COVID-19 Response

Della Taghipour: This really is an opportunity to take a look deeply at every aspect of health. Daniel Kraft: We're going to see all this technology come into the market. Garth Graham: Complicated, challenging, complicated solution. Speaker 4: Where do you go to get tested? Daniel Kraft: Not just how we test, but where? Della Taghipour: Community Health. Garth Graham: A new normal. Speaker 5: There is no one right solution. It's going to take all of us. Daniel Kraft: Welcome to Healthy Conversations, the podcast. An open discussion amongst health care professionals about what we've learned from the front lines of the pandemic and how it's transforming our industry in real time. I'm Dr. Daniel Kraft. We're here to share the latest insights around our collective response to Covid 19. And this episode will discuss the evolving approach to testing strategies and how all of us on the front lines can ensure that care is equitable and accessible to everyone. I'd like to hand it over to Dr. Della Taghipour and Dr. Garth Graham to discuss this complicated issue and what we as health care professionals can do to mitigate its impact moving forward. Della Taghipour: Hi everyone. My name is Dr. Della Taghipour, and I'm here with Healthy Conversations. I have the opportunity to speak with our esteemed guest, Dr. Garth Graham. Dr. Graham is Vice President of Community Health and Chief Community Health Officer at CVS Health. Thank you so much for joining us, Dr. Graham. Garth Graham: Thank you for having me, Dr. Taghipour. Della Taghipour: Dr. Graham, I'd really love to talk to you about a few topics that I have felt particularly impassioned about recently with COVID-19 being the number one thing on all of our minds. I really want to bring that together with one of the most important topics I feel exist in medicine, which is health disparities. What would you say the state of health disparities were before COVID-19 hit the United States? Garth Graham: This country has had a long history of issues in terms of differences in life expectancy, morbidity or mortality between minority communities and the general population dating back as long as we've measured health outcomes. And I think certainly came together a lot in terms of public policy in the 1980s. But as I often say to folks, the disparities we see with COVID-19, we saw with H1N1, we saw with influenza in terms of impact on our minority communities and have been seeing this for some time. I would say that the state is a long history just evidenced in a new emerging novel pandemic by definition. And so as this pandemic has raised awareness, it really just more reflects what has been going on for a very long time. Della Taghipour: Absolutely. And as you mentioned, this pandemic specifically seems to have brought to light the existence of health disparities for even other people in the medical profession and in health care that maybe weren't as aware as some of us who have researched health disparities. Is there anything specific that makes this pandemic stand out as far as why it's bringing disparities to light? Garth Graham: Well, I think the pandemic on a whole captured attention from everyone, because it affected everyone's life. I think it created a heightened sensitivity to the topic area. And then I think a lot of folks who had not heard about this issue before were just amazed and astonished to understand that these disparities do exist. The Kaiser Family Foundation had done some polling on health disparities way back when, which still is relevant now because the updated polls showed the same. There's only really about half of the general population that have been in tune to this issue around health disparities. And that number has stayed consistent over time. You definitely have a large swath of the population that had not necessarily all just a lack of awareness, but certainly we're not engaged in this topic around health disparities. I think the discussions around the pandemic, because I guess it's one kind of new disease entities that has affected everyone's life in one way, shape, or form globally. And so I think it allowed us to have this conversation in a more direct manner around health disparities. Della Taghipour: Absolutely. And what you're saying is so important because sometimes maybe it takes sort of a disease or an illness or process leveling the playing field and making everyone aware of their vulnerability. But of course, we saw that even in this virus that we didn't think should show bias actually did. For example, in New York, there were statistics that there was almost double the rate in the black population of the virus affecting them. For example, there was a rate of 92.3 deaths per thousand in the black population and 45.2 deaths per thousand in the white population. Why do you think that was? Garth Graham: Well, the same kind of factors, Dr. Taghipour that have caused infant mortality rates to be persistently double that between black and white populations. And I would say many of those factors contributed, although there were some new factors in terms of exposures to minority communities that are overrepresented in essential jobs. If I was going to summarize, I would say a couple key factors. One, the underlying issue around social determinants of health. Those kinds of things in terms of education, housing, socioeconomic status. The fact that there are more minorities living in multi-generational households, which by itself allows for potentially more spread of the virus and less people able to socially isolate. And then as I mentioned before, the over-representation of African-American and Hispanic populations in frontline essential jobs. People who we needed to power our country, but by doing that, they're putting themselves continuously at risk. And again, a lot of folks have also alluded to the disproportionate impact of underlying disease from diabetes, hypertension, asthma, et cetera, on black and brown communities. I think all of that comes together and none of that is new. All of that just kind of were the ingredients that I think played on in the numbers that we're seeing now. Della Taghipour: You're absolutely right, and these health disparities are really broad and have been impacting the communities