In this episode, Dr. Brownsyne Tucker Edmonds and Dr. Sylk Sotto talk with Dr. Aaron Carroll about the importance of diversity and equity in research, higher education, and medicine. They share insights about underlying issues they've seen and talk about ways to encourage success for underrepresented minorities.
This episode of the Healthcare Triage podcast is sponsored by Indiana University School of Medicine whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care.
IU School of Medicine is leading Indiana University's first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma and prevent type 2 diabetes and Alzheimer's disease.
Dr. Aaron Carrol (00:02): Welcome back to the Healthcare Triage Podcast. Our topic this week is going to be equity and diversity in research, and it's such a huge topic. I got to be honest, I didn't even know where to start. But I have two guests with me this week who, if I had to pick two people to talk about, it would be them. The first is Brownsyne Tucker Edmonds. She's an associate professor of obstetrics and gynecology here at IU School of Medicine. She's also an assistant dean for Diversity Affairs. Our other guest is Sylk Sotto. She's an assistant professor of medicine and vice chair for Faculty Affairs Development and Diversity. Both of you, Brownsyne and Sylk, welcome.
Dr. Brownsyne Tucker Edmonds (00:37): Thank you, it's great to be here.
Dr. Sylk Sotto (00:38): Thank you for having me.
Dr. Aaron Carrol (00:40): This Healthcare Triage Podcast is sponsored by Indiana University School of Medicine, whose mission is to advance health in the state of Indiana and beyond by promoting innovation and excellence in education, research and patient care. IU School of Medicine is leading Indiana University's first grand challenge, the Precision Health Initiative, with bold goals to cure multiple myeloma, triple negative breast cancer and childhood sarcoma, and prevent type 2 diabetes and Alzheimer's disease. When we have guests, we usually like to start with, what do you do, and how did you decide this is what you want to do, and how did you get here? I'll start with you Brownsyne.
Dr. Brownsyne Tucker Edmonds (01:16): Well, I'm an associate professor of obstetrics and gynecology. I am an OB-GYN, a generalist by training, and I also am a health services researcher. For folks who don't know what that means, health services is a big bucket kind of a term that sort of characterizes folks who are interested in understanding how healthcare is delivered and the outcomes that result from that delivery. So that's what I studied. I trained to do research in health services. Most of my research is about shared decision-making, it's about how doctors and patients communicate with one another and make decisions together. I'm particularly focused on how they do that in a manner that's equitable and centered on what patient's needs and values are.
In terms of how I got here, I guess it started in medical school, but without having a full amount of time to go through my whole life story. Yeah, basically, after my residency training to become an OB-GYN, did a special kind of research fellowship through the Robert Wood Johnson Foundation, it's called the Clinical Scholars Program. And there, they trained us to do research that could inform policy and practice. And that was sort of the start of my academic career. That's how I ended up coming into faculty at a medical school, and then sort of working toward doing that research, getting grant funding, writing papers in order to build up a reputation that would allow me to become an associate professor.
In terms of the Dean's office, once I got promoted, I really started to think about what other kinds of contributions I could make alongside the research work that I was doing, and had the opportunity to join the dean's office in diversity affairs to do programming to try to help other faculty of color be successful in academic careers, and learning how to navigate academic medicine, and successfully advance the ranks in the ways that I had.
Dr. Aaron Carrol (03:08): Sylk, can you tell us more about you?
Dr. Sylk Sotto (03:11): I don't think that I can tell you what I do without telling you how I got here. So I think about three pivotal moments in my life. One, I was born and raised in Puerto Rico and I transferred to study biochemistry here in the States. And it was the first time that I realized that there was a problem with representation of women in STEM. My courses in Puerto Rico at University of Puerto Rico, I was chemistry major, half of the class were women. I had women professors. And then I transferred to Colorado and I was one of three women in my class. I had maybe one female professor, and nobody, was underrepresented, not a Latina insight.
That impacted me quite a bit and it took me a little bit longer to finish college. And that experience really also made me realize that I wanted to do a Ph.D. program specifically at the time I was looking at atmospheric chemistry, but there was no support for me in that environment. So I left and I went to work in biotech, and I ended up in academic medicine, and academic medicine is where I found my home. It's where I decided, "Okay, here's the place where I can do research, I can learn, and I can do lots of things." So that's where I did my commitment to spend my career, in academic medicine.
But that didn't stop there because there was still the issue that there was only one black faculty member in my division. So I did research in med-onc and pulmonary diseases at the time. There was no fellow of color until much later on. Again, wondering where's everybody? By the age of my mid-30s, and I had, at that point, moved on to executive level administration positions at other universities, I realized before I'm 40, I'm going to finish a Ph.D. and I'm going to do it in higher education. And that's what I did, at night, with three kids, set out to do this. And I center my dissertation in faculty of color, really centered on inclusive excellence on the issues of equity.
