Transcription:
Leveraging Rheumatology Medical Education to Address Health Disparities

Melanie Cole (Host): Welcome to Better Edge, a Northwestern Medicine podcast for physicians. I'm Melanie Cole. And joining me today is Dr. Irene Blanco. She's a Professor of Medicine in the Division of Rheumatology at Northwestern Medicine. She's here to address health disparities in rheumatology medical education.

Dr. Blanco, it's a pleasure to have you join us today. This is a really great topic. Can you tell us a little bit, as we get into this topic, about your role as the co-chair of the Diversity, Equity and Inclusion Subcommittee of the American College of Rheumatology and the work that you're doing to help diversify the field of rheumatology.

Dr Irene Blanco: Sure. Thanks so much for the question. And thank you so much for having me today. So as part of the DEI team for the American College of Rheumatology, our role is to really think about how the college can not only be more responsive in terms to addressing health disparities, but how we can actually diversify rheumatology.

The results from our 2015 workforce study showed that we actually have a huge paucity of black and Hispanic rheumatologists. This is in a field that is actually seeing a lot of workforce issues because not a lot of people go into rheumatology and we are seeing a lot of our workforce leave due to retirement or going part-time for other reasons, et cetera. So, we're seeing a drain on rheumatologists. And in terms of the patients that are most impacted by the rheumatic diseases, oftentimes they don't necessarily see rheumatologists that look like them. So how do we work to recruit and retain these rheumatologists within the workforce to not only diversify the providers that the patients are seeing, but also a lot of the questions that we're asking in terms of research.

Melanie Cole (Host): This is such an interesting topic. So, much of your research is focused on the health disparities in rheumatic diseases. Can you tell us a little bit about that and the background of your work?

Dr Irene Blanco: Sure. So, the health disparities impact every single medical specialty, right? So this is not something that is unique to rheumatology or unique to internal medicine. I mean, we see it across the board in the surgical subspecialties, in the medical subspecialties, pediatrics, you name it, right? So in essence, we know that patients from marginalized groups, be it racial and ethnic minorities, patients facing poverty, patients being undomiciled, et cetera, are going to have worse outcomes.

Now, the question is, what do we do about that? So a lot of my work, because at my prior institution, I was an educator and administrator, as well as being a clinician. So through that role, I decided to dedicate my career to using medical education to bring these issues into rheumatology medical education and to help program directors think about how they're going to address these topics when they're training the next generation of rheumatologists.

Melanie Cole (Host): Well, then, what role do race and ethnicity play and even gender, as we're seeing more females coming into the field of medicine, rheumatology and pediatrics, you mentioned, even orthopedics? Tell us a little bit about the role that all of these things play together. Do you see an implicit bias or if genetics are a factor as well? Do you feel that some of the problems with diversity are mistrust in the medical community? This is a complicated issue.

Dr Irene Blanco: Most definitely. And I think yes to all of the above. So, is there a genetic component to the rheumatic diseases? Certainly, particularly in those diseases that fall under the spectrum of like the connective tissue diseases, namely lupus, scleroderma, Sjogren's, et cetera, where we do see a much higher proportion of women, particularly after puberty.

So we do see, for example, childhood lupus. And there, the rates of male children to female children are one to two. So about for every two girls impacted by lupus, there's one boy. So as they reach puberty, the rates of women with lupus actually skyrocket and become somewhere on the order of like nine to twelve to one, right? So about 10 times more women than men having lupus, though men continue to develop lupus. After menopause again, the rates go down. It's still a female predominant disease, but not as much. So there's likely something having to do with hormones and the hormonal interplay with the immune system that impacts it.

However, there is something to be said for the fact that racial and ethnic minorities are disproportionately impacted by all diseases, right? And that is part and parcel of how medical systems have been set up. There's a long history of structural racism, both on how we allocate housing and resources, education, medical systems, et cetera, that our nation is still grappling with. So, when you take all of these factors, in addition to a patient's education, socioeconomic status, their baseline access to resources, and then layer in the components of the rheumatic diseases, it can really be this multiplicative impact on all of these factors coming together.

Now, rheumatology is a very female predominant specialty. So as women come into fields, and this is not only medicine, you see this across multiple industries, you see, for example, salaries become lower. You see, for example, women not getting promoted at the same rates as men within the same fields. You see, for example, women in lower level positions as opposed to men being, for example, department chairs, division chiefs, et cetera.

So I think we're grappling gender, racial and ethnic minority issues on the part of the patients, but also on the part of the workforce. And this isn't only impacting the female rheumatologists, but then when you think of it in terms of intersectionality, right? The female rheumatologists that are of marginalized groups themselves that are of racial, ethnic minorities themselves, how are they impacted? And that's actually part of a study that I'm doing now with a colleague out of UPENN.

Melanie Cole (Host): Dr. Blanco, as you said, data has shown that people from racial or ethnic minority groups are less likely to receive preventive healthcare. And across the board, various ethnic groups have faced a disproportionate burden of health. Can you talk about some of the interventions and strategies to address this and share your experiences of prioritizing diversity, equity, and inclusion, and why it's so important for an academic medical center to do so?

