19 has been a great example, which I'm sure we're going to get into. [96.0s]

Srinivas: [00:10:47] The system that you were doing at Brigham sounds really innovative compared to what I've heard prior. What came out of that? I know you said you had a lot of outcomes that certainly rang the bell saying, hey, we have equities everywhere. Did that turn into solutions?

Shivashanker: [00:11:05] Yeah. So this is a five driver approach that we developed originally at Brigham and Women's with the Institute for Health Care Improvement, implemented at Brigham and Women's with a lot of success and power. It since spread, for example, in part to New York City health and hospitals. We're now advancing at the AMA with those partners as a national strategy. So there's five drivers to it, which I just briefly mentioned, embed equity in all of your risk analysis, embed equity into all of your high reliability, education, quality, safety, education, et cetera. Use data to support your equity data, to support your higher reliability efforts, engage leaders and then organizational accountability. But at the core of this whole model is we're taking an individual patient event and an individual harm and we're going deep into that to identify the root causes. We're then layering data on top of that to say this is not just this one patient, this is a broader problem. And then we're taking our existing technologies, our processes, our structures and leveraging them to actually drive in advance equity as opposed to trying to do equity as a thing over there. We're doing it as a core part of our mission strategy operations. And that's what success looks like when you don't need equity leaders like me, because this is a core part of all of our work. So it's a powerful approach. We are launching a network at the AMA with other partners at end of this year to continue to share this approach. But I think it is the future for health care and quality and safety, specifically in terms of advancing equity.

Srinivas: [00:12:46] That is really exciting for me to hear, and I agree with you. I really want to see these kind of initiatives being part of the everyday. Unfortunately, we're not there yet, as you've both highlighted. But it makes me wonder, as you alluded to it, the pandemic. Dr Bell, being at the CDC, you've probably seen a lot more of the national data coming from all different sectors and how systems are handling it. So when looking at the pandemic and adoption of models such as the one that Dr Savchenko referred to, are you seeing that starting to become a trend or is that something that is still not being acknowledged in most places in our country?

Bell: [00:13:25] I wish I could say there was a trend. I don't think we're there yet, you know, echoing what you just heard about having to have an equity leader, I feel the same way about patient safety advocates. Right. Why should there have to be patient advocates? I, as a physician, should be a patient advocate. Every nurse should be a patient advocate. We need to embrace that level of responsibility. And yet many of us, I think, focus mostly on the technical element that we bring to the bedside or to a patient care process. I think that when I think about this, there are two elements that are particularly germane. One is the blindness that Dr Severe Shankar mentioned. And to me, that means what are the data elements? How do we measure this? Because if we're not able to look at it and measure it, it becomes very challenging to know if we're making progress. And so some of what we are learning right now, and this is not the science side of the house. This is the social engineering. This is the communications and population dynamics side of the house that is learning about how do we ask these questions? What does it mean? Many of the people who are harmed by this have had generations of training that what they say doesn't matter. They've had generations of training to just stay quiet and try to get through it. And that makes it even harder to establish a new culture and that culture changes. I think the other thing that I think is central here, you know, it's great to embed metrics. It's great to have policies. But I think at the heart there needs to be a deep sense of cultural expectation and that is particularly hard for the health care world, because we all feel that we wear white hats. Right. We all think we are doers of justice and great things for people. And it is extremely ego dystonic to then be told. But actually, you're doing a bad thing to that person. You may not know it, but you are. And making that something people can talk about is something that I think is a very big but necessary lift. The culture change is something that I think about even on technical levels. When I expressed this to colleagues on the infection control side of the House, I bring up the idea of any of us walking into a hospital right now and lighting a cigarette what would happen. It's not just the clinical staff that would jump on you and tell you that's ridiculous and unacceptable. The entire group of people, whoever they are in that facility, would tell you that's ridiculous. Don't do that. And yet, when I was in training, there were cigarette burns on the armrests of the medical school lecture halls. Right. So we're able to make big changes. What I wonder is how we make a similarly pervasive change when it comes to a topic as complex and subtle as this.

