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Health Equity Webinar Series: Operationalizing Racial Justice

Learning Objectives
1. Review core concepts related to health equity
2. Identify how social determinants of health uniquely impact marginalized groups
3. Apply strategies in practice for advancing health equity
0.25 Credit CME

Internet Enduring Material Sponsored by Stanford University School of Medicine. Presented by the Stanford Center for Continuing Medical Education, the Stanford Medicine Health Equity Committee, and the Stanford Medicine Racial Equity to Advance a Community of Health (REACH) at Stanford University School of Medicine.

This microlearning series on health equity will feature experts and leaders discussing strategies for promoting anti-racism in health care, addressing structural determinants of health, and identifying other root causes of health inequity. The overarching goal of each lecture will be to expand learners' knowledge and pass along strategies that will help clinicians advance health equity at their home institutions and in practice.

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  1. Leadership in Health Care


Video Transcript

Terrance Mayes, EdD: Hello everyone, thank you for joining us here at Stanford Medicine for our Building a Culture of Health Equity monthly lecture series. My name is Terrence Mayes. I'm the associate Dean for Equity and Strategic Initiatives and the Executive Director of Stanford Medicine Commission on Justice and Equity.

The Building a Culture of Health Equity program is organized by Stanford Medicine's Office of Continuing Medical Education, the Stanford Medicine Health Equity Committee, and the Stanford Medicine REACH Initiative (Racial Equity to Advance a Community of Health). This lecture series will highlight education, research, and innovation that work towards ensuring all individuals receive equal priority and the highest level of care, so that together we are building a culture of health equity across our nation.

Aletha Maybank, MD, MPH: So awesome to be with you all to talk about the work that we're doing at the American Medical Association. As we said, you know, so I'm a pediatrician by training, as well as a preventive medicine public health doctor, and really, after my pediatric residency and practicing for two years in a NICU, I really, you know, wanted to go back to my public health roots, but also was really turned off by the medical culture and by medical culturally at that time, you know.

Oftentimes I was told, well, you know we shouldn't be focused on all these other aspects of what's happening in a patient's lives, but it didn't make sense to me. You know if a patient was coming back repeatedly for, you know, an infection, or for obesity or for something else that I wouldn't understand the reasons of why they're coming back. And that let alone, it was really hard to figure out, once you understood the reasons, what we were going to do about it, you know, within the context of health care.

And health care has, you know, and had and still has, a pretty narrow view of what creates health in the first place, and so I wanted to go into a much broader space. And then I really got exposed to equity around the time of the unequal treatment report came out from Institute of Medicine several years ago. And then I was asked to be founding director of an Office of Minority Health in Suffolk County in the health department. And then came to New York City to the health department. Now at AMA and I'm also now a senior adviser at the CDC for internal equity work as well.

So at AMA in the year 20, 2020, rather, the House of Delegates. Well, first there was a public murder of George Floyd that all of us well, absolutely remember. Our board of Trustees put forward a pledge, and this came to surprise as many for AMA to kind of go forward in this direction because of our historical context, which I'll come to as well. But we released in past three policies, one to name racism as a public health threat, two to rid racial essentialism in our health care system. So you know, saying that for sure, you know race is a social construct. This data has been out for a long time, but we needed to say it explicitly as the AMA. And to support the elimination of racism proxy for ancestry, genetics, biology, etc, in clinical practice. So, we launched in last spring, May 2021. We released the publication of our first strategic plan at AMA to embed racial justice and advance equity.

We have 5 strategic approaches and it received and is still receiving, still, a lot of attention and we took our time, you know it's an 80-page document. That's usually way too long for a strategic plan. But what was obvious to me, as going through the space that we don't have a shared analysis or an understanding of the root causes of why these problems exist in the first place, and so we needed to spend time to kind of walk people through terms and start just to develop and shift some critical consciousness about how we're looking at understanding these problems of inequity, so that we can get to solutions in different types of ways, not in the downstream spaces only, but also in the upstream spaces only.

So these are the 5 approaches that we have. One is to embed equity throughout all the work that we do, so this is the internal work and I'll come to that in a second. Building alliances and sharing power. Ensuring equity and innovation, pushing upstream and fostering pathways for truth, reconciliation and healing and transformation.

Some work that you all have already started and so our first strategy is to embed racial and social justice throughout AMA's enterprise in the culture, inside our systems, policies and practices.

So if the teams within AMA...so the way I am a kind of works right, we have a membership arm and piece and so I'm on the management team. There's there are 1100 folks who are hired and on board to work on behalf of the physicians within membership, but also kind of a larger context of medicine. As the membership passes policy, it's our responsibility to execute on the policy, so this is an execution of the policy, creating a strategic plan. But if there's a policy on, like, say, a drug policy as an example or opioids, if our teams are responsible for doing that work, they need to have an equity lens themselves. They need to have an understanding, they need to understand how their own biases show up in their work every single day potentially, and what are the systems and the thinking behind it that cause them to show up. So, a lot of our work internally is building our own capacity around understanding anti-racism and equity strategies and really focus not on just like workforce as I mentioned before but contracts and budgeting. Who are we giving our money to? Communications...how are we? How are we communicating? What languages are we communicating? And when we think about ability, you know are we up to speed with what we have on our many different vehicles of communication to make sure it's really accessible? and then important to that also is having a trauma informed lens.