I realized as I was working that, you have heard the 80, 20? The 20% that was keeping me happy was helping faculty, helping students. And I decided to really make it my career. So it was not so much a midlife crisis, but certainly, a point where I decided that this is what I'm going to do the rest of my life. So in terms of my research, it has always centered around equity in academic medicine, higher ed. I focus on the learning environment. I focus on the development, mostly of those underrepresented in academic medicine. And also, because of my professional experience, I do keep track of research ethics and the intersection of health equity. And that's where I find my joy, and that's how I ended up at Indiana University as vice chair.
Dr. Aaron Carrol (06:25): So as I said at the beginning of the podcast, talking about equity and diversity in research is so big that it's hard to even think about where do we start? Because as you both were talking even, clearly, it comes up with respect to faculty. Clearly, it's going to come up with patients, it's going to come up with respect to how we do research. I mean, there're just so many ways in which it's important. So where would you like to start? How would you begin to talk about this? Why is this such an important topic?
Dr. Brownsyne Tucker Edmonds (07:04): One of the threads that unites Sylk and I in terms of our passions and joy is this piece around faculty development, sort of the workforce development piece. So maybe we could start the conversation there, even though I think we both have lots of thoughts and concerns about many other aspects of diversity, equity in the space around research from recruitment to study design, variable selection, et cetera.
But I think with regards to the workforce, so much extends from that point. I mean, I think to the point that Sylk's narrative raises with regards to people sort of seeing themselves represented in these spaces of scholarship, in these trajectories for academic life when there aren't women, people of color, et cetera, as successful models, seeing the potential for that to be you, then that signals something in terms of a sense of belonging, a sense of support, that's like one piece of it.
But an important piece that comes out, I think, right away, when people start to talk about the path that they've taken and the role models they've had, the mentors and sponsors that have been available to them. I think that a huge piece of it is where our young folks are seeing possibility for themselves in terms of careers that they might pursue or places that they might belong, frankly. And then I think with that as an extension, you then have a bit of a ripple effect. Because when you start to even get out to these questions about recruitment, and equitable representation, and things along those lines, there's an implication [inaudible 00:08:51] the entire workforce that is conducting and producing the enterprise of knowledge and research, is one where there's actually not diverse perspectives and representation present.
And I'm sure, at some point, our conversation will go to these concerns about trustworthiness and about representation, things like that, all of that comes full circle on itself from the whole premise that this is not a space that was built for us or that is a space that's welcome to us. That signaling is on both sides in terms of what the workforce looks like and the populations that are considered to be important to be included or not.
Dr. Sylk Sotto (09:32): I think the path to equality, to me, is education and health of our minorities populations in the US. Again, talking about the education piece, it's the importance of educating this generation to be the next one that will take care of health disparities, that will eliminate all the imbalances, at least, in that area. And taking care of our patients, keeping them healthy, it's, again, another aspect of getting to that equality place. So workforce, I think it's the very center of a lot of what we do in hopes that we will get there. But there's also those other pillars of academic medicine that we can't ignore, the importance of the clinical mission, the importance of education, and research and advancing all of this. But-
Dr. Aaron Carrol (10:26): So I want to stick with workforce, I mean, because I'm tempted to go onto everything else you just said, but I'd love to stick with workforce just for a second. So how do we make this better? I mean, we talk about it. I mean, it's not easy, clearly, because you could just do it. But I mean, I think everyone's go-to is we just need to increase the diversity in our faculty, we need to hire more people. And we say that, and we say that, and we say that, and then I feel we have this conversation again. So what do we need to do to make our workforce more diverse and see more equity and diversity in it?
Dr. Sylk Sotto (10:59): I think there's many things that can be said. I think that we have extensive research in all areas, higher ed, business, you name it, that point to best practices in achieving a lot of this, not just in recruitment, hiring retention, et cetera. But why I paused a little bit is because we know these things yet we have apparently difficulty implementing them. With all the wealth of knowledge that higher ed in academic medicine, and I may use one term versus the other, but it's all the same, with all the wealth of knowledge that we have, we are so behind in so many levels and ways.
So because of that, a thought that comes to mind is from a higher ed scholar that actually said, "The reason why we haven't achieved this is because we don't want to." It may seem a little harsh, it does make sense because we know what works. We know what will bring people to IU. We know what will bring people to other institutions. We know how to teach students in inclusive ways but yet we don't do it. We know all these things, but we don't implement it. So to be honest, when it comes down, and thank God it's a podcast and I don't have to try to submit it to a journal, but I think the problem is leadership, period. In all academic missions, if we really commit to what we say, then it will get done. And that might be a little harsh.
