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In Episode 6 of the Antiracism in Medicine series, “Racism, Trustworthiness, and the #COVID19 vaccine,” we are joined by two forces in the field of health equity and academic medicine, Dr. Giselle Corbie-Smith and Dr. Kimberly Manning, to discuss why the pandemic is the moment to ensure trust in medicine.
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Show Notes – Episode 6: Racism, Trustworthiness, and the COVID-19 Vaccine
Rohan Khazanchi
February 23rd, 2021
Summary
In this episode of Clinical Problem Solvers: Anti-Racism in Medicine, we are joined by Dr. Kimberly Manning, Professor of Medicine and Associate Vice Chair for Diversity, Equity, and Inclusion at Emory University, and Dr. Giselle Corbie-Smith, the Kenan Distinguished Professor of Social Medicine and Director of the Center for Health Equity Research at University of North Carolina-Chapel Hill. We dig into Dr. Manning’s leading perspectives on trust in the Black community and Dr. Corbie-Smith’s longstanding community-engaged research agenda, and we discuss implications for ongoing discourse about COVID-19 vaccine equity.
Timestamps
00:00 Music/Intro
1:25 Guest Introductions
02:34 Reflecting upon the current “moment of hope” in the COVID-19 pandemic
07:46 Why is Mistrust the “Tip of a 400-Year-Old Iceberg”?
12:04 Getting to the Individual “Why” of Declining the COVID-19 Vaccine
13:01 Is Mistrust the True Root Cause?
16:28 Moving past our preconceptions about vaccine mistrust
19:01 “When your immune system is knuckin’ and buckin’, it’s gonna be a little raucous!”
22:43 Shifting our framing from “vaccine hesitant” to vaccine deliberations
27:58 Recognizing our biases, centering the margins, and avoiding diluted generalizations
37:20 Valuing diversity rather than classifying minoritized groups as monoliths
43:34 Why Dr. Manning chose to participate in the Moderna vaccine trial
49:20 The “allostatic load” of the minority tax in a white supremacist system
55:45 Performative advocacy and the “musical chairs” of representation in medicine
58:12 The fallacy of the meritocracy
59:10 What can health systems do to reduce vaccine disparities?
1:06:20 Takeaways and conclusions
1:08:51 Outtakes
Takeaways
Medical Mistrust in the Black Community is More than Tuskegee
Framing medical mistrust solely around watershed incidents like the U.S. Public Health Service Study of Untreated Syphilis at Tuskegee is harmful. It treats Black Americans as a monolith, when there is an enormous diversity and heterogeneity within the Black community. It treats mistrust as an isolated construct, when medical mistrust is intertwined with broader societal injustices. Lastly, our rhetoric often treats mistrust as an individual failing or “uninformed belief”, rather than a consequence of structural inequity.
In contrast, scholarship and clinical care which acknowledges within-group differences and shifts from a deficit-based to an asset-based view of marginalized groups can help us better serve our minoritized patients. Dr. Manning reaffirmed what Dr. Camara Jones told us last episode– that solutions lie in simultaneously emphasizing the importance of individual humanity and value in “hard to reach” (hardly reached) communities and dismantling the structures which push those communities down.
“Black Why’s Matter”
“Simply telling people what to do doesn’t work on your children, and it doesn’t work on your patients.” – Dr. Kimberly Manning
Every person who declines a COVID-19 vaccine has a reason to do so which is theirs, and theirs alone. As clinicians, we need to slow down and demonstrate our willingness to hear the “why’s” of our patients, colleagues, neighbors, and community members. In particular, racial concordance is a key piece of doing this work; authentic communication styles from people who personally understand the needs of their community and can better help motivate a “slow yes” through shared decision-making.
Addressing Racial Vaccine Inequities Requires Race and Community-Informed Solutions
This pandemic has highlighted a faultline between public health and medicine. Crossing that breach must involve organizing with faith-based and community-based organizations, community health workers, and beyond. Geographically-based interventions need to prioritize individuals from those communities, rather than allowing outsiders to take designated slots. Scapegoating mistrust can no longer be an excuse for not meeting people where they are and addressing longstanding, long-understood barriers.