This is what I learned when I was at New York City Department of Health, this work is hard. Conflict is absolutely going to happen and folks are already traumatized, kind of just going into the space and living life in general. But then when you start to introduce concepts like this and work like this, you have the potential to actually re-traumatize, so you really have to be very intentional about having spaces and creating spaces for psychological safety. Everything is not going to be comfortable. This is not about not being comfortable, but it's about: are people safe to be able to share and to communicate what is going on with them? And is the institution going to be accountable to what they're hearing and listening to and then we have to assess change overtime.

I do say we do lead with race. We've, I've done that since I was at the New York City Department of Health and a lot of this guidance comes from a Race Forward, which is one of the largest racial justice institutions in this country. And mainly it's because, as it says here, racial inequities are deep and pervasive. Some of the greatest gaps in this country as it relates to data are along the lines of race and ethnicity. It's one of the hardest ones in areas for people to really talk about, and probably the area that we have the least analysis about or the one that makes people most uncomfortable, but while I say we're race explicit, we're not exclusive to an intersectional analysis, and I think that's really important and that we do have to look at the intersections of class and gender and all the other opportunities around intersection, so it's not to the exclusion of others. It's just to say that we need to keep that at the forefront because it'll be the one that people don't want to talk about.

We're using a model from the Government Alliance for Racial Equity. It's the inside part of it actually, so normalizing you know there's a lot of the training and, you know, again, we have to build a shared analysis. We have to be able to talk about these issues and operate with a sense of urgency, but as many of you know, training alone is never enough, and so how do we organize for accountability and action and engagement across our institution? And so it's important to have an internal infrastructure that's usually created of where you have champions and people who are really helping to guide the work and it doesn't have to be people necessarily that hired, but people have different voices and ideas around you know what should happen in the institution. And then operationalize like, what are the tools that people need for them in order to help change their mental models? What's the data that you can use to help drive your decision making? And you have to visualize, like you have to have an understanding. What is the experience that you want all people within your workplace to have and articulate that and have that be, you know, widely shared. And then I, We added on the outside of trauma informed and healing lends supports for all of this.

So our second approach is building alliances and sharing power with historically marginalized and minoritized physicians and other stakeholders. We have a history of excluding Black physicians for over 100 years, which at which I'll talk about also a little bit later. But the idea is that to make sure an idea, the intention and the impact is to make sure that we are centering the voices, the people, the ideas of those who have been historically marginalized, and all that we do, and so we're finding many different ways to engage. Just one quick example, excuse me. As a partnership that we have with the American College of Preventive Medicine. We receive CDC funding to actually identify 15 BIPOC, LGBTQ+ or people with disability physician-led practices across the country and help support them starting care coordination pilots, but also enhancing their capacity around COVID-19 prevention and vaccination and testing. But we also want to learn and document like what kind of equity strategies are they using in the communities that they're serving so that we're able to kind of collect and share those with many people.

The next approach is ensuring equitable structures and opportunities and innovation. This is a space that is highly, highly exclusive in this country. It's predominantly white men again within this space have been valued and their ideas have been valued. Very small margin, extremely of black and brown women, people with disabilities, people identify with LGBTQ, you know are one, just are being valued to be there, having their ideas kind of listened to and then and definitely getting little opportunity to have their ideas funded for many different reasons and so, because this is an important aspect of work, it's also an accelerator for the AMA. I felt it was important that we have some energy and some effort in this space, but we needed some support and some help, you know, in doing this and so we've been engaging with an equity and innovation external advisory group over the last, I would say, year and a half, maybe at this point in time. And it's a great group and some of you may know some of these folks on this list. I would imagine you do, but a great group of folks from across the country who have been just really holding us accountable to what it is that we say we were going, we are going to do.

And so one of the first opportunities that we felt in this space is that, you know, as everyone saying, they're doing equity and they want to do equity and do this that and that the challenge is that everyone has like different ideologies and thinking around what, you know, equity is about and justice is about.

And so we really needed to be grounded in like values and principles. And so we you know we're working on releasing a set of principles, but engaging through a learning community and hopefully, you know, influencing all these folks that are now in this space especially post the public murder of George Floyd. You know, take a step back and really think about critically. What are they doing? Who are they giving to? How are they really offering sustainability and growth within the context of communities that have been historically marginalized? And really, creating space and decision-making power amongst and within our communities.