Dr. Aaron Carrol (12:49): No, I don't think it's harsh at all. In fact, I think it's probably spot on. I mean, I think you said it far better than I did but it is not as if we've not had this conversation before, and it's not as if we've not seen this play over, and over, and over again. I mean, I'm sure you feel the frustration more than I do, but it's like, "Why, what are we waiting for?" I mean, what do we need to do that we're not doing? Just this week alone, I've been involved in more than one conversation where someone's like, "We need to do a real study. We need to really look at this and figure out a plan for moving forward." And I'm like, "I just can't believe we're back here again."
Dr. Brownsyne Tucker Edmonds (13:30): We don't need any more studies, that's what we don't need.
Dr. Aaron Carrol (13:34): I mean, I know I'm going to ramble for two seconds and I don't even care if Stan cuts this up. But I remember when I was a fellow at an RWJ Clinical Scholars meeting and there must have been four presentations in a row that were like, "We're going to do another secondary database analysis and prove that disparities exist in this." And I just remember sitting there as a fellow, and this is 20 years ago, I went like, "Do we really need another study? Is there anyone left who doesn't know that health disparities exist? And would they be convinced by one more study? When are we going to actually do something about this?" And it's just still, it feels as if we're acting as if this is new. Brownsyne, your leadership, not your... but let's say you are now in charge, what do you do? Like I'm saying, if you had to talk to leadership and say, "This is what we do right now, what do we do?"
Dr. Brownsyne Tucker Edmonds (14:23): So there's two threads that I think people fall to kind of justify an action. There's sort of a notion that there's just no one out there, that you just got to shaking the trees and it's just so hard to find the qualified applicants. And I think that that's actually just false, that we need to disabuse ourselves of this notion, and then decide we're going to make the investments to actually recruit and, or retain the diverse talent that really is out there.
And I'm specifically speaking to mid and senior-level folks, recognizing that there are significant challenges in terms of the leaky pipeline, that there is less and less representation of faculty from underrepresented backgrounds as you go up the ranks in academic medicine, that is a true fact. And that said, because of that, it will require a different level of investment and different kinds of attractive packages and incentivization to be able to attract diverse talent at higher levels in the organization.
And I do think that that is where investments need to be made in the short term because the other sort of train of thought or sort of piece that I just want to caution people about is that we always start, "Well, the real problem is third-grade science." And I'm not saying that that is not a true statement. I'm not saying that we don't have a significant crisis in our nation in terms of the quality of elementary school education and what's happening in those formative years in terms of, again, systemic inequity and racism that is creating huge gaps in terms of opportunities to obtain high quality science education, arts, I mean, high quality all of the above.
But that said, and I'm not pooh-poohing on anybody's effort to do pipeline programming because I think that that is important, there is a place for it, but that is not a solution to help us today. That is a solution to help us 10 years, 15 years, 20 years. And if we keep waiting 10 years, 15 years, 20 years to create diverse leadership and diverse decision-makers, which is what we've been doing for the last many decades, then we won't be any further along in another 20 years.
So I think that with the degree of urgency, we should talk seriously about what it means to incentivize, to attract, to support, to promote diverse talent in terms of leadership and decision-making positions right now with regards to kind of moving the needle on what's going on in academic medicine. Because there's really also clear evidence that you can see pretty impressive kind of rapid change in terms of culture, in terms of attracting more diverse talent in the early career levels, and when you diversify your leadership. And that is something that I think is really lacking, and wanting, and not entirely because there's just no diverse talent out there.
Dr. Aaron Carrol (17:21): Are there institutions that you can think of right off the top of your head, you're like, "They're doing this really well?"
Dr. Brownsyne Tucker Edmonds (17:25): No, there are some that are making bigger investments though, really substantial, I mean-
Dr. Sylk Sotto (17:33): Bigger investments, yes.
Dr. Aaron Carrol (17:35): Well, I'm asking, are there concrete examples? You're like, "Okay, that right there, that's what..." What are those things? What do they look like?
Dr. Brownsyne Tucker Edmonds (17:44): I'll say interestingly that Michigan, their president, I think, I believe something like $25 million or something, big, big money where your mouth is. They're funding like 30 slots. And those are impressive levels of investment for-
Dr. Aaron Carrol (18:08): I noticed they're saying, "We'll take $25 million and we can just..." That's what, 750,000, I mean, maybe I'm doing my math wrong. Notice you're saying we need to create more slots for more hiring, although I imagine those are mostly junior, or mid-level faculty or?
Dr. Brownsyne Tucker Edmonds (18:25): Yeah, these are early, this is not to that earlier comment. This was to the new question about are there people who are at least making some larger level investments?