for a long time. And as we're trying to figure out what to do, some of the suggestions have been downstream and some upstream as far as coming up with some solutions. Do you have any suggested solutions that we could at least start with? Garth Graham: Yeah. I think there's immediate pandemic that's right in front of us and what we do about that. For sure, one of the first things we have to address is testing in black and brown communities. We need to get more communities into testing, so that not only define the pandemic for the nation, but define what it means for individuals. Having them, especially if they're symptomatic or expose, understand their clinical status and take appropriate actions depending on that. I think testing and understanding is going to be key, and that is a vital short term. And I say short term in the next couple of weeks to months thing that we have to continue to promote. As we get longer term, that's when we get into a lot of the traditional discussions around interventions that can tackle these kinds of issues. And I definitely believe investments in housing and the investment in infrastructure, investing in job opportunities are a part of the solution to help get people out of the initial challenge that got us there in the first place. Della Taghipour: Absolutely. I could not agree more. And I think this really is an opportunity to take a look deeply at what's going on systemically in the system that not only has impacted the outcomes in this pandemic, but really as you said, in every aspect of health. Very, very critical points. Thank you for sharing those. Do you think there's anything else about health disparities specifically that we could help elucidate for our audience right now? Garth Graham: Yeah. As long as I've been involved both as an academic researcher, certain government official in the private sector, there's been an ongoing discussion around what is the impact of social determinants of health and is it genes, environment? What is it one answer versus the other? And I would say it's complicated. Certainly there are issues where, and we are published on that particularly in heart disease, showing that socioeconomic status disproportionately added to the burden and impact of dying from a heart attack. But then you look at African American women around maternal health, and you see where even women of higher educational status still have challenging outcomes from maternal health and subsequent infant mortality related to that. And so the one thing that I would say does us a disservice is to try to simplify it. We need to accept it for the complicated challenge it is with the complicated solution, which requires, and as you just pointed on, investment upstream, investment in immediate and then investment along the full spectrum of that. Della Taghipour: Yeah. Thank you. And I think this brings me to something else I want to discuss with you about implicit bias, because often we sort of see the problem as away from us, outside of the health care system that maybe it's something that the policymakers need to deal with or something that is just outside of something that we can immediately change and control. And often in health care, we sort of want to hope and assume that we are not participating in any of the biases or any of the problems that are leading to these challenges for our patients. But we do know through various different research that implicit bias exists. And so outcomes are impacted not only from what patients are coming to us with, but once they're in the hospital, there's actually different outcomes. And we don't know if that's 100% due to implicit bias or not, but we certainly think it's coming to light that it is playing a role. How do you think implicit bias plays out in our industry in health care? Garth Graham: Sure, very good point. Nicki, Laurie and team publish it study a long time ago, but still relevant now, showing that most people, clinicians believe there may be implicit bias in the health care system, implicit bias in health care overall. But as you got closer to home and talking about an individual practice, most folks did not think there was implicit bias within their practice or even within themselves. And it's hard to believe that you can have system that's biased without individuals being biased in it. And so I think it's that cognitive dissonance that has happened that allowed us not to have any nexus or responsibility. One of the more troubling things, Dr. Taghipour, that I've seen is even the data around pain and how clinicians treating the same patients with the same pain syndrome, this proportionately feel like African Americans among of the minorities may be tougher and need less pain medications. And as you know, some of this data filters on even to trainees, meaning kind of the next generations are coming behind us around clinical care. You're absolute right. The first onus is responsibility. And so realizing that biases inherently as we're part of the society live many times within us in terms of decisions that we make. That acknowledgement starts the train, but then you have to build in what I would think are quality checks and barriers. And you see this a lot around the discussion of maternal and child health and black women in particular, and how can you build in defaults where they may be judgment challenges on a clinical level. The system may catch that by improving quality of care and metrics across the board. And so I think there's a three prong role in terms of intervention. I think there's a role in intervening of individual and in implicit bias, training, cultural competency, cultural linguistic competency, and things that go along with that. And then you think through what are some of the checks and balances that you put in along the way where if bias or other decision making doesn't lead to the best outcome, then at least there's a quality procedure or a quality check that makes sure that that clinician makes that decision that's in the best interest of the patient. It's again, much like all the other issues affecting this particular topic, it's multifactorial, challenging and the one that you want to think through on different levels, but certainly not in any way, shape or form insurmountable. Della