Srinivas: [00:16:22] I love that concept that we need to bring out the discussion that we really need to realize that honestly, paraphrasing what you were saying, that people make mistakes all the time, even if we have good intentions in our approach. And recognizing those is fundamental to shifting our approach to these issues. I would love to know from both of you just because personal stories help so many relate and discussing how when you take away the stigma of admitting these mistakes, I would love to follow trend and ask each of you what was some moment that you realized that this was something you needed a change or a defining moment that made you really go into this health care equity viewpoint?

Shivashanker: [00:17:10] Do you want to start, Mike, are you going to start here OK?

Srinivas: [00:17:13] I'm not being easy on you guys. This was a hard one.

Shivashanker: [00:17:17] Sure. And I just want to follow up on a couple of Mike's comments, which were which were I agree with most of what he said and if not all of it. One thing I'll say about culture change is, it's not easy, as we know. And is it because it's pervasive? It's even more hard to tackle so that this is the inequities that we're seeing are not being driven by individual bad actors. Individuals have a role, but it's being driven by systems, policies, practices, culture, norms. So I noticed Mike and what I'm about to do is a difficult thing, but it's is like calling each other in for moments of curiosity, because that's what culture change is going to look like, because we're all at risk at times for for these things. So when we say white hat or white coat or white label or white paper as opposed to blacklisting. So these are the subtle ways that it shows up in. And I do this stuff, too, right? We're all because we're all exposed to the same media, the same books, the same education in large part. And so it's a pervasive thing. And another way to put this is don't critique, don't personalize the critique of systems. So in me mentioning that, for example, that's not saying that like Mike is good or bad or I if I make that fall into that trap, which I fall into it every day, I'm good or bad. This is about saying it's in the systems, it's in the air we breathe. That's why it's so difficult and that's why we're gonna have to do it together with curiosity. And so when we talk about culture change, we're talking about creating a container of safety where we can actually explore this together, transparently, examine ourselves, examine how we're working with each other, and then seek improvement that way. So I'll give you a personal story and then I'll be really interested to hear, Mike, how that felt for you, because sometimes we gloss over, like, how it actually feels to have these conversations in our bodies. But that's where this trauma lives for all of us. So we're really curious to hear how that felt. So the story that always sticks with me around the pandemic especially, is we found early on that our lower income employees were getting COVID at much higher rates, up to 10 times the rates of our physicians and nurses. And we did contact tracing, etc. We found that it was probably a community level transmission and that community level transmission, unsurprisingly, reflected historical redlining. So it was more often the communities of color that were historically red line and poor communities that were getting covered at higher rates. And that was reflected in our employees. So we launched a very big internal initiative to meet with a thousand plus staff in person during COVID with all the precautions based out in multiple languages. So these are environmental services staff, our food services, our transport workers, our security workers. And the goal was was multifold. It was to share the data with them. It was to encourage them to get testing, to let them know it was safe if they tested positive that their job was safe to provide them resources, including, for example, hardship grants. So a whole bunch of things. But where we did it was in the Bornstein Auditorium at the Brigham and Women's, which, as you know, back in twenty eighteen, I want to say there was a lot of controversy around taking down all the portraits because the portraits in that auditorium were all of white men, except for one which was an Asian man. And so there was a backlash to taking down those portraits. And so when we were having those meetings in the auditorium at the end of one of them, one of the employees came up to me and she said I didn't. Well, she said thank you. And then she said I didn't know I was allowed to be here because the only time she'd ever been there was to clean the room. So think about how caste or class racism shows up in the hospitals, it shows up not just in terms of our interactions, she shows up in terms of space and who feels like they can belong in that space. And so imagine if we'd had mostly brown, black employees, poor employees sitting in an auditorium with only white men surrounding them as the example. This is what excellence looks like. How comfortable and safe would they have been and what does it mean that they never have been there as an audience member? And that's not saying that excellence that those folks didn't do excellent things is just saying it's the wrong narrative. And so that always stuck with me because it was bringing together all these things, the disproportionate impact on these staff, the sense of belonging. And that story always just hit me that we have not created an environment in health care where our employees across the spectrum have a sense of belonging and are being given fair opportunities.

Srinivas: [00:22:35] Thank you for sharing that, I know you had a couple of questions for Dr Bell that I would love to hear, Dr Bell. Also, just a defining moment for you.

