To achieve health equity, culturally relevant care must be the standard of care [PODCAST]

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“Practicing culturally relevant care means we can account for the social determinants of health, barriers to access, and the emotional disconnect that results from the status quo, one-size-fits-all approach many patients have come to expect. It helps us reach into underserved communities and lift them up, which is essential during a pandemic that disproportionately affects low-income and diverse Americans.

If we, as clinicians, can align around the fact that we exist to serve all patients, we must realize that culturally relevant care is more than a situational deviation from the norm. Rather, it must represent the new normal—the new standard of care.”

Vik Bakhru is a clinician and health care executive.

He shares his story and discusses his KevinMD article, “To achieve health equity, we must make culturally relevant care the standard of care.”

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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, 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 on the show we have Vik Bakhru. He is a clinician and health care executive, and he wrote the KevinMD article “To achieve health equity, we must make culturally relevant care the standard of care.” Vik, welcome to the show.

Vik Bakhru: Thank you so much for having me, Kevin. It’s an honor to be here.

Kevin Pho: We’ll get into the article in a little bit, but first off, can you share your story and journey to where you are today?

Vik Bakhru: Yeah, sure. How much time do you have? No, I’m teasing. I’m originally from upstate New York. I’m a clinician by training. I went to school in D.C. and residency in Philadelphia, and then did an MBA, and that’s really where my career took a different direction.

So after the MBA, I worked as a hospital administrator at NewYork-Presbyterian, followed by a stint in private equity at Fortress Investment Group, where I ended up being a chief medical officer for one of their portfolio companies focused on medical travel. So folks in East Africa and the Middle East who didn’t have access to great local care were able to travel to Europe and India for procedures, mainly. And so I did that, spent about 95 percent of my time outside the U.S., missed family and friends, and ended up moving back to the U.S.

I spent time in San Francisco building out telemedicine, and after that, moved to Los Angeles and built out a patient engagement platform called ConsejoSano, which means “healthy advice” in Spanish. We actually ended up serving people who came from over 25 different cultures and spoke that many languages, and mostly we supported people who received their benefits through the Medicaid program. So about 90 percent or so of the folks that we served are on Medicaid. And more recently, in the last few months, I’ve moved to a company called Circulo Health, where I serve as our chief medical officer and also lead our partnerships and strategy and a few other areas focused around our care model. And we are a Medicaid health plan, just for clarity.

Kevin Pho: I talk to a lot of clinicians who sometimes want to delve outside of clinical medicine into the entrepreneurial space, and clearly you’re in that space. What are some characteristics that clinicians should have that would self-select them outside of clinical medicine and into the administrative, entrepreneurial space?

Vik Bakhru: An appreciation for pain. No, I’m just kidding. Being an entrepreneur is, you know, sometimes getting punched in the stomach more than a few times in a row. So you really have to have a strong stomach, number one, pun intended.

But no, it’s a phenomenally rewarding way to spend your time, from the standpoint of, I don’t get the immediate gratification of having served a patient in front of me, or a person in front of me. I still do one weekend a month when I work clinically. But in this world, it’s just a very different feedback loop for your efforts. You are at times impacting thousands or tens of thousands of individuals with the decisions and the support that you’re providing to your team. It’s very much a multidisciplinary team-type approach, much like you might have on the wards in the hospital or in the clinic. It takes many people to support the health of an individual or of a group of individuals. And so from that standpoint, it’s a way to scale your impact, and I think that’s the part of it I’ve enjoyed the most, the ability to impact many, many folks with the time that I’m spending.

Kevin Pho: I talk to a lot of health care entrepreneurs on this podcast, and they’ve written on my site, and there are thousands of them out there, and they each want to get their product or service integrated into the health care system. And as you know, in our current health care system, the status quo is very strong. So what separates companies that get their product or service integrated into the status quo?

Vik Bakhru: A few things, in my mind. One is perseverance. You really have to be able to learn how the status quo is working, because there are so many wonderful things about our health care system, and we don’t talk about the things that are actually working in beautiful ways. But then the areas that are opportunities for improvement, it takes time to understand what those are. It takes time to understand who the stakeholders and decision-makers are in making that change. It’s a very fragmented system.

