Presentation: How to sustain a (health) revolution

I gave this presentation, what I call my 2nd TED talk (although not affiliated with an actual TED event, just a person named TED – me), exactly 3 years to the day after I gave my first one, at Henry Ford Health System, in 2012 (see: “Embrace of Failure” – TEDx talk with Regina Holliday ), with awesome leader Regina Holliday (@ReginaHolliday).

Back in 2012, it’s highly possible that I thought that everything that needed to be done had been, and then a mobile app (see:What it means to earn a perfect score on the Human Rights Campaign Corporate Equality Index) and an anonymous email sent to me around the time of the 2012 presentation changed everything.

Thanks to my colleagues, who are doctors, nurses, lawyers in our government relations organization who asked me to bring this dialogue forward in 2015.

As it says on slide 2, I 🙂 Kaiser Permanente, and all of the people who have trust and hope that physicians, nurses, health professionals, and patients have the power to change everything. It’s in our DNA. Oh, and love always wins.

Enjoy, feel free to post any questions or comments.

Just Read: Eliminating physician biases against gay and lesbian people, don’t forget the “T”

This is a study from Yale University about medical students’ explicit and implicit attitudes toward people who are gay and lesbian. Not surprisingly, medical students reflect the biases of the society around them:

Explicit and implicit attitudes among medical students 54443
A lot of bias: Explicit and Implicit attitudes among medical students against gay and lesbian individuals (Where’s the “T”?) (View on Flickr)

I created the chart above from the study data which shows that a little less than half of medical students today harbor openly negative attitudes toward gay and lesbian people. When looking at their unconscious attitudes, that jumps to 82 %.

This is about the same percentage as adult physicians’ negative implicit attitudes toward latino individuals, but more negative than adult physicians’ attitudes toward african american people. (see: Blair I V, Havranek EP, Price DW, et al. Assessment of biases against Latinos and African Americans among primary care providers and community members. Am. J. Public Health. 2013;103(1):92–8.)

What you do with it that matters

This data obviously doesn’t make people feel good about their potential treatment in health care, which can be hostile bordering on brutal (I’ll post on that in the near future).

What’s more important is that physicians and the profession in general should desire to know their biases, and do something about them. The researchers in the first paper correlated attitudes to prior contact with gay or lesbian individuals, and found that, indeed, having had positive contact was protective, as has been shown in the literature for many years.

In other words, there are things that can be done, we should not be disappointed that bias exists, we should be disappointed if it is allowed to continue unmodulated.

Enter the “hidden curriculum”

The commentary piece attached to this one brings up, again (for the nth time this month alone – must be newly popular?), the concept of the “hidden curriculum,” which has been foreign to me as a non-academic, so I appreciate it being defined here:

The compilation of implicit biases, explicit biases, institutional climate, and ingrained behaviors at an academic health center also form the foundation of the institution’s hidden curriculum, or what health professions trainees learn from what they observe and experience rather than what they are overtly taught.

This doesn’t strike me as good news, since recent research shows that the hidden curriculum seems to be promoting rather than eliminating bias (see: Just Read: Sexual and Gender Minority Identity Disclosure: “In the Closet” in Medical School | Ted Eytan, MD). For example this quote:

On my surgery rotation, we saw a male- to-female transgender patient who had “do-it-yourself ” silicone breast implants which had become infected. He [sic] was treated like a freak by the residents and attendings behind closed doors, joking at his [sic] expense. (25-year-old, third-year, lesbian, white, female, U.S. MD student)

I’d like to point out that the researchers in the study above didn’t get the pronouns right themselves when they transcribed the quote, so bias is quite pervasive.

There’s no “T” in this discussion of “LGBT”

I used the quote above to point out that while the topic of the commentary piece is “anti-LGBT” bias, bias against people who are transgender or non-conforming is not mentioned once.

The study of medical student bias did not address this bias (against transgender or gender non-conforming individuals) at all. There is currently no implicit attitudes test for people who are trans or gender non-conforming, but I understand one is being developed. It would have been useful to at least ask about explicit bias for this group, because if we think about the harm to gay and lesbian people in health care, imagine the special harm that people who are transgender face. I diagrammed it out here to assist:

Impact of implicit and explicit bias in the health of transgender persons 54442
Impact of implicit and explicit bias in the health of transgender persons (View on Flickr)

I’m wondering if academic medicine is going to follow, rather than lead, in changing the profession.

In my glass 3/4 fullness, that’s okay, the rest of us are here and we have accountability too. We have to change the health care industry’s position on providing medically necessary care, so that care is provided routinely in the first place.