Pearls
Reframe “Vaccine Hesitancy” as “Vaccine Deliberations”
“Vaccine hesitancy” is a symptom of a larger, chronic issue about the way Black and Brown people are treated in the United States. Yet, our narrow focus on the individual drives us to assign blame to those who decline a vaccine as “hesitant” or “distrusting” when there are a plurality of reasons why. Deliberating on big decisions is quite normal, especially when the lived experiences of individuals in historically marginalized groups inform their reasonable apprehension about inequities in U.S. systems writ large.
Minority Tax and the “Musical Chairs” of Representation in Medicine
“My taxation is not without representation… [musical chairs] is all fun and games until somebody has to give up their seat. If everything has been built on privilege, you have to be willing to give something up” – Dr. Kimberly Manning
Dr. Manning presented an analogy to us about a game of musical chairs, in which everyone is happy to participate and speak up for marginalized groups until the music stops and only one seat is left. Minoritized clinicians and researchers face the allostatic burden of stepping up to fix a broken system designed within a white supremacist culture. Performative activism only goes so far; when our colleagues with privilege aren’t willing to give up that power, the needle doesn’t get moved.
“I’m not interested in changing hearts and minds; I’m interested in seeing behavior change and changes in policies, practices, and norms.” – Dr. Giselle Corbie-Smith
References Mentioned
08:14
Manning KD. More than medical mistrust. The Lancet. 2020 Nov; 396(10261): 1481-1482. doi:10.1016/S0140-6736(20)32286-8.
13:01
Corbie-Smith G, Thomas SB, St George DM. Distrust, race, and research. Arch Intern Med. 2002 Nov 25;162(21):2458-63. doi: 10.1001/archinte.162.21.2458. PMID: 12437405.
32:18
Corbie-Smith G, Miller WC, Ransohoff DF. Interpretations of ‘appropriate’ minority inclusion in clinical research. Am J Med. 2004 Feb 15;116(4):249-52. doi: 10.1016/j.amjmed.2003.09.032. PMID: 14969653.
33:56
Corbie-Smith G, Thomas SB, St George DM. Distrust, race, and research. Arch Intern Med. 2002 Nov 25;162(21):2458-63. doi: 10.1001/archinte.162.21.2458. PMID: 12437405.
Corbie-Smith G, Thomas SB, Williams MV, Moody-Ayers S. Attitudes and beliefs of African Americans toward participation in medical research. J Gen Intern Med. 1999 Sep;14(9):537-46. doi: 10.1046/j.1525-1497.1999.07048.x. PMID: 10491242; PMCID: PMC1496744.
39:42
Wilkerson, I. (2020). Caste: The origins of our discontents.
59:10
Corbie-Smith, G. “A Different Kind of Leader” Podcast. Retrieved from https://adifferentkindofleader.buzzsprout.com/
Additional References
Disclosures
The hosts and guests report no relevant financial disclosures.
Citation
Manning KD, Corbie-Smith G, Khazanchi R, Nolen L, Fields N, Ogunwole M, Onuoha C, Tsai J, Paul D, Essien UR. “Episode 6: Racism, Trustworthiness, and the COVID-19 Vaccine.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. February 23, 2021.
We kick off our new series, “The Consult Question”, aimed at highlighting the clinical reasoning of our subspecialty colleagues, with a case of hypoglycemia presented to master endocrinologist Dr. Elizabeth Murphy.
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Dr. Elizabeth Murphy
Dr. Elizabeth Murphy is a professor of Medicine at the University of California, San Francisco, where she serves as the Deborah Cowan Endowed Professor of Endocrinology and chief of the Endocrinology and Metabolism Division at Zuckerberg San Francisco General Hospital.
We continue our mission to #EndNeurophobia with an episode of Neurology VMR with Dr. Aaron Berkowitz
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Dhruv SrinivasacharDhruv Srinivasachar is a 4th year medical student at Virginia Commonwealth University School of Medicine (the Medical College of Virginia for all the veteran attendings out there). Introduced to medicine through research, Dhruv has shifted his passions to empathetic clinical care and medical education, as a contributor to the CPSolvers (especially through VMR as a case presenter, discussant, and compiler of cases) and team member for the Not Just Little Adults podcast (CPedsSolvers, if you will). When he’s not interviewing for Med-Peds residency, he can be found biking around Richmond, VA, gardening, and cooking.
