COVID-19 amplifies health disparities [PODCAST]

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“The daily email update on COVID-19 affecting our hospital system is a glaring reflection of the health disparities amongst those in marginalized groups. The farther south you go, generally in San Diego, the higher the number of socioeconomically disadvantaged persons, and that tends to include a disproportionate number of persons of color.  These populations may be unable to physically distance due to living conditions and job conditions.  Perhaps there is a higher number of persons living together per household, in a smaller space, along with the inability to work from home.  And the mortality rates of those from COVID-19 amongst these persons is higher than white counterparts. Sometimes there is an inherent distrust in the medical system.  COVID-19 and racism intersect. However, this is not a unique situation in health care—many chronic illnesses portend worse outcomes for those in marginalized groups.  Marginalization means just that: glaringly apparent in health outcomes and socioeconomic disparities.”

Ni-Cheng Liang is a pulmonary physician and founder, the Mindful Healthcare Collective.

She shares her story and discuss her KevinMD article, “COVID-19 becomes a magnifying glass for health disparities.”

Resources mentioned in the show:

Implicit bias test: https://implicit.harvard.edu/implicit/takeatest.html
Health Disparities Widget: https://www.healthypeople.gov/2020/data-search/health-disparities-data/health-disparities-widget
Strategies for Reducing Health Disparities: https://www.cdc.gov/minorityhealth/strategies2016/index.html
Conscious Anti-Racism: https://www.jillwener.com/consciousantiracism

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Hosted by Kevin Pho, MD, The Podcast by KevinMD shares the stories of the many who intersect with our health care system but are rarely heard from.

Transcript

Kevin Pho: Hi, and welcome to the show, where we share the stories of the many who intersect with our health care system but are rarely heard from. My name is Kevin Pho, founder and editor of KevinMD. Today, we welcome back on the show Dr. Ni-Cheng Liang. She’s a pulmonary physician, and she wrote the KevinMD article “COVID-19 becomes a magnifying glass for health disparities.” Welcome back to the show.

Ni-Cheng Liang: Thanks so much for having me again, Kevin.

Kevin Pho: So for those who didn’t listen to your first podcast, can you briefly share your story of how you got to where you are today?

Ni-Cheng Liang: Yes, absolutely. I’m a pulmonologist practicing in San Diego, and I’m a cancer survivor. I got breast cancer in the second year of my pulmonary fellowship, and that cancer experience has really informed how I returned to the practice of medicine, having been an integrative medicine patient to help with my mindset as well as my general health and well-being, even to this day, after receiving the allopathic medicine that saved my life. Mindfulness meditation in particular has been a daily routine for me, and also something that I incorporate into my practice of medicine, with my patients and for health care professional well-being. So thanks for having me back.

Kevin Pho: Sure. Now, you wrote a wonderful KevinMD article, “COVID-19 becomes a magnifying glass for health disparities.” For those who haven’t read that article, can you walk my audience through it and share the story of why you decided to write it?

Ni-Cheng Liang: Yeah, absolutely. It was during the onslaught of increased racial tensions brought about by the George Floyd murder, and how dehumanizing that whole situation was, and how angered the nation became. Ironically, but also perfectly, this whole situation intertwines with coronavirus, and I am reminded daily of the health disparities that exist currently where I practice medicine. Every day, we get a daily update of coronavirus cases in the Scripps health care system, which spreads up and down the San Diego County coastline, basically. The further south you go, the more cases there are, and that is a glaring, direct representation of socioeconomic status in San Diego.

So that kind of galvanized me, wanting to draw connections between racism and how dehumanizing taking away the breath is, whether it be through racism or through having coronavirus. So that was the initial inspiration for the article.

Kevin Pho: Now, what are some statistics and details about the racial disparities when it comes to the effects of coronavirus?

Ni-Cheng Liang: You know, I actually don’t know the specific data, but I do know that Black, Indigenous, and other peoples of color have worse outcomes compared to their white counterparts. I can’t give you statistics quite just yet, though. I think the final numbers have yet to be seen.

Kevin Pho: And what are some of the underlying reasons, because coronavirus kind of magnifies the health disparities that already exist?

Ni-Cheng Liang: So we do know that those who have chronic comorbidities, such as diabetes, hypertension, high blood pressure with cardiovascular disease, chronic lung disease like COPD, which tend to have worse outcomes in people who are otherwise basically non-white, are already set up for worse outcomes with something as virulent as coronavirus.

Kevin Pho: Now, what are some of the answers? I’m going to ask you this from a policy level, but also from an individual physician level. So what are some things that we can do on a macro scale, and what are some things that we can do when we’re in the exam room?

Ni-Cheng Liang: Yeah. On a macro level, the government has to really be behind change in our health care system. A lot of practicing physicians agree with the statement that this is actually not a health care system; it’s a disease care system. We’re focused upon individualized diseases rather than whole-person, holistic approaches, and so I think this reductionistic attitude toward health and wellness definitely has to change.