In addition we need to bring a human understanding to the lives of the people we are serving, which seems quite lacking. That’s what #KPLantern is working to accomplish. Watch this space for updates 🙂 .

Papers cited:

Burke SE, Dovidio JF, Przedworski JM, et al. Do Contact and Empathy Mitigate Bias Against Gay and Lesbian People Among Heterosexual First-Year Medical Students? A Report From the Medical Student CHANGE Study. Acad. Med. 2015.

Fallin-Bennett K. Implicit Bias Against Sexual Minorities in Medicine: Cycles of Professional Influence and the Role of the Hidden Curriculum. Acad. Med. 2015.

Just Read: Dream City – the incredible story (and social determinants) of Washington, DC

This book is what I would call the climax of three books devoted to the history of (one of) the most important cities in the world, definitely the most important city in my world.

The other two, also reviewed here are Just Read: S Street Rising: Crack, Murder, and Redemption in D.C. and Just Read: Mayor for Life: The Incredible Story of Marion Barry, Jr..

There was also a book published around that summer of 1994 called Dream City by two white Washington reporters, Tom Sherwood and Harry S. Jaffe. In this book, I was essentially blamed for everything that was wrong with Washington. I was fairly satisfied with Tom’s historical reporting of my public service in Washington, but not with Harry’s reporting of my current life. It was if I had done nothing right int he city in my recent years. Of course, that was always the case for some white Americans. Any black man who dared to look out for the progress of his people became an immediate political enemy to some whites. – Marion Barry, Mayor for Life: The Incredible Story of Marion Barry, Jr. (2014)

Most Americans and world citizens, including myself, have grown up to idealize this place, where everything must work, as much as a society is going to, and yet:

Americans feel that this federal city belongs to them, but if they lay claim to the national treasures, they can’t deny their collective responsibility for the other Washington where drugs, murder, and poverty are testaments to the nation’s failure. Washington is America’s city, in glorious myth and tragic reality.

Jaffe, Harry (2014-04-22). Dream City: Race, Power, and the Decline of Washington, D.C. (Kindle Locations 148-150). Argo-Navis. Kindle Edition.

That quote is from the era of the book’s authorship, 1994, which is when the book was written. However, it’s been updated with an epilogue that takes it to 2014.

It turns out, as almost everyone acknowledges, Washington, DC is not yet complete. It is in many ways a divided place (see this post: New Maps of DC health data – Not yet one culture of health), with limitations placed on its innovation and survival by our federal government.

That’s the history that this book covers. If you live here or have ever lived here, I guarantee your pupils will dilate every other page, the stories are too incredible.

Against a national trend that showed the number of households with phones climbing slowly to 94 percent in 1992, the number fell in the District from a high of nearly 95 percent in 1988 to 88 percent in 1992. In numbers, 14,000 households didn’t have phones in 1988; four years later, 27,000 were without phone services. In essence, the poor parts of the city were becoming unhitched from the upper and middle-class sections of the capital— and from the rest of America. The message inherent in these grim statistics is that a fundamental dream died in Washington over the last thirty years. The dream was that if integration could work anywhere, it could work in the District. It was a dream that wasn’t taken lightly by people like Willard Wirtz, the labor secretary who launched Marion Barry into Pride, Inc. in 1967.

Jaffe, Harry (2014-04-22). Dream City: Race, Power, and the Decline of Washington, D.C. (Kindle Locations 5784-5790). Argo-Navis. Kindle Edition.

Our history, triumphs, tragedies are what also makes Washington the most amazing learning lab for any innovator. A 2 mile walk can span 10 years of life expectancy and 20 or 250 years of history, with more emotion than in a lifetime anywhere else. If you think about purpose and meaning in life being related to making the world better, this is the place to do it.

The street corner where the riots started in 1968 that destroyed Washington, DC, following the assassination of Martin Luther King, Jr., will, in 2015, host Capital TransPride for the first time ever.

There’s no mistaking the society-leading nature of this place. Nothing else like it anywhere.

DC People and Places 53847
The Reeves Center, 2015, nidus of the rebirth of Washington, DC, USA (View on Flickr.com)

Remember that Stokely Carmichael helped start the 1968 riots by chucking a brick through the window of People’s Drug Store at the corner of 14th and U Streets in Shaw? And Marion Barry had made a symbolic point of locating the Franklin Reeves Municipal Center at that same corner in the late 1980s? In early 2014 the city was negotiating to trade the Reeves building as part of a land swap to build a new soccer stadium. So much for symbolism.