Dr Irene Blanco: We strive as academic medical centers to give our patients the best, most cutting edge care. And our ideals are that we provide the best medical care to anyone that walks through our doors. This goes for every single medical center. The fact that certain groups do worse goes against our ideals and our mission, and this is my personal opinion. I think that for a very long time in medicine, we were just okay. We had gotten used to the idea that certain populations do worse for whatever reason. And we're like, "Oh, well, you know, these patients do worse." And so when we saw worse outcomes, we're like, "Well, what do you expect? They do worse." And in terms of the work that I do, it's getting my fellows to stop and think about the why. So don't come to me and say, "Patient so and so is not taking their medicines." You better come to me and say, "Patient so and so is not taking their medicines because of X, Y, and Z. And this is the way that we plan to help them."

So I think in terms of institutions on the individual provider's level, medical education until unfortunately quite recently was very centered on what I like to call the molecules, the basic science, the pathophysiology, which of course is the crux of medicine and something that we all need to learn. But we know that, for example, 60% of all the morbidity and mortality that a patient faces from any chronic illness is secondary to the social determinants of health. So if we, as physicians, don't get in there and really start advocating and dealing with those things, we're doing our patients a disservice.

Now, the patient and provider can't go at it alone. There's only so much one individual provider can do against an enormous system that's set up with multiple barriers to care. For example, the time delays that we're seeing with prior authorizations and whatnot, which actually drastically impacts the care of patients with rheumatic diseases because our medications are so costly. We face huge prior authorization limits that directly impact our patients that are of low socioeconomic means, don't necessarily have the resources to overcome all those prior auth barriers, for example.

So how can health systems provide the resources and the infrastructure to help the providers that are on the front lines, dealing with their patients and helping their patients overcome their social determinants of health? How do they all work together? And in many hospital systems, a lot of these interventions are set up through primary care and definitely primary care is the first line of defense for all of this. But we see it very much in all of the subspecialties that are providing chronic care to chronically ill patients as well, rheumatology being a specialty that has very long-term relationships with our patients, right?

I left an institution where I had been for 15 years and I'd known many of my patients for 15 years. We'd gone through pregnancies together. We've gone through job gains and losses and everything in between. If I, as a rheumatologist, don't have the resources provided to me to help those patients, I'm at a disservice because more often than not, when a patient has a very complicated autoimmune disease, they're probably coming to me more than primary care. So we really need to think about how we distribute a lot of those frontline resources to other settings and providers that may be having those sort of same interactions with the patients and addressing the needs of those patients.

Melanie Cole (Host): Such a complex issue and you speak about it so beautifully. And working with people from different backgrounds or cultures can present unique opportunities for collaboration and creativity as you were just pointing out. And thank you for telling us how physicians play a critical role in addressing these public health concerns.

As we get ready to wrap up, I'd like you to specifically speak about rheumatology medical curriculums, the training programs, the ways they can address this and thinking about long-term solutions, Dr. Blanco. How do you think the healthcare industry can be better reformed to serve minority patients? And in your personal experience, how have you seen this materialize at Northwestern Medicine?

Dr Irene Blanco: I think the ACGME, which is one of the bodies that hold our standards for our training programs, mandates that we incorporate education into health disparities and health equity across all of our graduate medical education training programs. The issue is a lot of the program directors are not necessarily content experts in this material. So, they're busy with all of the administrative tasks that need to be done in order to run a training program. In addition, they're just trying to set the curriculum for their individual specialty, namely for me rheumatology, but it could be cardiology, gastroenterology, hematology, oncology, you name it.

The issue is how can we provide these program directors the tools that they need to not only get up to speed themselves on these issues so they can develop a certain level of self-efficacy, and feeling comfortable having these critical and sometimes challenging conversations with their trainees and with their faculty, but also ensure that there's a standardization of the content across the board for our specialty.

So for example, in general internal medicine, the Society of General Internal Medicine has had a Train the Trainer Program for decades at this point. How do we bring that to the subspecialties to really enrich our trainees' education? And so that's a lot of what I've been focusing on. I've done needs assessments in both fellows and with program directors and both sides are itching for this content. So it's how do we bring it to them in a way that can be easily integrated in their curriculum? And does it look like an add-on, like one more thing I have to do? But also is really centered within the data of everyone's own specialty. So that way, I'm not using diabetes data to treat rheumatology fellows because the second I do that, something in their brain just kind of shuts off because they're like, "Oh, well, this isn't pertinent to me, right? This is endocrinology. This is not me." So if I create content that's very centered in room, hopefully that'll create a generation and subsequent generations of rheumatologists that really start to think about these issues and how to address them in patients.

I mean, Northwestern has an amazing infrastructure, whether it's the Center for Education on the Social Determinants of Health, the NUCATS, and several colleagues, Melissa Simon and Clyde Yancy, right? They just got an enormous grant to do cluster hires. So that way, you can bring in providers and faculty and investigators for marginalized groups that tend to think about different questions and how these issues impact patients.

I think it can really be viewed as sort of like a translational endeavor where we really need to think about what's happening at the bedside, how to bring all of the issues of the bedside to our research to then bring back interventions back to the bedside.

Melanie Cole (Host): Thank you so much, Dr. Blanco, for joining us today and for sharing with other providers to help provide better treatment for diverse populations.

To refer your patient or for more information, please visit our website at breakthroughsforphysicians.nm.org/rheumatology to get connected with one of our providers. That concludes this episode of Better edge, A Northwestern Medicine podcast for physicians. Please remember to subscribe, rate and review this podcast and all the other Northwestern Medicine podcasts. I'm Melanie Cole.