Elena Vasti
Elena Vasti is a second-year resident at Stanford in the Department of Internal Medicine. She attended UC Davis to study Human Development and Exercise Biology and went on to UCLA Fielding School of Public Health to complete an MPH in Epidemiology and Community Health Sciences. She decided to switch careers to pursue clinical medicine and matriculated at UCSF School of Medicine in 2015. She enjoys running every day, analyzing movie trailers and both listening to and joining the CPSolvers any chance she gets! She plans to pursue a career in academic cardiology.
Rabih, Reza, PrezSharmin, and Arsalan break down thyrotoxicosis, by revisiting a case initially presented at our December 18th VMR.
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Maani, Priyanka, and Lindsey discuss a clinical unknown with Dr. Jori May.
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Dr. Jori May
Jori May, MD, is Assistant Professor of Medicine in the Division of Hematology/Oncology at the University of Alabama at Birmingham (UAB). Her clinical interest is non-malignant hematology, focusing on the care of patients with thrombosis and coagulation disorders. Additionally, she focuses on systems-based hematology, which works to improve hematologic care delivery across health systems. Dr. May earned her M.D. from Washington University School of Medicine in St. Louis. She completed her residency, chief residency, and fellowship in Hematology/Oncology at UAB.
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Mansour presents a case of sudden vision loss to Dan, Erica, and Kristin.
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Dr. Erica Smith
Erica Smith is a fourth year Internal Medicine-Pediatrics resident at the University of Michigan. She is from Detroit, MI and attended Wayne State University School of Medicine for medical school. She is planning to pursue a career in hospital medicine. In her free time, she enjoys golf, yoga, and hiking.
Dr. Mansour Alkhunaizi
Mansour Alkhunaizi went to the Royal College of Surgeons in Ireland for medical school and is currently an Internal Medicine Resident at Baylor College of Medicine. He is interested in a career in pulmonary/critical care medicine. Outside of work, he enjoys hiking, working out, and watching his favorite soccer team Manchester United!
Dr. Kristin Andres
Kristin Andres is currently a third year Internal Medicine-Pediatrics resident at the University of Michigan. She grew up in Lexington Kentucky and attended the University of Kentucky for both undergraduate and medical school. She hopes to pursue Pediatric Cardiology fellowship with a career goal of optimizing transitional care for patients with congenital heart disease. Outside of the hospital, Kristin enjoys musical theatre, pub-style trivia, making ice-cream, and snuggling on the couch with her husband Andrew and dog Nutmeg.
Dr. Sabal presents a case of bilateral wrist pain to Sharmin, Dr. Davey, and Dr. Singh.
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Dr. Sonya Davey
Sonya Davey attended medical school at the Perelman School of Medicine at the University of Pennsylvania and is currently an Internal Medicine PGY-1 at Brigham & Women’s Hospital. She loves to travel, read, and enjoy meals with family and friends.
Dr. Nicky Singh
Nicky Singh attended medical school at the Perelman School of Medicine at the University of Pennsylvania and is a current PGY-3 resident at Massachusetts General Hospital. As a resident, he has been involved with several educational initiatives, including co-leading the Residents in Medical Education interest group and the Point of Care Ultrasound group and serving as an Education Council representative and Simulation Program Chief. He is interested in cardiology and medical education. Outside of medicine, he enjoys hiking, South Asian dance, exploring new recipes with his Instant Pot, and trying to up his Peloton numbers.
Dr. Aaron Sabal
Aaron is currently a PGY-3 at Mercy Health Muskegon aspiring for a career in hospital medicine. He was born and raised in Westland, MI (Detroit metro area) and went to Wayne State University for his undergraduate studies thinking he would be a physical therapist, massage therapist, and dietitian (yes, all three of those). However, one week prior to starting a massage therapy program, he had an epiphany and decided to go to medical school instead. He was fortunate to be accepted at MSUCOM and fell in love with Internal Medicine. His passions include all things medical. In particular, he is passionate about medical education, how best to help physicians learn, diagnostic reasoning, and creating an environment of learning where no one is afraid to express what they’re thinking. When he is not pursuing his love of learning, he is spending time with his wife and their boys (2 cats and a dog), playing with his animals, preparing to be a father to his soon-to-be-born son, crossfitting, doing DIY home-improvement projects, exploring national parks, or reading good nonmedical fiction with a cat or dog in his lap begging for his love and attention.
