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Join podiatrist Amol Saxena as we delve into the often overlooked disparities in the U.S. health care system. We discuss the historical underrepresentation of BIPOC individuals in both patient care and medical leadership, shedding light on biases, “sham peer review,” and limited advancement opportunities. Explore the crucial need for cultural competence, unbiased mediation, and diverse leadership to rectify these issues and pave the way for a more equitable health care landscape.

Amol Saxena is a podiatrist.

He discusses the KevinMD article, “How BIPOC doctors and patients suffer in the U.S. health care system.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Amol Saxena. He is a podiatrist. His KevinMD article today is “How BIPOC doctors and patients suffer in the U.S. health care system.” Amol, welcome to the show.

Amol Saxena: Thank you.

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

Amol Saxena: Well, I’ve been in practice specializing in sports medicine and foot and ankle surgery for over 30 years. After operating on three Olympic gold medalists and three orthopedic surgeons, and publishing 150 scientific papers, I think I pretty much ticked all the boxes I needed to in podiatry, and I wanted to help more patients.

During the pandemic, I read two books. One was “Caste” by Isabel Wilkerson, and the other is Paul Starr’s “The Social Transformation of American Medicine.” Two things came out of that that impacted me. One was just the disparities in health care in the United States. And then, podiatry wasn’t mentioned one time in 500 pages in this book. So we’re very similar to Asians in America in not having political clout.

Then I went on a trip with a college buddy of mine who’s a family doc, and we talked about how health care is really impacting the United States, and about my experiences, because I’m involved with the German Foot and Ankle Society as a lifetime honorary member. We talked about how our education system takes a long time and how that affects people who want to go into primary care. Ultimately, it all boils down to this: It affects health care in America, particularly for minorities.

Kevin Pho: All right, and we’re going to talk more about that in your KevinMD article, “How BIPOC doctors and patients suffer in the U.S. health care system.” Now, before getting to the article, you mentioned that you were a podiatrist for 30-plus years and then you wanted to help patients outside the exam room and make a little bit more of a difference. Why is that? Not every physician has that motivation.

Amol Saxena: Well, personally, I’ve had some roadblocks. One of the things that my article shows is that Asian doctors are 20 percent of the medical profession but less than 4 percent of the leadership. So I really didn’t have opportunities to lead the way I thought things should go, to help more patients and help podiatrists.

I still practice, but I decided to go back and get some more skills. I went back to the Dartmouth TDI program, which has opened my eyes even more. So that’s how my road started, and I came across a lot of interesting readings that opened my eyes about areas where I could hopefully make an impact.

Kevin Pho: All right, so tell us, how did this particular article come together?

Amol Saxena: As I said, there was that one quote about Asians not having leadership roles, analogous or parallel to their representation. Another article was about Black residents. Black medical students are 5 percent of medical school, 20 percent of the doctors who are dismissed during their residency, and they only hold 1 percent of the leadership roles. I started learning about sham peer review, where doctors of color start to get a little bit more isolation, intimidation and retaliation, and that affected me quite a bit, and I wanted to bring attention to that. I noticed the lack of diversity in my particular profession, and sham peer review seems to be a problem in medicine, so I wanted to start looking at that more.

I’ve recently aligned myself with a group called Physician Just Equity, PJE, and we try to help all doctors who may be undergoing sham peer review. We notice that sometimes, when people are a little bit higher profile than other people would like them to be, they tend to become targets. Craig Ferguson, the comedian, had a variation of Bette Midler’s quote on success: The problem with success is that not everybody’s happy for you.

Then there was an article we had to read for our course that was really impactful on me, about bias in the medical professions in the United States versus Europe. They looked at doctors and nurses on both sides of the Atlantic, and they found that the biases in medical professionals were the same as in the general population. But the difference is that in America, the bias is based on skin color. In Europe, the bias is more on country of origin. So the Swiss don’t trust Eastern Europeans; they love Western Africans. In England, there’s bias toward people of the same skin color just because they come from a different country. In the United States, it’s just based on skin color. So these types of things were really impactful to me.