Taghipour: Thank you for that. Yeah, very inspirational and true, because sometimes these issues then become too big and we don't necessarily know where to start or how to start if our institution isn't the one putting the measures in place. Can you suggest a few scenarios perhaps that we could watch out for as individual providers and practitioners where implicit bias might play out? Garth Graham: Yeah. I'm going to say one big scenario from a population health standpoint. I believe as long, this may be more statistic of the scenario, the infant mortality statistic that we see between black population, the general population has been persistent in terms of that disparity and persistently unacceptable. And there's a lot that kind of goes into that. And so I think until we see that number eradicated, I would saying that we have still fundamentally have inherent flaws if not failed as a system to have addressed all of the things that going to that. Now, what are the kinds of things that we would do both things individually and collectively, and then as a system? I alluded to this, I think the training and the cultural appropriateness and understanding your community and the treatment community, whoever the communities that you're interacting with is particularly important. One of the other things that I've seen that I think has been important is the leaders of institutions acknowledging that bias exists, acknowledging bias exists there, and then what are the domino effect kinds of things. And then I believe that there is a role for the quality movement. And if you have standardized quality of care measures or processes or standardized practices, and if you bring that standard of care to all populations, no matter zip code or genetic code, then I think you can see some degree of equalization in terms of outcomes, though I think that that doesn't eradicate it. I think that's kind of the systematics way I would encourage us to think about it. Della Taghipour: So beautifully put. And it's funny because as practitioners, we really love our algorithms, and we really like to know what to do when your K levels are high or your calcium is low, and we really like those algorithms. Yet somehow for things like pain, as you mentioned, or things that require a more subjective interpretation, we're unfortunately not doing that as well as we can ideally do. And so what a great suggestion to standardize that until we can get over this bump of the implicit biases that we're representing. Do you think there's a way for health care providers to recognize their own biases outside of taking the implicit association test or other implicit bias testing mechanisms? Is there any way [inaudible 00:16:11]. Garth Graham: I often say this, we were people before we came, became professionals. And so we have to understand as people, what about our backgrounds, all of us? What do we bring to the table that may cause a unintended consequence in a particular either clinical or nonclinical patient interaction? I always tell folks, including myself is take some time to understand you, your thoughts, interactions. As clinicians, we process our training through who we are, but we still are who we are. And so understanding yourself as a person. And I tell you, even for myself, a lot of times if I'm a clinical scenario and afterwards I go, "Did I do the best I could for that patient? What are some of the things I could have done better?" And that reassessment allows me to then when I enter the next examination room, I then think differently. And I think a lot of this is just about understanding ourselves. Dr. Taghipour, one of the things I often say is if you take blame out of these conversations, much like you took the blame out of the conversations around physician errors, you allow people to grow and to come up with solutions. And so this is not a blame to say that one person is evil and there's a good team and a bad team and a good guy and a bad guy. I think this is just more understanding how we all as individuals bring our own baggage to the table and try to dissect that as we interact with patients who we're responsible for. Della Taghipour: Yeah, absolutely. And it's a sense of humility without, as you say, if we can remove the blame, and then we can just go back to the root of likely why we all got in this the first place was to truly help our patients and to make a change. And I think recognizing that it doesn't have to be about intentions, it has to be about now that you know make it intentional to make a change. Garth Graham: Exactly. Della Taghipour: Yeah. And I think another thing that I've seen in light of everything going on and all the movements and all the energy and awareness about health disparities, I've also seen conversations about having providers that look like the population they're treating. Of course, we know that women we're making our way up into the different subspecialties in one of my subspecialty's surgery. We still make up a minority when it comes to leadership positions. And of course for black and brown individuals and doctors, they make up much less proportion of the actual health care workforce. There are some statistics that cite that there's fewer than 7% black doctors. Can you tell me what you would think about maybe encouraging more youth, more mentorship to try to bring that sort of representation into our specialties and into our field? Garth Graham: One of the more challenging statistics that I'll add to the ones you just mentioned is the amount of black men, the Institute of Medicine, National Academy of Medicine are looking at this. The number of black men in medical school now is actually a little bit less than it was in the 70s. In some areas is not about even making progress. It's kind of incremental steps back. Getting into medical school I think starts with third grade reading levels. And if you look at some of the data where a lot of communities start to really fall off is around that time, around that third grade time period. And lack of confidence in your ability to succeed academically then sets you up for the rest of your life in terms of being able to get through the hurdles that allow you to become a clinician in whatever way, shape, or form. I think a lot of this starts with the