In this episode of Clinical Problem Solvers: Anti-Racism in Medicine, we are joined by Aletha Maybank MD, MPH, the American Medical Association’s (AMA) inaugural Chief Health Equity Officer and director of the AMA’s Center for Health Equity, and Camara Jones MD, PhD, MPH, thought leader in the fields of health equity and public health and former president of the American Public Health Association (APHA). We discuss policy, professional organizations, and history as they relate to advancing health equity, and imagine what the anti-racist health system of the future looks like.
Learning Objectives
After listening to this episode listeners will be able to…
Credits
Download Transcript Here
Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future
Show Notes
Chioma Onuoha
Timestamps
00:00 Music/Intro
01:14 Guest Introductions
03:09 Framing Racism
05:15 Allegory: Cement Dust in Our Lungs
07:00 The AMA’s Declaration on Racism as a Public Health Threat
13:28 History and the AMA and APHA Movements
15:20 Barriers to Achieving Health Equity in Medicine
20:55 Documenting, Centering, and Institutionalizing “The Work”
23:30 The AMA’s Racist Past
31:00 How Do We Create Sustainable Work?
35:25 Creating and Maintaining Urgency
39:00 Racism Saps the Strength of the Whole Society
43:43 Building an Anti-Racism Health Care System from A Grassroots Level
52:15 Building an Anti-Racism Health Care System from A Governmental Level
53:45 Health is Not Created with the Health Sector
56:53 Why Must All Health Workers Practice Anti-racism?
1:05:57 Outtakes
Takeaways
If we don’t explicitly say the word racism, and identify its historical context, then we are complicit in its denial. Racism denial is deeply ingrained in our society and it needs to be called out and recognized as a system in order to be addressed. Though the field of medicine often fails to think systematically, it is imperative that all healthcare workers learn to recognize racism, actively practice anti-racism, and acknowledge the many systems that impact people and community’s health.
Four Key Messages for Naming Racism:
Our country habitually denials racism by working to make its impacts invisible. Remembering history and collecting institutional memory avoids the danger of repeating work, wasting labor, and makes clear racism’s long standing effects. Part of this effort also includes learning the history of the organizations and institutions we are a part of.
While the health sector is where illness and ailments are often treated, a person’s health largely manifests outside of the health sector and is impacted by their community and environment. One of the biggest barriers to health equity is the narrow focus on the individual and a failure to see health as a widespread community issue. We must recognize that all policy is health policy and that which affects someone outside of the health sector may also affect their health. Our future should be grounded in our communities; our solutions cannot solely be declarative or institution-driven.
Pearls
Barriers to Achieving Health Equity
To learn more, read about Dr. Jones’ Seven Values Targets for Anti-Racism Action
Institutionalizing Anti-Racism
A movement can disappear as quickly as it arose if it is not institutionally ingrained. This means that anti-racism must be embedded into practice, performance standards and institutional culture. All policies, decisions, and behaviors should occur through the lens of anti-racism in order for its impact to be longstanding and effective.
The Power of Collective Action
“When we acknowledge each other’s work we acknowledge the power of collective action”
– Dr. Camara Jones
Addressing structural racism is a collective effort and is more effective when we shift from “what can I do” to “what can we do”. When we lift up our peers and validate/center the work of people on the margins, we recognize the power of collective action and ensure that efforts are not erased or lost. This includes recognizing the experts that have come before us and reaching out to younger generations.
Addressing Structures and Values
Racism is a system of structuring opportunity and assigning value based on the social interpretation of how one looks. In order to address racism, we must address both the structures and the values. Structures include the ways that racism is institutionalized and systematically reinforced, and values include the way that racism manifests in our shared consciousness. Addressing values will require us to make clear that “racism saps the strength of the whole society” and to highlight the urgency of anti-racism efforts. Additionally, we should equip educators, parents, and those who will guide the next generations with the tools to operate within the framework of anti-racism. Because structural racism often operates through inaction and complacency, the work to combat it must be persistent and collective. Racism hurts all people and achieving anti-racism will require active “fellows in the struggle” not just feeling allies.
References Mentioned
01:55
Jones, C. Camara Jones, Allegories on race and racism | Camara Jones | TEDxEmory. [Video]. YouTube. https://www.youtube.com/watch?v=GNhcY6fTyBM&ab_channel=TEDxTalks. Published June 10, 2014. Accessed January 11, 2021.
03:55
Jones, C. Camara Jones, APHA executive director citation award acceptance speech. [Video]. YouTube. https://youtu.be/BGmIXV859YQ. Published December 2, 2020. Accessed December 9, 2020.