So I started researching sham peer review more, particularly for minorities. The Society for Vascular Surgery has a document that they’ve circulated to help practitioners if they feel that they’ve been targeted. One thing is getting help and support, so that’s what PJE is there for, but there’s also third-party review. Basically, if you’re getting criticized or asked to meet about an issue that none of your other colleagues get asked to meet about, and you’re the only person of color in the room, there’s some bias going on.

Again, the bias in American medicine seems to be based on skin color. A lot of times we don’t think of it, particularly the so-called successful minorities. Sometimes we don’t even realize it’s happening to us until later, and we’ve been ambushed. So it is a problem. There’s a guy, Quinn Capers IV, out of UT Southwestern, who has a really good talk about how to make your departments and your med school more diverse. It needs to come from leadership, and you need to take it from the top, so to speak, and purposely try to look for diversity and make it happen. Diversity has been shown time and time again to help improve outcomes for patients.

The original bias that I was a beneficiary of is that I was a runner in college, and runners say, “I want to be treated by runners.” So that’s a bias right there. And Asian patients tend to prefer Asian doctors, and unfortunately, Asian patients grade doctors harder. So Asian doctors were getting lower patient satisfaction scores, and people were holding the doctors accountable for lower scores and requiring them to go into courses about patient satisfaction, when the data is already out there. So there are these biases that we don’t talk about, and unfortunately, when you’re a victim of this, it’s also something you don’t talk about, and it’s bad. It’s unhealthy.

So I think it’s important to call it out and try to fix the medical system, because it does affect patients all the way down the line. It affects the specialty that medical students choose, because some of the higher-paying specialties are very underrepresented by minorities. And again, it’s been shown time and time again that patients who get treated by doctors of the same ethnicity have better outcomes. There’s more trust, but even more important is the trustworthiness of a provider.

Kevin Pho: So have you personally experienced some negative repercussions of bias during your career? And if so, perhaps share a story or an anecdote.

Amol Saxena: Absolutely. There has been a lot, so that’s kind of what led me down this road. But not to personalize it too much, just to show you, in my profession, I showed how podiatrists have similar biases against them because we’re not MDs. I used to think you don’t need to be an MD; it would be like changing the color of my skin. Then I realized that we are closed out of the USMLEs. So it’s like Black people in the 1800s: You can vote, but if you can’t read, you can’t vote, and we’re not going to let you in school. The AMA has closed podiatrists out from taking the USMLEs. So I have a whole talk on podiatry prejudice and possible solutions, and I show how the prejudice against podiatrists is similar to prejudice against people of color.

Kevin Pho: Now, you mentioned the concept of sham peer review earlier on. Let’s go into more detail. Tell us exactly what that is, and perhaps give some examples of this going on in our medical institutions today.

Amol Saxena: An example is that you get called in to meet with a peer review committee on an outcome that was less than desirable. That outcome is common knowledge, and yet you’re being called out, when colleagues have had the same exact thing or worse. And now a strategy, in this corporate medical playbook to hinder or decrease the ability of doctors in medicine, particularly doctors of color, seems to be that instead of picking white people to evaluate you when you have to meet with the principal, they pick people of color.

Again, I’m going back to the book. The same thing happens in certain cultures: In order to assimilate into the dominant caste, you act like the dominant caste. This has happened historically, time and time again. I know that some states have apparently tried to ban the book “Caste.” It’s a lady’s biography and history of the world. It resonated with me because, as I said, I was inducted into the German Foot and Ankle Society, and I’m Indian by origin. She talked about what happened in Nazi Germany. A lot of doctors joined the Nazi party because they wanted to keep their positions and professorships, and so they jumped on and tried to get rid of the Jewish professors in the medical schools, and the Jewish accountants and the Jewish lawyers. So people assimilate with the dominant caste.

These shams are there to control doctors. If you’re a high-producing doctor and you’re not of the dominant caste, you’ll have a target on your back. In general, if you’re successful, there’s that Bette Midler quote: If you’re successful, you might have some odds against you. Unfortunately, if you’re not the dominant skin color, and if you’re a podiatrist, heaven forbid, in an orthopedic group, you have three strikes against you.

Kevin Pho: One of the things that you mentioned earlier was the statistic that 5 percent of Black doctors represent 20 percent of reprimands at medical institutions. Go into more detail about that specific statistic, and perhaps some of the hypotheses or reasons behind that type of bias.