Bell: [00:22:43] Yeah. So to dove into your initial question, I felt fine. I am happy to be corrected. I you know, one of the things that I learned when I moved here to Georgia from a friend who grew up here was when people say things went south, that's actually not a welcome phrase either to people who live there. And so there's a lot of stuff that we do linguistically, especially in a big, diverse country like ours that, you know, can have unintended consequences. I find that kind of correction to be very welcome and easy. There is no physical thing happening there for something like that, especially in contrast to the smoldering, if not flaming anger that people live with from daily assaults, if you will. I am set up to tolerate a great deal of criticism because I come from a position of privilege. Right. I am a lucky guy who got, you know, born into a family that valued education, sent me to school. I'm in a profession that comes with great privileges and amazing responsibilities. I can I can pay my rent. I'm not worried about being evicted this week. There are so many ways in which I am free from that kind of pressure and anger. And so the minor criticisms bring them on. More is better there. I think, you know, getting to the question of personal experiences, there are so many just in medicine. You know, I've been in the field for forty years and you see a lot. And it ranges from recent immigrants who have to navigate an extremely frightening system to misdiagnoses related to language challenges, where someone didn't take the time to figure out what was actually going on. There are those sorts of things. And then there is the work that you do with colleagues. And I'll focus on that for the story part. I have a very dear colleague who is a doctor, highly trained woman of color. She is brilliant and at times quite angry. And she expressed it better than anyone I've ever heard do so about how exhausting it is to always have to claim your right to exist in a space. And her point is, I shouldn't have to claim. And yet every minute of every day I spend time and effort claiming my legitimacy. And, you know, it was this exhausted sense of frustration and anger that I think comes from that endlessness. I see that as a very important thing to sort of reflect some of what you just said in terms of the person who didn't think they were allowed in a certain room. Right. That's a very specific instance of it. But it's not just in a fancy boardroom, right? It is everywhere. And, you know, that is something that I think we need to start considering in the clinical realm, not just what are we doing in the clinical realm, what is our system, but what are people bringing in with them? What were they dealing with five minutes before they walked in the door? And how does that affect their interaction with me, regardless of whether I was out there with them or not? And I think we are quite literally blind to that. We like to assume that everyone comes in and sits down in front of us in the same mindset, in a similar sort of frame of existence. And that is painfully not true. Also in the occupational realm, I will share a happy story, not an angry, frustrated story. And that was the sort of acoustic response in a room. This is before COVID. I was talking to Environmental Services staff at a national meeting and I made a very simple bar chart of interaction intensity between a patient and health care staff and what it looks like over the course of a two week stay. And I'm very quick to point out that as a diagnostic physician, I have value on arrival. I make a diagnosis. Hopefully it's right. I make a prescription. I follow you up and see you every day or so and make sure things are going well. But my impact is up front and then little bits downthe road. Nurses, on the other hand, lots of interaction every single day, all day long. But invisible is the Elysées service and the environment itself that is constantly in contact with that patient. I can do a perfect job, but if the staff aren't there to do theirs, my patients are going to likely get an infection and die. It's extremely probable. And that mere moment of simple recognition led to this cavernous sigh and then jubilant cheer of people who were responding to being recognized maybe for the first time by other professions, and I think certainly as physicians, we have an obligation to do better with regard to not being this sort of perceptual monolith. I think we hear plenty of feedback from our nursing colleagues who are more positioned to claim an equal role in health care. I would suggest it might be greater than equal, but we have many other colleagues, whether their respiratory therapist, environmental services staff, dialysis technicians who often come from less privileged backgrounds, who are not educationally at an equal level, equal in air quotes, but whose role or roles are at least as important on a survival basis for our patients.

Srinivas: [00:28:22] That is so interesting that you bring that up, because that is a push that I know a lot of health systems are trying to go towards, recognizing that everyone has a hand in ensuring that the patient outcome is the best it can be. And actually, it made me think of one. I went to University of Iowa for my medical school and one of the things I was so proud to see this past year in the middle of the pandemic is when vaccine rollout happened at the University of Iowa hospitals and clinics. The very first person in the entire system to get that shot was somebody on the housekeeping staff, and they made sure to put that message out there. What is the importance to people in our health care systems, in our communities of seeing a message like that?