Dr. Sylk Sotto (18:35): I fully agree with you, Pitt, it's another place that actually they already had made this. So when I say no, is because there's no eutopic university out there, especially when we're talking about predominantly white institutions such as is the case with academic medicine. But I do believe wholeheartedly in what Brownsyne just said, the investment, however, that there's institutions that are making considerable investment, and that investment will pay, it will. And it doesn't matter where they're located, this is another thing. If we had a podcast alone about the myths of equity, I think that you can fill out a whole series. When we think about "Oh, they won't move here or there," or "They don't exist." Or if we actually look into qualifying people instead of disqualifying them for jobs, we might actually be a lot further.
Dr. Brownsyne Tucker Edmonds (19:39): I keep wanting to do mic drops, Sylk, but then I realize these are Aaron's mics, so I don't want to mess them up.
Dr. Aaron Carrol (19:39): Please don't.
Dr. Brownsyne Tucker Edmonds (19:45): But you keep doing mic drop moments.
Dr. Aaron Carrol (19:48): Plus, I have more to ask, so you can mic drop at the end, but we can't do it quite yet. So the investments you've talked about so far seemed to be mostly about, we need to put packages together to do more hiring. But I imagine there's a lot we need to do after we've hired faculty from underrepresented minorities. Could you talk about some of the things that you think are important in order to make sure that we don't just hire but that we grow, and develop and retain those faculty?
Dr. Brownsyne Tucker Edmonds (20:15): Yeah, happily. I mean, Sylk, we both actually do a fair amount of programming in this space. I run a program that we call the Program to Launch URM support here at the school of medicine, and it was really developed as a retention strategy. There's a whole, I guess, literature kind of discourse about being careful about not having a deficit model, not doing so much programming as though somehow the faculty are lacking something that's needed and that that's the reason why they're not sort of succeeding.
And so, I think that it's important to kind of hold that critique intention. Because mostly, that critique is saying it's actually not the faculty who are deficient, it's the systems that are structured for them to not be successful, and are placing them at a disadvantage. So it's really the structures that we need to be programming to change. I think the challenge where I sit and live with that tension is that we have faculty who are trying to get promoted today. These are structures that have been built inequitably and designed for us to not succeed for centuries.
So there is a need, in my mind, to kind of really create additional supports to, from an equity lens, provide some things that you're not providing for others, to try to enhance the probability and the rates at which they can succeed, to try to plug those holes where people are leaking out as they're trying to advance. We're facing real challenges that cater our transition for investigators of color and there's data out there more relatively recently that suggests that a lot of the kinds of questions that are community-focused and sort of problem-focused about the populations and equity are not the things that the NIH is funding. So what does that mean for a faculty of color? If those are the things that they care about studying, and the kind of knowledge that they want to advance, but the NIH isn't interested in funding it. Those are the kinds of real challenges. So what are the supports that we're then going to put in place and how are we going to devise different kinds of systems and structures to try to assess the contribution that these faculty are making if it's not going to kind of easily fall into the traditional currency of publications R01 funding? But we do recognize that they're adding and making real contributions to our community, so how do we reward that? What does that look like in a promotion and tenure kind of methods?
So anyway, programming is important, but structures are also important. And we're going to have to think about structuring rewards and incentives differently if we're going to have more equitable outcomes. Sylk can say a lot more about that actually because she's guru in this space.
Dr. Sylk Sotto (22:59): No, I think that you set up a really good foundation. And it might be, Aaron, at the end of the day, I can tell you how to recruit, we can all talk about how to recruit because it's no different than recruiting a researcher of any race or ethnicity. We got to put the funds. The problem in where I spend my time is in the retention piece, in the lack of inclusive environments that we have. I don't know if you want to include this but I do need to say this. Yesterday, we hosted virtual brave space for our Asian, Asian-American faculty learners and trainees. And one of the faculty members has been here for 30-something years from undergrad all the way to the point where he's an attending now. And he pointed out how last year, he was told by a colleague who he has known for over 20 years the F word, and this Chinese virus, ignoring completely that he is a Chinese American.
This is the environment. And this is not to pooh-pooh Indiana University or anywhere, this is happening everywhere. It affects our faculty, it affects our students. The student that told me, "No, I went into my clerkship rotation and the attending said, what's my name? I said, my name. And the attending said, I'll just call you by the name of the last X student, that I had, and proceeded to do that for a week." Again these are the experiences. So how are we pretending that we are advancing health equity when we have that type of environment, that we're advancing equity in a way that is creating inclusive environments?
We don't have to look very far, and this happens at every institution. So really addressing the environment after you're here, while you're here, the supporting structures, the asset-based thinking, all the retention efforts that you can put together, that's all wonderful. But again, it goes back to these inclusive environments that do not necessarily exist.
Dr. Aaron Carrol (25:27): We need to talk about, this clearly needs massive cultural change, how do we do that?