Jaffe, Harry (2014-04-22). Dream City: Race, Power, and the Decline of Washington, D.C. (Kindle Locations 117-120). Argo-Navis. Kindle Edition.

DC People and Places 54029
14th and U Streets at night, alive again in 2015 (View on Flickr.com)

DC People and Places 53995
Two cranes and a plane, taking off from Washington National Airport (View on Flickr.com)

Just Read: In DC, there’s up to a 14 year life expectancy gap between blacks and whites that hasn’t changed in 15 years

The life expectancy of a black male in Washington, DC as of 2009 is the same as a man in North Korea as of 2012. For a white male, the life expectancy is higher than Israel, lower than Switzerland.

Sources: World Health Organization; Harper S, MacLehose RF, Kaufman JS. Trends In The Black-White Life Expectancy Gap Among US States, 1990-2009. Health Aff. (Millwood). 2014;33(8):1375–82. View Life Expectancy World and DC – Male – 46576 on Flickr.com

The life expectancy of black females in Washington, DC as of 2009 is in between The Russian Federation and Syria or Iran as of 2012. It’s higher than North Korea, which is 73 years. For white females in Washington, DC, it’s just below the highest life expectancy in the world, Japan.

Sources: World Health Organization; Harper S, MacLehose RF, Kaufman JS. Trends In The Black-White Life Expectancy Gap Among US States, 1990-2009. Health Aff. (Millwood). 2014;33(8):1375–82. View Life Expectancy World and DC – Female – 46577 on Flickr.com

Yikes.

This article caught my eye because of my recent trip to Anacostia, in Washington DC’s Ward 8, where health disparities are extremely tangible (underscore): The People of Washington, DC’s Anacostia are Building a Culture of Health | Ted Eytan, MD

They are not just tangible in Anacostia, they’re visible on my walk to work through the city, where I pass through about 8 years of life expectancy. Just do a search of “#activetransportation” on my Twitter feed to see photos of what this looks like; it’s obvious.

This paper, published in this month’s Health Affairs (Harper S, MacLehose RF, Kaufman JS. Trends In The Black-White Life Expectancy Gap Among US States, 1990-2009. Health Aff. (Millwood). 2014;33(8):1375–82) is an analysis of the disparity in life expectancy between whites and blacks in all 50 states and the District of Columbia, using census data.

It confirms what I see on my walk to work, and adds another piece of data that I don’t see, which is that this disparity has continued, unchanged, for the last 15 years:

The estimated state-specific racial gap in life expectancy among males in 1990 ranged from 14.4 years (95% CI: 13.3, 15.4) in the District of Columbia to 0.0 years (95% CI: −5.2, 5.3)

For females, the District of Columbia and New Hampshire also had the largest (10.4 years; 95% CI: 9.5, 11.2) and smallest (1.2 years; 95% CI: −3.9, 6.2) gaps, respectively, in 1990. In 2009, despite overall improvement at the national level, the enormous racial gap in the District of Columbia remained almost completely unchanged for both males (+0.4 years; 95% CI: −1.1, 1.8) and females (+0.2 years; 95% CI: −1.1, 1.6). Life expectancy there remained dramatically more unequal than in every other state.

And then if you compare the change in life expectancy for women (men show the same trend), it’s been constantly disparate since 1990.

And then there was New York

New York State has shown a different trajectory, as you can see from this chart. There has been a massive upgrade in life expectancy for black men and women compared to their white counterparts, narrowing the gap the greatest.

The largest decrease in the gap for males occurred in New York (−5.6 years; 95% CI: −6.0, −5.1), largely because of a dramatic increase in black life expectancy, from 63.9 years to 75.4 years. This was a gain of 11.5 years; the national average gain was 6.5 years.

I’ve written about this previously (New Yorkers Living Longer Than Ever, Outpacing National Trend, a look at the data | Ted Eytan, MD). It’s real. And since I’ve written about it, a review of what happened in New York has been published just this year (Preston SH, Elo IT. Anatomy of a Municipal Triumph: New York City’s Upsurge in Life Expectancy. Popul. Dev. Rev. 2013). A lot of New York’s success has come from identification and treatment of HIV, as well as the same for drug and alcohol related injury/death. It’s worth a read for sure.

Our cities are changing, we just need to make the change happen for all

A few more really important DC datapoints:

  1. Population in 1950: 802,178
  2. Population in 1990: 606,900, 70 % black
  3. Population in 2010: 601,723, 50 % black
  4. Population in 2013: 646,449

In this map you can see where the black and white population live. The green color represents black residents, the blue represents white residents:

You can grab and manipulate this map yourself at the continually awesome CommunityCommons.org (@CommunityCommon)

I cross the “dividing line” in the middle when I walk to work. Ward 8 (Anacostia) is in the lower right. Every other map you could draw, from bikeshare rentals to income to education is going to show the same disparity. With this visual, it’s not hard to tell why an “enormous” disparity still exists between black and white people.