early interventions around reading, around the amount of words your child has a certain point, and how do we create some of the kindergarten and pre-K investments as a country that kind of get us there. The other thing that is vitally important is mentorship. As people start to get through these hurdles and navigate life, who are the mentors that they see that then can advise them in one way, shape or form to continue to pursue, navigate these challenges, et cetera. And so for me, we have to build a pipeline, but then for those in the pipeline right now, we have to try to figure out a way for them to ascend to leadership position so that they can help redefine the landscape and certainly I think at the very least, provide inspiration to individuals coming after them. Della Taghipour: Absolutely. I know myself, I'm an immigrant, and I didn't necessarily have some of the connections and the contacts that some of my colleagues did and didn't really have mentorship for medicine until very late in my career and really just noticed the difference between the trajectory I took and the path I took to get where I am versus others. And it's made me want to go back and do a lot of mentorship. Do you think that there's a way to encourage all of our colleagues to go back and really go into the pipeline, be mentors and pull people through? Garth Graham: One of the things about being a mentor is you got to want to do it, because people can sense your energy. And so I would add to what you're saying to just say, we got to make people understand the excitement of the opportunity that you've been given to help somebody become their best self. And that person can then go on and influence other people. And it's really sometimes about the legacy of your interactions and things that you do. One of the things you said earlier is you mentioned a lot of the energy around the moment, and there have been energetic moments before. The thing to think through if we're going to think through this from a kinetic standpoint is how do you translate energy into motion? And so we have to move all of this energy and somehow something needs to be different a year from now than it is now, and then subsequent of that, because that's growth. And so my thinking about the discussion around mentorship is in building out that cadre, building out that passion, using the energy of the moment to create excitement about mentorship and reaching in the communities. Then we start to get more progress and more outcomes and more impact over the next couple of years. Della Taghipour: That sounds wonderful. I'm all for it. Happy to be by your side during that process. Dr. Graham, I also wanted to talk about this concept that you're talking about, learning from the moment and then applying it, putting it into motion. What do you think we can learn from this moment in general now? Whether that's the combination of this life altering once in our lifetime level pandemic with also all the movements that are going on and the awareness with Black Lives Matter and health disparities. What can we combine with this, once again, energy that's available so that we can transition it into action? Garth Graham: The interesting thing is a lot of the folks who have come together to create a lot of the energy now, they come from disparaged backgrounds. You have people who are coming from low income communities who have seen and felt this pressure for a long time, and then now are seeing it as a time to be able to raise their voice. And I see a lot of folks from where I am from, and that makes me excited, because that makes me know that they're engaged in the process. Then you have people in many cases who are pouring influence, who are not from these communities, but recognize that something is wrong. They may not be sure exactly what it is, but recognize that something is wrong and that we have to address it. The key learning point here is movement, and movement means that things have changed and moved. And so if you have all of these ingredients like you did in the 1960s, how do you mix and bring everything together so that the outcome from this is some degree of change? One of the things that used to always get me down is when I'd see patients who thought that whatever their drastically bad hypertensive number was, what it was always supposed to be. Sorry, blood pressure 190 over 100. And a lot of times you'll be like, "Wait, that's not acceptable." And they'll be, "It's always been that high." So that they've kind of reset themselves to a new normal that is actually not normal. And I think for a long time as a country, we've been in a not normal stage for a lot of those folks in our community. And then now the question is against similar hypertension. How can we let folks know that normal should be better and normal should be good, and that the old normal doesn't always have to be. Della Taghipour: That's right. And it's as you said, recognition that there is this problem to address in the first place, and many of us have always recognized the existence of systemic racism and the impact on the health care system and society as a whole, and others are just kind of recognizing the puzzle pieces that are also interconnected. Do you have some pragmatic sort of suggestions for how to begin to dismantle and tackle this problem? Garth Graham: Yeah, I do. I'm a clinician, a doctor who's worked in health care, but I believe a lot of the solutions don't lie in health care. I believe it lies in education and creating opportunity. I think if we're going to collectively think through one place that we want to focus our efforts, I would focus on an early childhood education. Because the kinds of domino effects and things that happen once we give kids that good fundamental start, they can both succeed professionally and go on to become whatever they wanted to be or their house desires and their passions are. But also that actually makes them healthier. We know that there's seven to nine year difference to life expectancy, whether you graduate high school or not. Just allowing them to achieve that goal then sets them up for a longer life. And so I think that, again, if we were going to take all the energy, all the osmosis, all the molecules, all the ingredients in this particular