Dr. Sylk Sotto (25:35): The problem is we can't talk just about diversity. And I know that there was a point that we would say the word diversity and people's eyes started rolling, but we can't just talk about that because what happens is, now at this point, the definition of diversity itself has evolved in a way that includes everything, and it's hard to focus on one thing. Just because you have the people, just because you're bringing representational diversity doesn't mean that automatically these inclusive environments are created.
So to me, you can't stop there. You have to talk about inclusion, how do people feel once they're here? You got to talk about equity. What are we doing to help them get to that point of equality that we are all striving for? How do we actually address racism in the system? And I'm glad that we're moving into conversations about anti-racist structures because that's what it has been all along. So just bringing people of color into the system is not enough. We have to really shift in many ways.
Dr. Brownsyne Tucker Edmonds (26:52): In fact, we can see it's a pretty good barometer because you can just watch the revolving door, which is basically what we'd been doing for the last couple of decades when the focus has been on diverse representation without really being concerned about the climate and environment, and sort of dismantling racist kind of structures. Then, we find people come, they're treated poorly, they leave. They come, they're treated poorly, they leave. And that is sort of a cycle that we won't stop if we don't take seriously the work of changing the climate and the culture, and kind of raising awareness, but also creating accountability for people who say those things and go on and say them again to someone else. Again, I think that that circles back to this issue around leadership that Sylk spoke to earlier. It takes both will and courage to do the hard work of creating systems that will hold people accountable to sort of the values that we profess.
Dr. Aaron Carrol (27:55): And this clearly has, of course, ripple down effects up and down the chain. And I would love to focus a little bit on the importance of this in diversity and inclusion in research as well, because without a diverse research workforce, it's clearly going to hamper our ability to do research that's robust and is also diverse and inclusive. So could I get you to talk about that a bit?
Dr. Brownsyne Tucker Edmonds (28:19): So we did a presentation today with some folks from the Indiana CTSI, for their national meeting, the ACTS meeting, and we were actually reviewing some of our data from sort of this engagement effort, I think it was for the AstraZeneca trials, when they were doing the all-in for health effort. And actually, we were really talking about some, I think, really valuable and well-deployed strategies to try to enhance the representation of those underrepresented populations in the trial, and that was noted as an important priority from the beginning, I think is key. So if you don't make the commitment upfront, it won't happen by osmosis. It requires intention, it requires strategy, and they had a strategy. It actually way outperformed the representation of the Hispanic Latinx population in Indiana actually and had really good success rates with that.
And then when they looked, the African-American numbers, they fell short. And it was really interesting because they also did some work to say, "Well, did we fall short with who we approached? Did we fall short with who we screened? Did we fall short with who we enrolled?" And that's an important question to ask of your process when it's not delivering what you hoped for it to deliver, because it was actually showing sort of this distance between the folks that were screened and the people who actually enrolled, and somehow we were losing them and missing them.
And we actually had a quick conversation about really some of these structural barriers, so much of the national conversation has been about distrust and hesitancy, which is not to say that those are not real factors that we have to contend with, but there's not been enough attention to the fact that there are actually access points and structural barriers to communities of color accessing the vaccine, for example. But also, I think you could say the same thing to sort of accessing the research as an enterprise, to be able to participate at equitable levels. And oftentimes in our design, as we're thinking about incentives, as we're thinking about provision, be it for childcare, for transportation, as we think about time of day that people can participate or do these interviews, oftentimes we actually are setting it up based on ways that are convenient for us and for our workflow, but not necessarily convenient for folks from diverse, be it backgrounds, socioeconomic status, et cetera, to be able to engage, and to be able to enroll.
And so, that's just one piece of a very complex puzzle but recognizing that a lot of times, we start talking about research and representation. We jump to Tuskegee and really there's been way more insults than Tuskegee, first of all, in the contemporary moment. Tuskegee and the mistrust is a piece of it. I mean, there is that legacy, but actually, it doesn't tell the whole story. And just like in this vaccine story, there are actually some people clamoring to get vaccines who can't, because of real issues around access and equity. And then there also those who, we're going to have to do the work to show ourselves trustworthy if we're going to engage them. And that's true of this whole vaccine story, but it's also true as we think about clinical trials. And as we think about research engagement more fully.
Dr. Sylk Sotto (31:36): I agree with you Brownsyne, and I'm glad that you bring up, at least to date, the vaccine hesitancy conversation. And I've been guilty about this. I mean, one of my degrees is in ethics. So I think about research ethics a lot. But there is a truth, that I think is who controls the narrative. Conversation that is happening is really talking historical aspects, talking about Tuskegee, talking about all the other operations in research. But what is not being talked about is what happened yesterday to my dear, to my auntie, to ourselves going through the system. It's not talked about in a way that brings Dr. Susan Moore to the forefront.