I still see proclamations of Washington, DC as the “third thinnest” state, which badly misrepresents the huge disparities here and harms our ability to understand the health of our community.

Why this is not good

There is good news, which is that life expectancy for both black and white men and women has increased in Washington, DC (by 4+ years for both black and white women, by 8+ years for black and white men).

A significant inequality still exists and that’s a problem. This means that the opportunity of black men and women to achieve their life goals starting with a long life is blunted compared to white men and women.

Diversity brings with it a torrent of innovation. If this trend does not change, we’ll learn less every day, and enjoy our community and the world a lot less. And why would we want to do that?

We share our community with incredible leaders who don’t support the status quo:

I’m with Ruby. We are going to change everything 🙂 .

Permission to reproduce the images courtesy Health Affairs (@Health_Affairs)

TEDMED Blog : Examined Lives: An MD on living and helping to guide the evolution of transgender health

I’ve done more than 10,000 surgeries and they had little emotional impact on me because I was shut down. There’s no emotional attachment. I know I did it; I earned a good living; I remember things people wrote and cakes people made for me, but there’s no attachment.  It’s only after I transitioned that everything has been more real and alive and colorful.  We do know that the memories that most vivid and are easiest to retrieve are those with the most emotional content to them, but you need to be receptive.

Wonderful interview of Dana Beyer, MD. Thanks, TEDMED (@TEDMED) team for listening – the best use of technology ever.

via TEDMED Blog | The future of health & medicine is here too.TEDMED Blog | The future of health & medicine is here too..

Don’t forget to catch the special Google + Hangout today at 2:00 pm – Great Challenges : Transgender Health : An Evolution to Understanding.

The E Pluribus Unum Prize and Learning about Language Access in Health Care

Gayle Tang, Senior Director, National Diversity and Inclusion, accepts the award on behalf of Kaiser Permanente (View on Flickr.com)

Although I am one to mention all of the things I wasn’t taught in medical school, interacting with a professional language interpreter was something I was taught in medical school, and it had a huge impact on me. This goes to show that even the briefest of training early in one’s career can make a big difference…

Last week, I got to observe Kaiser Permanente receive the E Pluribus Unum Prize Corporate Leadership Award. As quoted from: Kaiser Permanente Share | Kaiser Permanente Recognized with Corporate Leadership Award for Providing Culturally and Linguistically Appropriate Health Care and Services

The Migration Policy Institute (@MigrationPolicy) has awarded Kaiser Permanente with the prestigious E Pluribus Unum Prizes’ Corporate Leadership Award, recognizing the organization’s leadership in immigrant integration and providing culturally and linguistically appropriate health care and services.

National Diversity and Inclusion Conference – Earns the Badge View ‘Patients Included’ on Flickr.com

Recently, I helped facilitate a panel of our members at our National Diversity and Inclusion conference, which included a member with limited english proficiency. It was a great experience for me. Gayle Tang (pictured above) and colleague Jane Tong Delore L.Ac, provided professional interpretation in the setup and during the session. As with so much other work I have done with diverse populations, it is great to see the impact of involving a person fully in an experience, whether it be to prepare for a session on stage or to engage in their health.

Even though I was taught about professional interpretation in medical school, I think an unintended perception that was left was that this type of service is costly and slows things down. The reality of my experiences and this work is that respect and accommodation at the outset results in a more accurate diagnosis and effective treatment approach, which means speeding the time to recovery, and more importantly to life. Just like the other vulnerable populations I have worked with…

In prep for the panel, I recalled a quote from 1966’s “A Fortunate Man,” (Now Reading: A Fortunate Man: The Story of a Country Doctor, by John Berger | Ted Eytan, MD) which provides an important reminder about the value of respect in the era of HIT (in the decade of the patient).

It may be that computers will soon diagnose better than doctors. But the facts fed to computers will still have to be the result of intimate, individual recognition of the patient.

You can read more about the Qualified Bilingual Staff Model & Program at its website. Thanks, Gayle and the Kaiser Permanente National Diversity and Inclusion team for connecting doctors, nurses, and staff to experiences that teach us that while our patients have a lot of differences, they have a lot of needs in common, and they are a lot smarter than we sometimes give them credit for :).

2013 E Pluribus Unum Prizes Awardee Panel Discussion from Migration Policy Institute on Vimeo.