So if you’re going to make change across the entire health care system, you can go the policy route, which allows you to have perhaps that broad impact in one fell swoop that might take five or 10 years to drive forward. Or you can perhaps go into a digital health route, like I have, and in that case you might have a more focused impact, in terms of one hospital system or one clinic system, or even potentially one doctor’s office at a time, or another type of care facility, right? It’s not only doctor’s offices where health care is delivered; it’s many, many types of care settings. And so whatever your area of focus is, or if it’s directly to patients and their families, or people and their families, there are so many ways to think about it. But I would say, depending on the path you choose, perseverance is probably the most important attribute that leads to changing the health care system’s status quo.

The second is collaboration. You really have to approach these problems in a very collaborative, team-oriented way. If you try to do it yourself as an individual, it’s not that you won’t be successful; it’s just that the magnitude of your success may be different than what otherwise might be able to be achieved if you are collaborating with a number of folks. Both at my current company and my last company, I’ve had the true privilege of working alongside some incredibly talented product management folks and engineers, and many, many other operators and clinicians alike, who see the world in many, many different ways. And it’s that collaboration of spirit, of mind, of focus, of energy, of effort, that allows you to think of the solutions first and then implement those solutions. Because health care today can sometimes be seen as a one-size-fits-all type forum or offering, and we really need to get away from that.

Kevin Pho: Let’s transition into the KevinMD article that you wrote, titled “To achieve health equity, we must make culturally relevant care the standard of care.” Now, for those who didn’t get a chance to read your article, can you just walk my audience through it and share the story of why you decided to write it?

Vik Bakhru: Yeah, of course, happy to. You know, I’ve been passionate for a long time about health equity, because in our health care system, if we look at the Medicaid program, for example, in the five largest states, between 60 and 80 percent of people who receive their benefits through Medicaid are culturally, ethnically, racially different. Nationally, that statistic is about 60 percent for the Medicaid program.

And when we think about the infrastructure that we have in the United States to serve those who live perhaps in rural and outlying areas, similarly in suburban or urban areas, sometimes there’s a mismatch, and not just in terms of the similarity in color of skin, but in terms of the cultural competency of the clinician providing that care to the individual being served. And it extends to linguistics and so many other aspects of culture and how you might define culture, right? It’s everything from health literacy levels to what your home setting is like, what your family structure is like.

You know, without appropriate understanding of those elements. At least on the front lines of medicine when I’ve practiced, I don’t have access to that information at the outset of an encounter, typically. I may gain insights through the course of interacting with someone. So, you know, I think when we think about making something the standard of care, it means that some of those data elements and some of the information is necessary to provide an effective encounter, and an effective encounter might include behavior change.

As a health care system as a whole, we have so much work to do in certain chronic disease states like diabetes or hypertension or what have you, right? I mean, I think most would agree that we are not where we want to be as an ecosystem. And because we’re not where we want to be, we start examining why that is. And often it’s because we throw medications and other therapeutic options at people who may be at different stages of their pathway, their own path, until we understand at the outset where people are. And that takes time, and in health care, most of us don’t often feel that we have the time we need to spend with the people we’re trying to serve.

So I would represent that, I think, making something the standard of care means taking a step back and understanding what the key pieces of information and key attributes are that we need to understand at the outset, so we can build the right experience for the person we’re trying to serve. Because it really has to start with trust. And you can’t build trust until you understand the person. You can’t understand the person until you know more about them. And you can’t know more about them until you’ve interacted with them, either through technology in some cases, or having a conversation.

Maybe medical encounters don’t start with “Tell me what’s wrong today” or “Why are you here today?” and they start more with “Tell me about yourself.” Should we learn about the person we’re serving before we learn about the reason they’re in our office? Maybe some of us do that already. But when we think about culturally relevant care, there’s a person sitting in front of me. I have to understand who they are. What do they do for work? Where do they live? What’s their family like? Maybe I’d have to treat it more like a coffee chat, if I could. But many of us understand we don’t feel like we have time for that.