moment, and channel it in one place, I would channel it towards giving our kids as best a start as they could in terms of success in life. Della Taghipour: Absolutely. The future is always in the hands of our youth, thank goodness. Is there anything specifically we can do to challenge ourselves as health care providers to do better when it comes to equality of care? Garth Graham: One of the things we often, as you know well from training and the future ahead is we constantly reassess ourselves, whether that be board exams or different things. There are often things to make sure that we are reassessing where we are from a clinical standpoint. And I think we should do that assessment for where we are in terms of what we bring to the table from a moral caliber standpoint, and what are the kinds of things that influence our clinical and non-clinical decisions. And I say it's certainly often if I go from one room to the next time, I stop and go, "What did I do there? How was that interaction? Did I treat them in a culturally sensitive manner so that patient knew I cared about them?" I think a lot more times patients want, they both definitely want a caring and competent doctor, but we sometimes put less emphasis on the caring. And so I think as clinicians, as we continue to maintain our competency, let's maintain our caring for how we care and how we see pain and how we see suffering and how we treat that regardless of race or ethnicity. Della Taghipour: Yeah, absolutely. Taking the opportunity to do some self-reflection and introspection is always really, really important, particularly with what we're doing and how much of a gift it is to have the opportunity to do what we do and have potentially very vulnerable population in front of us, and every one of our decisions can impact that. Thank you for sharing that. It's been absolutely wonderful speaking with you, Dr. Graham, and really enlightening, and I really appreciate this opportunity. Is there anything speaking directly to health care providers that you would like to add or share? Garth Graham: Yeah. Right now, I think as a country and certainly as a community, we all believe that there should be some change. There may be different viewpoints on what the degree of change is and what are the things that need to be changed. What I would say to all of us in the health care communities, let's commit to being a part of the process. Let's commit to thinking through again how our actions individually are both responsible for the problem and part of the solution. And then let's think through how we create the systems and the infrastructure that helps to reverse that. When we stick out what happened in 1960s, what initial periods of turmoil eventually led to the birth of things like Medicare and Medicaid and kind of things that we view as a normal part of health care now. We do know that that things can change. And so I would say just commit to being a part of the change, and certainly being a part of being a better person, if not a better system. Della Taghipour: Wonderful. And is there anything else that we haven't covered that you'd like to share with our audience? Garth Graham: No. I think you covered it all. It's a challenging time, an exciting time, but I once heard somebody say, "Never let a good crisis go to waste." And so let's take advantage of the moment to make sure that we leave it better than we found it. Della Taghipour: That's right. And I think one of the benefits that has happened during the pandemic is sort of bringing to light the moral injury, the mental health crises and the stressors that the frontline and others have experienced. And I hope that out works towards removing some of the stigma that's been, unfortunately surrounded with mental health issues, but in the past. Dr. Graham, I just have one more question for you. How can clinicians take care of themselves in this moment, so that they can take care of others with empathy? Garth Graham: Yeah. That's such an important point that I myself have challenges with. I think we all have to realize our both personal and professional limitations, and again, understand that we bring to this ourselves as people before we became the clinical or health care professionals that we are. And burnout is a genuine, very real phenomenon. And so we have to really encourage both ourselves, as well as the people we interact with, to take time to understand what you're feeling, understand the dynamics of what's happening, how that's impacting you, taking a step back any time, and just taking some time to yourself and refreshing your mind, your overall sensibilities, so that you can continue to thrive. I think right now is a good time for us all to take some time to just be ourselves and understand. I think that's what a lot of this moment is about, is that we want everyone to be comfortable being themselves. And so thinking a lot about how you can do that and be that, but again, understanding that burnout is a very real phenomenon, but it's also a treatable phenomenon. And they're the kinds of things in terms of community and individual connectiveness that's important. Della Taghipour: I agree. Thank you so much, Dr. Graham. Thank you for your incredible insight and your dedication to addressing all this change. It's been an absolute pleasure speaking with you. Garth Graham: Thank you for having me. Agreed. Totally. Thank you, Dr. Taghipour, that was- Della Taghipour: Truly, Dr. Graham, it was really wonderful speaking with you. Garth Graham: All right. Good stuff. Thank you guys. Della Taghipour: I really appreciate it. Garth Graham: Okay. Della Taghipour: Thank you for your time. Garth Graham: All right, talk to you later. Bye-Bye. Della Taghipour: Bye. Daniel Kraft: Thank you for listening to Healthy Conversations, the podcast. It's our mission to reveal the front lines of the health care profession and educate everyone as to the challenges and potential opportunities of a world change by Corona. Next time we'll look at Covid recovery efforts, how we're using data and modeling to our advantage as we continue to tackle Covid, and the role that digital health tools play in recovery efforts. Have thoughts you'd like to share or Covid topics you'd like us to address? Let us know on Twitter at CVS Health.