Again, these are conversations that are happening behind closed doors with our minoritized populations. Yes, they may remember Tuskegee, but they remember more than their auntie wasn't diagnosed properly or things of that nature. So I think that we need to really have a look inward in terms of what we're doing, and I say we as if I were a physician, but as health providers and taking care of our populations and communities that we care about. That is not necessarily just being something that happened far away, it's happening to them right now.
Dr. Aaron Carrol (33:14): It's interesting you bring this up. Clearly, I'm babbling because I'm trying to find the right way to say this. So 2016, I think I wrote a column, because there was a study that came out and tried to show that Tuskegee caused all these health disparities and was trying to link them. And I wrote a column and being like, "You just put a dot in the middle of the South." I mean, what you're saying, it's like, we don't need to look for something that happened decades ago to talk about why minority populations are distrustful of the healthcare system, there's things going on every day. But I feel like there's sometimes a comfort in trying to say, "Oh, that happened in the past." I think, exactly what you're saying.
It's the, how do we fix that? And I mean, I know I'm not asking you because I can't think of anything, but I really want to hear your thoughts on sort of, what are the direct actions that we could take to try to mend these issues, knowing that some of those have to be fixing are obviously structural things. It's not just actions, it's not just programs, as you said before, Brownsyne, it's real deep fixes. But if we had to say like, "Here, let's operationalize this, what do we need to do?"
Dr. Sylk Sotto (34:35): Put us in power? No, no, I'm not-
Dr. Aaron Carrol (34:39): I got no problem with that. If that's the answer, I'm totally comfortable. But, okay, so if I put you in power, what would you do? I mean, all jokes aside, what would you do?
Dr. Sylk Sotto (34:54): No, no, I was sincerely joking because there's several aspects to your question, in terms of, how do we operationalize this and different environments, in terms of the academic structure, how do you operationalize that? And that's where the joke came in terms of, just put all of us in power. But there's other, obviously, issues around the question that you're asking, how do we operationalize health equity in a way that is really equity patient-centered care? Those are big questions and I do not have the answer at all or have many thoughts in my head and I wouldn't be able to verbalize it or do it justice in a way that probably Brownsyne and you as physicians would be to do that.
Dr. Brownsyne Tucker Edmonds (35:46): Sylk, I mean, the word that came, and I'm going to be super careful when I say it, because then we could have a whole another discussion about, what do we mean when we say this? So engagement and partnership came to my mind and that those words in and of themselves create gnashing of teeth for people who are in this space about what it means to partner in research. But I actually see sort of a thread that I carry. I said I studied shared decision-making, and really I see shared decision-making as a mechanism or kind of a modality to actually try to mitigate health disparity because it centers the patient, their experience, their context, their preferences, their needs, their concerns, as opposed to the agenda entirely being driven by providers who are a product of this sort of, challenging structure that we've been critiquing the entire time.
And so, I think putting patients at the center is going to be a big component to trying to create more equitable outcomes in healthcare. And I actually think in the same regard, that putting participants and communities at the center of the kinds of research questions that we are going to kind of ask and strategies that we're going to try to deploy in terms of intervening on the challenges that are facing communities and populations has to be a piece of it. But the problem with it, and the reason why it creates this eye-rolling kind of impulse is that people start talking about engagement and partnership, and most people don't really know how to do it well, kind of in an authentic manner, most people are really wanting to do it in a way that's very superficial to check a box-like, "Yeah, I went out, I talked to a person in the street. Good, I did my engagement."
And in fairness to investigators, our systems and structures for promotion, for tenure, how NIH funding, the timeline, we get to two to five years to solve a problem. No, we get two to five years to do something very incremental, and to do the kind of work that is actually going to engage populations and communities and transform their health, is not going to be done on a timetable of two to five years. But that's the wheel that we're on in terms of trying to achieve and advance in academic medicine. And I'm not trying to pooh-pooh on the NIH today, please, by all means. I want them to be my friends and fund my work. Just speaking to the real challenges, how do we do transformative work when we are kind of operating in kind of incremental spaces.
But I do think that we get closer to it if we really try to engage the folks who are suffering from these diseases, processes, broken systems, and structures. They are going to be in a better position to tell us what is needed to fix it, than we are going to be from our lofty positions in academic medicine, frankly. So I don't think we can do it without them, I'll say that.
Dr. Sylk Sotto (38:41): I love that you say that, that set engagement and partnership, hopefully, it wasn't my eye-roll that you saw because I didn't eye-roll that. But it did make me think about competence as a word that it is cherished so much, competence and expertise in academic medicine held very dear and when in reality, we need to move away from competence and everybody that has hurt me and my grandmother, that's why I pushed forward cultural humility so much. Because in the same way that the Belmont Report and thinking about beneficence justice and autonomy, I think cultural humility is one of these centerpieces of sparking curiosity in a way that doesn't put the pressure of achieving competence or becoming the expert on X, Y, and Z.