But making something the standard of care might involve understanding that person in front of you before you start thinking about what’s wrong with them or what medical issue they have. Or maybe they’re there for a well-child visit, for example. But yeah, I mean, in pediatrics we do ask often about social development and so forth, right? It seems to then not be a focus as we age. But probably, especially as we deal with seniors who may be feeling lonely, that might be the most important thing we uncover in that encounter, and allow us to be most effective.

Kevin Pho: One of the things that you mentioned was a cultural mismatch. And certainly, before we get deeper into some of the solutions that you propose to fix that, give us a real-life scenario, or even a hypothetical story, that would really paint that picture in my listeners’ minds.

Vik Bakhru: I can do better than hypothetical. Quite literally, yesterday I was in a part of Ohio talking to a direct support worker who is serving a member, a person living with intellectual and developmental disabilities. And one of the topics that came up was vaccination against COVID-19. This direct support worker was concerned about a requirement by their health care organization to be vaccinated. And I fall squarely on the side of the coin that says vaccines are important and a way to deal with the pandemic and all of the potentially very harmful negative effects from a medical standpoint. But this person felt differently and was very concerned about it, and we had a pretty lengthy conversation around why it’s important and so forth.

And I don’t know that I changed their mind. I don’t have that feedback loop yet. I’ll know probably in the next few weeks if they decide to get vaccinated versus stop working for a particular health care organization. So I expect to know at some point in time if I contributed to that journey, but right now, I don’t know.

But I can tell you from that interaction that, for me, a culturally relevant conversation meant getting to know the person first, and understanding more about their family, understanding more about their home setting, about their beliefs, their values, and not jumping into this notion: “Vaccines are important.” “I don’t want it.” You end up reaching a stalemate-type situation pretty quickly. Instead, it’s about the relationship that we’re able to develop. And I hope that I was able to develop a relationship with this individual to convey my concern for them, their family, and so on.

One of the things they raised during the conversation was that they had cared for someone with COVID when vaccines weren’t available, and unfortunately that person went on to pass. So they understand the devastating consequences very well. It was someone they deeply cared for, given that they had worked with that individual for years. It was an individual living with intellectual and developmental disabilities that passed. And through the conversation, it became clear that this person understands the consequences very clearly, and that wasn’t enough to maybe change their mind. But what was also clear is that this person had felt that they didn’t need the vaccine to make it through. And that’s where the gap might actually be: an understanding that simply because you didn’t get it before. And this person, by the way, has COPD, so I’m very concerned about this person in terms of needing the vaccine and why it’s even more important.

And so part of the conversation gravitated toward, you know, our disease states evolve over time. And so how susceptible you were at that particular moment in time, with that particular variant of the disease, in the particular capacity that you were serving, with the particular PPE that you had available to you, these are variables that can change over time, especially as your COPD may worsen. I can’t tell you for sure that it felt great, but a lot of the conversation went in this direction.

So culturally relevant care means understanding the individual, their preferences. This was not about the person’s race. It was not about the person’s language. We both spoke English. They were white; I’m brown. This was not about any of that. It was their culture. It was their daily life, how they live it, what their views are. And I needed to understand that to have what I hope, again, I don’t know for sure yet, but what I hope will have been an effective conversation.

Kevin Pho: Are there any pieces of data or evidence that suggest that our lack of culturally relevant care impacts patient outcomes?

Vik Bakhru: I think every failed outcome, or I should say every mammogram that’s not had, every colorectal cancer screening test that’s not done, every missed colonoscopy, therefore every missed mammogram, therefore, all of these are signs that the lack of culturally relevant care in those cases didn’t get the message across. And it wasn’t because we didn’t have good people on either side of the conversation. It was because they weren’t part of the same conversation.

And that takes training and education for our clinicians, for those who may need it. Some of us may not need it. We may be able to demonstrate. I think I know how to deal with stubborn dads, stubborn Indian dads. I’ve got one. I’ve grown up around him. I am not perfect at negotiating with him on all of the various health care items, but I have a lot of insight. And I don’t know that a training module will improve my skill set in that particular demographic or culture. But where I might need help is in other cultures, and potentially other clinical areas, right? I’m not a clinician that knows everything about everything. I’m human. I have an area of expertise, and I have areas that I don’t know enough about. So there’s a role for training on the clinician side, in my opinion. And there’s a role for making experiences in health care that build trust, and that’s partly a technology opportunity and partly a need for health literacy and improving it among people needing care.