Bell: [00:29:06] I'll jump in very quickly. I think it's invaluable. It would be even more valuable if the chief of staff was right next to that person and they both got their shots together. I think that so I'll be like Karthick for a moment and call you in. Housekeeping is for hotels, right? That's fluff the pillows and wipe up the crud. Environmental services need to apply disinfectants and stimulants in a successful way every single time, and this is a component of that labeling thing that this is my labeling soapbox. I really want to make sure that we recognize that we're asking for a technically very different thing. And when I hear housekeeping, I sigh a little bit because it just sounds like, yeah. Can I get a couple more towels here, please? And that's probably not the case.

Srinivas: [00:29:56] I appreciate that. Thank you so much for changing my vernacular. I'll be more conscientious in the future. I think we have a very unique group here in the sense of where we're all very equity minded. How can we do this calling in an overburdened workspace, especially one that is already filled with people who are burning out from all levels, from the EDS to the physician and beyond because of COVID? How can we do this without eroding at their well-being? And how can we do this in a way that affects change in that workspace?

Shivashanker: [00:30:32] I can take a first attempt at this, and what I would say is what it looks like is exactly this. It's so I would even reframe it from critique to it's an invitation to dialog and learning, because, for example, when we're using these terms, they're going to evolve. Some of the terms I was using last month are already feeling outdated. We talk about people of color and then I've heard recently people of the global majority. So terms are going to evolve. We're always learning and growing. And the goal here is not to be, you know, the term police. The goal is to just observe in a growth mindset how we're using language, how does it impact each other and our ability to do the work. So it's about curiosity. And we cannot be afraid to talk about these things because that's one of the things I see most often is especially with white folks, they're afraid to wade into the water. They're afraid of saying something wrong and then the repercussions. But we have to create enough safety for folks to take a step and fail. And then we have to work with them and move them along. Now, that's not to say that that burden should always fall on people of color. To be clear, this is primarily the work of white folks and other folks of privilege around their privilege. But for those of us in this space doing this work, it's important that we create that container and that safety. So burnout is, to me, I think, very tied to white supremacy culture. So what do I mean by white supremacy culture? I'm not talking about people in pointy hats, burning crosses. I'm not talking about that type of thing. I'm talking about the dominance of white Western values norms in everything. So that's, for example, the perfectionism, the sense of urgency, the right to comfort, etc. But what's important? Why am I bringing that up as it relates to burnout? Because it also burns out white folks. It's that culture that we see in medicine especially, and that culture is exhausting to work in. So it's so when we talk about equity, one of the concepts that's important is that equity is not a zero sum game. There's this myth that if you're doing something for one group, that it's only for that group, that's less pie for me if I give a slice to you. But actually, when you make things more equitable for our most historically disadvantaged groups, you tend to make things better for everyone. So when we think about burnout, let's not just talk about burnout of physicians. Let's talk about burnout of our frontline workers. Let's talk about burnout of our transport staff and food services. And they may be burning out for some of the same reasons and some of them different reasons. But at the end of the day, when you start to design solutions, let's design solutions that work for everyone and that improve the well-being for everyone. One last thing I'll say there is I just want to go back to Mike's comment about recognition. And I did see that happening. A lot of health systems, recognition for environmental services and their efforts and other from workers that had historically not been recognized. I think we have to state it. And this is something physicians need to do more of is advocating not for ourselves, but for other groups in the hospital. So real recognition for environmental services is paying them at least a living wage, ideally a thriving wage. That's what recognition looks like. It's not the pat on the back which feels good. It's not the award. It's not the flowers that we handed out. It's paying them a thriving wage. And what would it look like to get there? What would it look like for health systems to take the lead in that way? And with when you think about it, some of our health systems have 70, 80, 100 thousand more employees we're talking about now, community level impact. So I just felt the need to mention that.