If we did more of that then we would realize that maybe the community has the answer. The communities will tell us what needs to be done, how to do it in ways that is also interprofessional, in ways that admit that we don't know all the answers even with all these degrees of education and titles and many things of that nature. So if only we listened, I think that we might get there.
Dr. Aaron Carrol (40:19): I want to follow up because what you just said really struck me. When you talk about listening to communities, are you specifically thinking patients, or are you thinking a variety of community? Are you thinking about communities of workforce that we were talking about before? Are you thinking communities of patients, are you thinking communities of research participants, or were you specifically thinking about communities with respect to sort of like health care and trust in the healthcare system?
Dr. Sylk Sotto (40:45): That's actually a great question. And I don't define community in the same way that I never tried to define culture. So when I'm talking about communities it's in reference to all the groups, all the niches that we may have as researchers, as academicians, that we're talking about different communities in a way that is inclusive, in a way that is talking about research participants, in a way that is talking about patients, in a way that it's talking about those community leaders that are engaging in conversations with higher education systems. And we're talking about community as Brownsyne is part of my community at IU, this community of exceptional faculty of color, communities that we identify with. There's not one identity, we all have plenty of identities at play, and therefore we're going to be part of different communities. So it was a very general and inclusive way of talking about all those groups.
Dr. Aaron Carrol (42:00): There's too many things going on in my head, but the one that's driving me crazy is I was just thinking, I've been reading a book on leadership and trying to drive management because old mentor of mine recommended it. And I was struck, the person who wrote the book can find example after example of like, "This is a good example of how to do this." And I'm so disheartened by the fact that we can't think of a good example of like, "This is a place that's doing this right." It's like, "Who's going to write the book where there's like, here's some good examples of how to do this better." And it feels so disheartening and perhaps even somewhat telling that we can't come up with places that have operationalized how to do this better. You talk about listening to communities and that feels like, "Okay, of course, that's what we should do." But who's doing it. Are there good examples?
Dr. Sylk Sotto (42:52): I think there are, when you ask about what place is doing it right, I recognize now that in your question, when I said no, it's thinking about the institution. But you will find, over and over again, that there are programs that are doing exceptionally well, there are organizations and community-led organizations that are doing it exceptionally well. It's just that sometimes we fail and I have seen this as part of my job in academic medicine. I consider myself partly as a translator, that I can bring socio-educational frameworks to academic medicine that they're not even looked at and visa versa, so I'm not saying that it's a one-way street, that I can bring things from other fields to academic medicine in a way that it will enhance and maybe complement things.
I have seen it in a way that we often think that unless it was written in medicine, it does not exist. And this work in community engagement, civic engagement is real. They're real scholars out there, but yet we fail to take a look at many of those aspects. So I think that is part of the problem. And also thinking about the success of these programs is like, "Where do they publish this stuff?" There are limitations in terms of, if you don't find it in the journal, it doesn't exist, which is a big lie, they're out there.
Dr. Brownsyne Tucker Edmonds (44:36): Some of what keeps us in the dark ages is pride frankly. The notion that we have to discover it for ourselves or that if we didn't discover it and publish it, like she said, it doesn't exist, or at least that it can't be relevant because we're so different and unique in medicine. So I think that that is a stumbling block for us. And all the more reason for us to go back to the comments about humility that Sylk made earlier.
But just to the point about this notion about sharing and this was eyeopening for me when they're trying to develop this program that we're kind of rolling out right now about trying to enhance our retention of our sort of residents from underrepresented backgrounds. And I started trying to figure out like, "Where can I find this work published?" And I started asking, and people were kind of like, "Well, there's a lot of scrutiny that comes to the sort of programs." Kinds of equity efforts from, frankly, what I call anti equity groups, and interests.
And so, people are not usually waving their flag about their awesome programs, and they're awesome efforts that are actually enhancing equity because that creates risk and attention to their institution. And there's, frankly, fear about litigation, about lawsuits. And I consider myself to be pretty savvy, and frankly, some days a little cynical. I thought that that would have occurred to me, but it actually never occurred to me that that would preclude the ability to even share what's working, so even disseminate widely and share from institution to institution, that we put this program into place, and we were able to increase and enhance our diversity by X, that even putting that out there, poses a risk and causes folks in council to cringe and worry.
So I think that's a reality that had not occurred to me, but that I think is one that may really be operating to our detriment, because, to your point, Aaron, it's not like we can just go to the Journal of Equitable Interventions to enhance representation. It's like people are kind of talking about it at meetings, talking about it through networks. I'm not saying that no one's publishing these things, and there's some really good work, just to answer your question. I think Vanderbilt, I think Consuelo Wilkins' shop has really created a model that others are following.