And then lastly is about, you know, how are we fostering pathways for truth, reconciliation and racial healing? And my belief is that, you know, we can't have any commitments to anti-racism if we don't do an honest assessment of our own institution's history and present practices. And you know, lots of folks are very well aware. Maybe not very well, but are aware of AMA's history and I hear it all the time, but you all have the history of this. And I said that's true, but the reality is that the majority of white, historically white, institutions in this country, which is most of academia, you know, has a history of, and it's not always a good history, of how they've engaged with communities that they've served, and also within the context of policy, truthfully. And so you know, with the exclusion of Black physicians, there was also the Flexner Report, which has a lot of impact. Which has a lot. It had a lot of impact in terms of revolutionizing medical education. Medical education to this day is very much rooted in the recommendations of the Flexner Report of just really focusing predominantly on the basic and clinical sciences, taking on, this is an intentional, I feel it's intentional, outcome of the past of really removing, you know, the social context and conditions of health and learning within the medical space in in 1910.

And then there was, you know, AMA not supporting or really being very silent during civil rights, allowing for the construction of segregated hospitals. And so in order to do this work, you know, I think it's definitely critical that we're centering and hearing the narratives of historically marginalized physicians and patients. And I think there are many ways in which we do that. We quantify the effects of our policies and the harms that they have caused. And we have to find ways to repair. And so one of our you know, our early opportunities and we're just starting to embark on this work. And you know, we did some of this work in the early 2000s. There was a point in time where you know we issued an apology in in 2008 and there was a lot of work done to kind of understand this particular history and the historical context of excluding African American physicians.

But that work was, it's I mean, it's that's several years ago now and we need to kind of continue forward, you know, as this quote says by Ron Davis, and in the apology to the National Medical Association, that that was only a modest step forward in terms of the apology. And so we're now in the process of engaging with folks and experts on what do we do moving forward as the AMA to really embark in a truth, reconciliation and healing process? How do we understand the impacts of our decisions and monetize them or create action based upon those decisions?

More recently, about a year, almost a year ago now, our current CEO Jim Madara was reading some articles that were published during that same time that were joint articles from the AMA and the National Medical Association that was created because Black physicians were excluded from AMA and looking at the father of AMA and the founding editor of JAMA. Of that, seeing that you know he was very intentional about excluding women and Black physicians, sent an email, we'll never forget it, asking for, you know this bust to be removed on our 47th floor of the AMA building of Nathan Davis, you know, and it will be put there for educational purposes.

That's not an easy decision to make, but he did it. And it's possible 'cause a lot of times folks you know, we'll, we'll talk about, you know, the history lost. We're not trying to lose history or just trying to frame it in light of the harm that it caused and to elevate that particular history as well and leave space for other histories to be elevated that have not been, and so our board, our House of Delegates, rather, passed policy in June of 2021 to go through formally and for us to go formally through a path of truth and reconciliation, especially as it relates to the Flexner Report itself. So again, there's a lot of organizing that we're doing around that.

And then lastly, you know in doing this work, and this 2021 was a was an up and down year for everybody I would imagine. But definitely in this space of doing racial justice work, and I just I come to say, and to remind people to kind of step into, I'll say it in this way, but our sensibilities and our sense of who we are as human beings and what it is that we want and what is It that we desire. And all of us desire to be to be loved and to be cared for, and that you know to shy away from and move away sometimes on over intellectualizing inequities and the harms and the problems that are there. But just remembering that these are rooted in peoples' histories and again in people's hearts and spirits over time and that's why we're here to do this work again, because we all believe that everyone should have and absolutely deserves the opportunity to have the power and the resources and conditions to have optimal health.

Thank you.

Video Information

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Accreditation

In support of improving patient care, Stanford Medicine is jointly accredited by the Accreditation Council for Continuing Medical Education (ACCME), the Accreditation Council for Pharmacy Education (ACPE), and the American Nurses Credentialing Center (ANCC), to provide continuing education for the health care team.

Credit Designation Statement: Stanford Medicine designates this Enduring Material for a maximum of 0.25 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Disclosure Statement: Stanford Medicine adheres to the Standards for Integrity and Independence in Accredited Continuing Education.

The content of this activity is not related to products or the business lines of an ACCME-defined ineligible company. Hence, there are no relevant financial relationships with an ACCME-defined ineligible company for anyone who was in control of the content of this activity.

Terrance Mayes, EdD

Associate Dean for Equity and Strategic Initiatives

Stanford Medicine

Co-Course Director

Daryl A. Oakes, MD

Clinical Associate Professor of Anesthesiology, Perioperative and Pain Medicine

Stanford University

Co-Course Director

Amy Catherine Lu, MD

Clinical Assistant Professor, Anesthesiology, Perioperative And Pain Medicine

Stanford University School of Medicine

Course Director

Aletha Maybank, MD, MPH

Senior Vice President And Chief Health Equity Officer

American Medical Association (AMA)

Faculty Disclosure Information Not Available

Jayzona Alberto, EdD

Stanford

Planner

Marilyn Mejia, BA

Education Design Coordinator

Stanford University

Planner

Kurt Snyder, JD

Stanford University

Planner

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