Bell: [00:34:32] Well, to extend that thought, I would love to see a situation and this is not just for the stuff, but it probably extends to many different sort of work tracks. But I think that part of the problem that we have right now is that there is no recognition of development of skills in environmental services. We don't have a tiered approach, which means that anyone working in that setting is interchangeable. I think one of the things getting to your earlier point, which I love, is that, you know, making systems that drive equity is part of how we need to work. I think that gives us the pathway to make things better. And with regard to this, I would love to see a situation where, as an apprentice EVS staff member, you're allowed to clean the lobby, the hallways and maybe the cafeteria. Right. Once you've demonstrated capability there, you become a journey person and that allows you to clean ordinary rooms and clinic spaces. And then as a senior or master level staff member, you are able to do intensive care units and operating theaters. Think about what that would do, especially if we then had CMS and other payers saying, you know, for anyone with an operating room, you need at least X proportion of master's level of staff. That means you can't just swap them out. It means that there is inherent value related to reimbursement and thinking about patterns of that sort that, yes, it might raise the net cost of the provision in a health system. And I'm sure there are people looking at me going, quit saying things like that. You're making things harder. But from an equity perspective, that would create a way to have a career path. It would create an escalator of salary. It would create dignity and pride in what you're doing. And right now, I see that missing not just in the US, but in a variety of locations. We've done much better with our so-called professional staff, but not for the bulk of that iceberg of personnel. So I do think that there is that systematic thing that we can do in a lot of different ways parallel to that and related to both fatigue and also culture. I don't think it works to tell people to individually do better. I think it requires leadership and the use of let's and we. And for me, a lot of the drive is about kindness. What can we do for this patient to make their stay better, to make them do better? What can we do? Let's make this a better experience for them. Let's be kinder. I think those are some basic things that we forget about when we're rushed, when we're focused a lot on technical things. And don't get me wrong, technical things are crucial and we need to do them right. It makes our job even harder. But then again, we are in a privileged position and are set up to do these things. We just need to embrace them. I find that, you know, something I learned from one of my early mentors as a house staff trainee was at the end of writing a set of orders for admitting a patient, asking the question, what else can we do for this person? What might they need? And that has sort of echoed in my head through my career. What else can we do that would be helpful? I think we are pretty much geared towards that type of thinking as a profession. So it shouldn't be that big of a lift, but it does mean extending it to our colleagues and doing it as a team.

Srinivas: [00:46:52] Before we sign off, I would love to give you each just 30 seconds. You both touched on so many important points, but just a 30 second message that you want our listeners to take away from this conversation.

Bell: [00:47:03] I'll leave us with an optimistic note. As I said more than once during this podcast, we are a community of people who really do want to do good. That is, by and large, why we are here. And so I'm optimistic that if we understand the problem, if we are able to recognize it and put aside egos and other challenges, we can make steps in the right direction. I think the mistake is to expect to change everything all at once. This is a very big problem. It's been here for a very long time. And so we need to start by taking steps, acknowledging them and then not resting until we're done. I think it's very much a process thing and any input that you have for me or the government at large, I would love to hear. So this is also an open invitation for great ideas. If you've got a success story, we would love to trumpet it for you. Thanks. [54.8s]

Shivashanker: [00:48:00] I think it's a great closing thought. And I'll add to that to say, you know, we're dealing with a complex historical trauma when we talk about inequities and racism that's been going on for hundreds of years. And the tendency is to seek the quick solutions to want to say with urgency, let's do X and let's do Y without actually having thought through all the potential ramifications, unintended consequences. So I'm saying that because as with any trauma, it's like an abscess. And when you open the abscess first, pus is going to come out and it's going to be painful. The beginning of healing is actually things may look worse. Things are going to be complex and ambiguous. There's never any rarely any neat solutions to these complex problems. And so the the offer, I think, is for us to begin the journey to embrace the uncertainty, the complexity and to move with urgency, but to make sure that we're centering historically marginalized communities and voices throughout that process. [57.1s]

Srinivas: [00:48:59] Well, thank you both for your insightful conversation that is going to hopefully help launch many other conversations in different parts of this country. And thank you for being here today, for being a part of this and for helping us start this podcast off on a right note. So thank you.

Outro: Stories of Care is a publication of the AMA and CDC's Project Firstline. Project Firstline is a national infection control training collaborative working to provide all health care professionals with the foundational infection control knowledge they need and deserve to protect themselves, their patients, their coworkers, and their communities. For more information, trainings, and other infection control resources visit cdc.gov/projectfirstline and amafirstline.org.

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CME Disclosure Statement: Unless noted, all individuals in control of content reported no relevant financial relationships.

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