I think in this research realm and the community engagement piece, there are bright spots and models that we can look to, but I am disheartened at this larger enterprise, and maybe the research piece is a little bit sort of safer as a space to try to share and disseminate those kinds of strategies. But I was really disheartened when we go back to that conversation about workforce and how do we execute these best practices and things. And that there's actually, systemic disincentives that would actually keep us, or make us fearful of actually raising the banner to say that we're doing it well and we're trying really hard because there are people out there who absolutely don't want these shifts to occur.
Dr. Sylk Sotto (47:32): That is very disheartening and I'm glad that you brought that up. Again, it goes back to the systems that are controlling the narrative, journals are controlling the narrative, they're deciding what is worth putting out there. Although sometimes I look on Twitter and I say like, "I don't understand why my stuff cannot get published when you see some of these crazy stuff out there." But yeah, I think it goes back to, again, this controlling the narrative and posing risk to those that are truly impacting change.
Dr. Aaron Carrol (48:12): I mean, even in the news now there's talk about removing some variables of race into clinical calculations that we make that determine how people are sick. And obviously, it's complicated, but we got to work through these things. Can you talk a bit about how race is used sometimes, and how we do research or analysis or even clinical care in ways that might need rethinking?
Dr. Brownsyne Tucker Edmonds (48:37): I mean, we have the examples with GFR, and looking at sort of renal function, we have these race corrections that kind of linger in terms of pulmonary function, testing, and calculations. And these examples, I think, really are rooted in essentialized notions of race as being a genetic differentiator, which we've had the data from the genome for a very long time now that shows us there's more difference within a racial group even between them and that these are not sort of genetic categories. That these ancestral differences and sort of phenotypic manifestations, actually don't account for the wide range of variation and disparity in health inequities that we see communities of color, in particular, suffering from.
And so, we're kind of left to rethink that. And a lot of that conversation that's going on right now, we've been talking a long time about race being a social construct, but really, as we think about variable selection and for years and years, race as a covariate, ethnicity as covariate, really understanding that, shifting from our traditional notions, that that's some kind of marker of biological or genetic difference, to really understanding that as a marker of a different lived experience, of what it means to travel through life experiencing racism, to travel through life experiencing various aspects of oppression, and the impact that that has on one's health status and health outcomes.
So I think rethinking what we're utilizing these variables as a proxy for, has really come under a different level of scrutiny. You'll see journals and things are really calling people to justify their use. And we could talk another day about that, but even in that, what I don't want the journal to do is disincentivize people from bothering with those variables at all, because it's not that those variables aren't important, frankly. Someone said that we teach our kids that race is real, but that it doesn't matter when in fact we should be teaching them that race isn't real, but that it does matter.
And so, those variables are important to capture because the lived experience of structural racism and different aspects of oppression are very important and have real implications for our health. We have embodied experience of oppression and stress that those are real phenomenon. So I think that it isn't that we shouldn't be capturing them, we should just understand what it is that we're capturing. And it's very unlikely that we're going to find the answer, some golden ticket or magic bullet, in terms of genetic difference, that that's actually not the story that we should even be aspiring to tell.
Dr. Sylk Sotto (51:25): And Brownsyne and I were involved in a conversation where this was brought up and I can see the pushback. I hear it, I see it, from changing the status quo. From changing how people have learned medicine in the past, there is hesitancy there and there is resistance. To them, I say, "That's fine, you can keep this element if it's really important to you and your specialty and it works. However, I need you to also have the conversation about structural and social determinants of health. And we need to do that when we're publishing this work. If you want to continue to use these elements in your research and the way that you're describing health disparities, et cetera, I can't argue with that, but I beg you to include the conversation of why it's also impacted by the structural-social determinants of health in that particular population."
So I think that is something that we can do more of in order to really, again, address the conversation about systemic racism. Otherwise, we are complicit, and academic medicine has been complicit and we're all complicit in this system if we continue to ignore that type of conversation.
Dr. Aaron Carrol (53:03): Hear, hear, all right, I'm only sighing because literally, I'm just disappointed I got to bring this to a close. I've taken up enough of your time. I can't thank you both enough for doing this. I'm going to beg you both to come back in the future. I can think of countless threads that I would love to continue and talk about it and see what's going on, so I hope you'll both come back.
Dr. Brownsyne Tucker Edmonds (53:29): Yeah, sure thing.
Dr. Sylk Sotto (53:30): Over margaritas next time.
Dr. Aaron Carrol (53:32): Perfect, we'll find a way. All right, thank you.
Dr. Brownsyne Tucker Edmonds (53:35): Awesome, thank you.
Dr. Aaron Carrol (53:37): Again, this Healthcare Triage Podcast is sponsored by Indiana University School of Medicine, whose mission is to advance health in the State of Indiana and beyond by promoting innovation and excellence in education, research, and patient care.