Amol Saxena: Well, as I said, medical professionals in America base it on skin color. So if a Black resident had an outcome or a handoff or something that everybody else gets, they may be reprimanded for that, or called out for that, and then dismissed. It’s been going on for years, and it’s sad to see.

Medicine is hierarchical, and it’s hard to get the higher-paying residencies. So if you’re in a competitive specialty, the specialties that are at the top, that are hardest to get and have the highest pay, and you’re someone of color in that specialty, you may be a target. You have to realize that. I never felt that being twice as good in order to earn your spot was a bad thing. The issue is that if you always feel like you’re looking over your shoulder, like you have a target on your back, it’s not good for you health-wise either.

One of the other things that I read about, which was impactful to me, is that education and income are supposed to be protective in health outcomes. You’re supposed to have better health status if you have a higher level of education and higher income. Well, the highest level of heart disease in America is in people like me, Indian males, and we supposedly have the highest income and the highest education level. We’re higher than Black males. So that is impactful for me. My dad had a heart attack.

So I think we need to acknowledge these things and try to work on ways to help doctors, which helps patients, and vice versa. It’s all interconnected. And again, improving our diversity is never a bad thing. I always felt great when we had a great department with orthopedists, pediatricians, internists, podiatrists, physical therapists and athletic trainers, and it was all a win-win for the patient. Everybody is on the same page.

Growing up, I was born in Palo Alto and came back to Palo Alto for junior high and high school, but I lived in New Jersey, and I was the only brown kid in the neighborhood. We had Jewish kids who couldn’t play sports on Saturday, and we had Catholic kids who couldn’t play sports on Sunday. So I loved the weekdays, because we could play with everybody. Everybody was out there playing games. So I think that improving diversity is never a bad thing, and we need to acknowledge that there are problems. It’s low-hanging fruit to try to improve the diversity in medical specialties and to help outcomes for America.

Kevin Pho: So you mentioned a few solutions, and you’re certainly doing your part by coming on this podcast and writing for KevinMD and shining a light on these issues of bias. You mentioned increasing diversity as a way to solve this issue. What are some other things that we physicians can do to address some of the biases you talked about?

Amol Saxena: Well, it depends on what kind of environment you practice in, if you want to call attention to it and it’s not an environment that is agreeable. It’s surprising: Even in some of the most liberal areas, this is problematic.

If you’re a provider, it starts in medical school, with keeping everybody aware, as Dr. Capers said, and with people on committees and people who are your teachers. It starts at a lot of different levels. You get role models from people who sometimes look like you or share the same interests as you. For me, because no one looked like me when I was a podiatry student, and there are still not too many teachers who look like me, I aligned myself with people who had interests like mine, like the podiatrists who are more interested in sports medicine. So I think as a student, try to find people like that and role models like that, and take opportunities for leadership.

I’ve gotten a lot of rejection. I’m getting even more rejection now that I’m shopping my MPH projects around. I can’t even get my own congresswoman, who’s in my backyard, to answer me about my MPH projects. There’s a congressman from Ohio who happens to be a podiatrist as well, and I spent time with his staff in July, and I’m hoping to build more bridges with my MPH projects. They did discuss the shortening of medical education in the Doctors Caucus already, but I don’t think they quite understood it. So I’m trying to shop my stuff around. I mean, I’m still working basically full time.

Kevin Pho: Let’s end with some take-home messages that you want to leave with the KevinMD audience.

Amol Saxena: Well, I think it’s being aware of biases. Everybody has biases, so be aware of the biases, both conscious and what I call unconscious submission. I think that’s important. I think it’s important to realize, if you’re the only minority in the room and something’s being discussed about your care, to be aware of that and protect yourself. Document and get support; PJE is one group.

And then when you’re a decision-maker, when you get a position, again, don’t submit to unconscious submission. I think you need to try to purposely change things and make it diverse, make it open, make it representative, and call out these biases. I think that’s important. It’s sometimes difficult to do, but I think it’s important for the future of American medicine, because our health care system is broken on many levels, and to me, it’s just low-hanging fruit to try to improve diversity.

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

Amol Saxena: OK, thanks.