16:20
Jones, CP. (2020). Seeing the Water: Seven Values Targets for Anti-Racism Action. Harvard Medical School Primary Care Blog. Retrieved from http://info.primarycare.hms.harvard.edu/blog/seven-values-targets-anti-racism-action
27:17
Berney, B., & Friedman, R. (Producers), & Burnett, C., Loewenthal, D. (Directors). (2018). Power to Heal: Medicare and the Civil Rights Revolution. Retrieved from https://www.blbfilmproductions.com/
28:55
Baker, RB., et al. Creating a segregated medical profession: African American physicians and organized medicine, 1846-1910. J Natl Med Assoc. 2009 Jun;101(6):501-12. doi: 10.1016/s0027-9684(15)30935-4. PMID: 19585918.
Washington, HA., et al. Segregation, civil rights, and health disparities: the legacy of African American physicians and organized medicine, 1910-1968. J Natl Med Assoc. 2009 Jun;101(6):513-27. doi: 10.1016/s0027-9684(15)30936-6. PMID: 19585919.
Additional References
Disclosures
Dr. Maybank is the AMA’s Chief Health Equity Officer and director of the Center for Health Equity. Mr. Khazanchi is a member of the American Medical Association’s Council on Medical Education. The views presented herein represent their own and not necessarily those of the AMA. The hosts and guests report no other relevant financial disclosures.
Citation
Jones CP, Maybank A, Nolen L, Fields N, Ogunwole M, Onuoha C, Williams J, Tsai J, Paul D, Essien UR, Khazanchi, R. “Episode 5: Racism, Power, and Policy: Building the Antiracist Health Systems of the Future.” The Clinical Problem Solvers Podcast. https://clinicalproblemsolving.com/episodes. January 19, 2021.
Dr. Dayyan Adoor and Dr. Keith Albrektson present a clinical unknown case to Dr. Armitage
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Dr. Dayyan Adoor
Dayyan Adoor is a 2nd year internal medicine resident at Case Western Reserve/University Hospitals. Following residency, he hopes to pursue a fellowship in Gastroenterology! In his free time, he likes to spend his time outdoors, often exploring the beautiful parks in Cleveland, and lately, learning how to ski!
Dr. Keith Armitage
Dr. Keith Armitage is a professor of medicine in the division of infectious diseases at the Case Western Reserve University School of medicine. He is also the program director for the internal medicine residency at the Case Western Reserve/University hospitals internal medicine residency program where he is currently serving his 29th year as program director. In his free time Dr Armitage enjoys cheering on his beloved Arsenal Football Club and spending time with his wife and three daughters.
Dr. Keith Albrektson
Keith Albrektson is a current chief resident at the Case Western Reserve/University hospitals internal medicine residency where he completed his internship and residency in internal medicine. Following his chief year he will be continuing his training in pulmonary and critical care at the University of New Mexico Medical Center.
Our campaign to #EndNeurophobia continues with a neuro VMR featuring one of our favorite chief complaints, AMS!
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Kaitlyn Thomas
Kaitlyn Thomas is a 3rd year medical student at Lake Erie College of Osteopathic Medicine at their Seton Hill campus in Greensburg, Pennsylvania. She is interested in medical education, advocacy and assisting underserved populations. She has contributed to the CPSolvers on Virtual Morning Report on several occasions and produced a few videos for their illness scripts. In her free time, she enjoys hiking, spending time with family, and finding new recipes to cook.
Ninad Bhat
Ninad Bhat is a third-year medical student at UCSF. He has always been fascinated by communication and the brain, seeking to combine his interests by becoming a neurologist involved in medical education. In his free time, he writes poetry and works to keep his obligatory medical student plants alive.
Andrew Levy
Andrew Levy is a 4th-year medical student at the University of Colorado SOM applying to Family Medicine with interests in Primary Care, Global Health, and Population Health. After taking a year off to help implement a WHO educational community-based first aid response program, he is now pursuing further public health training through UCSF in Implementation Sciences. He has been a fan of CPSolvers since being turned onto it, as well as the general topic of diagnostic reasoning, through Juan Lessing, an IM attending at the University of Colorado Hospital. In his free time, he enjoys exploring the great outdoors with his wife, Emily a fourth-year medical student at RVU in Colorado, and their three dogs Layla, Jade, and Avalanche.
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