So, you know, to your question, I think the data is all around us, and it just takes opening our eyes to it and adopting a viewpoint. Are there randomized controlled trials? I hope not, because I’d hate to see people get care that’s not culturally relevant. And yet I do, right? It’s every informed consent where the person didn’t bother to get the translator on the line, and they relied on a family member, or they relied on some other resources that may or may not be the best for that particular person being served.

So committing to cultural competency can sometimes be done in a variety of ways. But what’s the data on it? I think it’s lacking. I think we need to do more to really understand how prevalent this issue is. But I can tell you, in every health care setting I’ve worked, it’s definitely been something I’ve observed, which is why I’ve come to the conclusions I have, that it ought to be a standard of care. We ought to do more to understand the cultures of the patients we’re serving, the people we’re serving.

Kevin Pho: We’re talking to Vik Bakhru. He’s a clinician and health care executive, and he wrote the KevinMD article “To achieve health equity, we must make culturally relevant care the standard of care.” Vik, you mentioned courses to train physicians about culturally relevant care, but you also mentioned a technology opportunity. What exactly did you mean by that?

Vik Bakhru: Thanks so much. You know, I think there are a few ways to improve culturally relevant care. Sometimes it’s about understanding the needs. And so with various tools available to us, whether it’s texting and asking the right questions of the people we’re trying to serve, or offering up apps and tools that allow the collection of that information, or understanding some of the analytics around where patients live, and what the probabilities are that they own a car or don’t own a car, and how that transportation may impact their ability to access care, and how that ability to access care is a part of who they are, right? Because it also means they probably aren’t able to access workplaces easily, or access the food stores as easily, or what have you, right? So that’s all, really, we call them social determinants, but social determinants are part of, more broadly, what I call cultural determinants of health, right? There’s a lot of focus, or there ought to be a lot of focus, on some of that cultural component.

So, you know, when I think about the tools, it’s both person-sided and then care-system-sided, right? So those tools on the care system side are things like Violet Health. It’s a very young company, but I just came across them a few weeks ago, and they do training for providers and clinicians around cultural competency. So when I think about someone who’s never seen a patient in their office that identifies as LGBTQ+, I worry a little bit about the experience that that patient might have. It doesn’t mean it’s going to be bad. I just worry about it, because that clinician may not have the training to use the correct terminology to properly respect that patient. Let’s say that they’re trans. Let’s say that they still have a cervix and therefore need cervical cancer screening. The way that you bring it up is of key importance to that person’s life experience, sense of identity, and so forth. As a health care system, it’s up to us to go and learn, but I don’t know that we all do all the time.

So companies like Violet Health are creating training modules and certifications that allow you to go through that learning cascade. I mean, most of us in clinical fields are academically curious individuals. We enjoy learning; we enjoy understanding new things. And for some of us, some of these topics are foreign; they’re needing more study. And so there are tools like Violet Health and others that help you get there. And they’re at Northwell in the New York City area and a few other health care organizations. Again, it’s a very young company. I don’t even know if you can sign up on your own. But whether it’s Violet Health or some other company, there are many of these tools out there that can help you learn the right terminology, help you practice, perhaps even have a conversation back and forth.

You can certainly do it with folks on your team. That’s where I turn when I have questions about topics that I don’t understand: I ask the people I trust, right? My advanced practice providers and other colleagues of mine who sometimes have more experience or more awareness about issues that I may not be familiar with. So it takes a Socratic method, if you will, right, an approach.

Kevin Pho: And my final question: What’s your take-home message that you want to leave with the KevinMD audience?

Vik Bakhru: The final message would be: Commit to health equity. Commit to serving those, while reimbursement rates may not be where they need to be, and while other factors may impact your decision to serve those in our country who do not have great access to care. Find a way to be relevant for people who do not have the type of life experience that those of you listening to this podcast likely have. Find a way to be impactful, and commit to health equity. That would be, I think, my request, or my ask of your audience.

Kevin Pho: Vik, thank you so much for sharing your time and insight, and thanks again for being on the show.

Vik Bakhru: My pleasure. Thanks for having me, Kevin.

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