So from a policy level, just from having worked in a safety-net hospital before: Now, with Medicare dinging hospitals for being over the mean number of 30-day readmissions, for a while safety-net hospitals were obviously potentially getting penalized more. So could there be some legislation that’s passed? I know that there was House legislation that was trying to get passed a couple of years ago about protecting these safety-net hospitals. But using health as an incentive rather than productivity outcomes, I think that the health care system right now is incentivized kind of backwards. We don’t get rewarded for true, good health care, and that’s true, and we’re certainly seeing that now. As productivity goes down, you’re seeing a lot of physicians and clinicians get further laid off, because simply we’re not seeing as many patients as we used to.

Kevin Pho: Now, from an individual standpoint, are there any things that we can do to help with the disparities, from an individual physician standpoint?

Ni-Cheng Liang: Yeah, I think that it actually has to start on an individual level rather than waiting around for even local, state, and national legislation to change. It can start with all of us as individual practitioners, because racism is so interwoven into the fabric of American society. I think it’s just the recognition and the acknowledgment that it, too, affects medicine and how we were taught medicine. Racism is quite pervasive, and I think it’s the acceptance of that, and then these individual educational goals that you can have about educating yourself.

There are a lot of great books out there now that have recently become New York Times bestsellers because of recent events that you can take the initiative to read. Professor Magee’s book is just one such example of that, where she introduces the concept of training yourself in color insight, as opposed to this blanket statement or blanket philosophy of “Oh, I’m not racist; I’m color-blind.” But actually, genetically and physiologically speaking, our brains aren’t wired for color blindness. Whether you like it or not, our brains see color, and it’s about getting closer to the recognition of that, and perhaps getting some formal bias training, whether or not that’s advocated for you by your health care system, but taking it upon yourself to do some of your own work in terms of implicit bias training. There are a lot of resources for that out there. I myself am currently enrolled in an anti-racism course, because I want to become aware of things that I wasn’t aware of, just practicing medicine the way that I was taught. So I think the desire to change needs to be there, but then also, more importantly, taking the action steps for you to change, so that you can catch yourself in a situation that you might otherwise have glossed over as a potential bias situation.

So it comes back to mindfulness, and paying attention, and being aware of why we practice medicine the way we do. Could some racism even inform the way that we practice medicine in our own individual practices? I dare say that at some level it probably does, unfortunately. So the awareness of that is step number one. Step number two is taking action, very intentional, purposeful action.

Kevin Pho: Now, you mentioned some resources about implicit bias and some resources about anti-racism. What are some resources that clinicians can look up online?

Ni-Cheng Liang: Professor Magee’s website, rhondavmagee.com, is a great starting point, and that has more information about her work and the intersection of mindfulness and racism. And then Dr. Jill Wener, who is on the executive board with me on the Mindful Healthcare Collective, actually put together a curriculum with Dr. Maisha Claiborne to basically educate those who are non-Black, Indigenous, people of color on anti-racism in health care, and also for the general public. You can actually just Google “Jill Wener anti-racism course.” And then there are also implicit bias tests that you can take online. I believe Harvard has one. But I can send you references in an email for you to include in the show notes later on, Kevin.

Kevin Pho: Now, can you give some specific examples or specific scenarios where a clinician may be guilty of implicit bias, but he or she may not be aware of it?

Ni-Cheng Liang: So I think that it can become more obvious when you see patients from different payer groups, for instance. We have all these different systems, and some are known to serve the underserved, and so we know that their coverage is not going to be as complementary or comprehensive as someone who is able to afford better health insurance. So I would challenge you to notice if the different prescriptions that you write or the referrals that you make are different between the two different payer groups. Sometimes that’s, quote unquote, out of our control, because some practices just won’t take, unfortunately, for instance in California, the Medi-Cal HMOs. So I think it’s noticing that.

And then, if there is a patient who is Black, Indigenous, or another person of color, or from a marginalized group, are you able to bring a critical but critically compassionate lens and reflect back on your patient experience, to notice if the way that you treated that patient was different from the way that you treated someone who was Caucasian? So I think it’s this curiosity, because if you don’t ask yourself or catch yourself, you’re likely to not notice any of this at all. And I dare say that even just looking at the different insurance companies of the patients that you do see, and then, on a subconscious level, if they’re not white, you might notice that there are slight differences in what you offer as a clinician.

Kevin Pho: We’re talking to Ni-Cheng Liang. She is a pulmonologist, and she wrote the KevinMD article “COVID-19 becomes a magnifying glass for health disparities.” Ni-Cheng, what is the take-home message that you want to leave with the KevinMD audience?

Ni-Cheng Liang: My take-home message for the audience is simply to notice. Notice how you treat your patients, and especially notice how you treat your patients who are Black, Indigenous, people of color. That’s the take-home message, because with awareness, you can then help foster compassionate change.

Kevin Pho: Thank you again for being on the show and sharing your insights, and thanks again for your time.

Ni-Cheng Liang: Thank you for having me on again.

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