Health Equity in Medical Education: A Commitment to Change

Podcast Transcript

Dr. James K. Stoller:

Hello, and welcome to MedEd Thread, a Cleveland Clinic Education Institute podcast that explores the latest innovations in medical education and amplifies the tremendous work of our educators across the enterprise. 

Dr. Tony Tizzano:

Hello, welcome to today's episode of MedEd Thread, an Education Institute podcast exploring ways for raising awareness around health equity in medical education. I'm your host, Dr. Tony Tizzano, Director of Student and Lerner Health, here at Cleveland Clinic in Cleveland, Ohio. Today, I'm very pleased to have Dr. Bud Isaacson, Professor of Medicine and Executive Dean for the Cleveland Clinic's Lerner College of Medicine of Case Western Reserve University, here to join us. Bud, welcome to the podcast. 

Dr. Bud Isaacson:

Thanks, Tony, delighted to be here. 

Dr. Tony Tizzano:

Well, to get us started, could you please tell us a little bit about yourself, your educational background, what brought you to Cleveland, and your role here at Cleveland Clinic? 

Dr. Bud Isaacson:

I've been here 31 years in Cleveland. I grew up in Michigan, did my training there and in University of Vermont, and was recruited to Cleveland Clinic in 1993. And I've had a general medicine practice since that time, was in practice this morning. I've been involved with education since I started here, about 10 years with our internal medicine residency program as an associate program director. And I became involved with our medical school really as it was being planned in 2002. We opened in 2004, just celebrated our 20th anniversary. I started out at the medical school really working on all the clinical programs. So anything that had students getting involved with patients, I was involved with. And was fortunate enough to be asked to take over as executive dean in 2018, really a privileged position, so I get to work with a lot of great people, and I've been in that role since. I still maintain my practice. I still do some teaching. 

Dr. Tony Tizzano:

It's amazing how you balance it all, for anyone who knows you. So, in today's segment, we'll focus on health equity and how Cleveland Clinic's Lerner College of Medicine is committed to raising student awareness around this critically important topic. So, Bud, if you could help us frame the topic of health equity and define it for the audience, please. 

Dr. Bud Isaacson:

Absolutely, Tony. And th- this is really a critical topic, and I'm so glad you asked me to be involved today. Health equity, I like the definition as the attainment of the highest level of health for all people regardless of social situation. I think it's something that no one can argue with, yet it's aspirational at this point. We have not achieved this. The World Health Organization has been involved, looking at this for many years. Our own Department of Health and Human Services has been involved, looking at health disparities and health equity for many years, and yet we still have major gaps. 

Dr. Tony Tizzano:

Do you think that's because of how we look at it and the populations we're serving or do you think it's because the research isn't there for us to become more aware? 

Dr. Bud Isaacson:

I think it's probably both. We have not done a good job of making our physicians and other healthcare providers aware of this. They sort of see the patients in front of them and they're not aware of all that goes into a patient even making it to your office or to your hospital. 

Dr. Tony Tizzano:

Yeah, I think that's w- w- well understood. So, when we look at the importance of this in medical education, it seems that we have maybe an opportunity to make a, a change by giving a different sort of bedrock, if you will. 

Dr. Bud Isaacson:

Huge opportunity. You know, you're of my vintage I think. I did not get trained in this during my training. I don't know if you did. 

Dr. Tony Tizzano:

Me either. 

Dr. Bud Isaacson:

So it is absolutely critical that we integrate this into our education of our students. And it's not a simple task, I'll admit that. I come at this with humility. And I don't have all the answers, but I think we're exploring it, and I'm excited about many of the things we're doing. If you think about, how does this actually present in settings that our students are exposed to? So, research shows, if I'm a patient of color and I come to the emergency room with a painful condition, I am less likely to leave that emergency room with adequate control of my pain. Okay? If I'm a woman who comes in with symptoms, I am less likely to be diagnosed with heart disease than a man. Just two examples. 

We have used some outdated teaching techniques. If someone comes in, a patient of color, with a skin disorder, and you look at our dermatology textbooks, most of the photographs are of Caucasian patients. So the idea that we're not really even looking at how do skin diseases manifest in patients of color. Uh, there's a good example of an estimate of renal function called the GFR. And for many years, based on really inadequate and wrong data, we have been using a different methodology to quantitate renal function in patients of color. And because of that methodology, which has only recently been questioned, we were overdiagnosing chronic kidney disease, inappropriate treatment for those patients. 

Beyond that, there are many other factors that really fall into the social determinants of health that we are increasingly aware of and paying more attention to. So, language barriers. What about people who come in and English is not their first language? Cost barriers to care. What if people don't have insurance? What if they don't have access to health care? Health deserts, probably more common in rural settings. Rural hospitals have closed. We know that, uh, some patients just can't find the care they need nearby. And there's been historical mistreatment and distrust of underrepresented patients in medicine, patients of color. They've often not been treated well. They've been the subject to some research that was really, frankly, completely u- unacceptable. And so, those bad experiences leave them more distrustful when they enter into our system. We have to be aware of that. We have to be sensitive to that. And finally, if you look at research, we have not done a good job of including a diverse patient population, you know, less research on women, less research on patients of color, really to guide our decision-making. 

Dr. Tony Tizzano:

Yeah, but these are just all extraordinarily great points. And, you know, the early on, when you spoke of some of the differences, emergency room, treatment of pain, etc., some of this is predicated on implicit bias. That's hard to change, because it's not something we're thinking about, it's just our experience, how we've been raised, we have this notion. 

Dr. Bud Isaacson:

It is. 

Dr. Tony Tizzano:

And so, you know, again, I, I would hope that in a medical school setting, especially one like Lerner that has importance of reflection, that we can start to really let this soak in. So- 

Dr. Bud Isaacson:

And let me just make one comment, too. I think, uh, I don't mean to indict the caregivers here. All members of the healthcare team come to work hoping to provide the best care they can for their patients, and I think most of them are shocked when they see data showing that, for instance, pain isn't being treated adequately in people of color or that we're underdiagnosing diagnoses of cardiac disease in women. And we all feel like that's not us, but collectively it is us. And I think implicit bias is really important. That's something that is not something we have complete control over. It's conditioned by our life experiences. So, raising awareness, I think, is a key as a first step. 

Dr. Tony Tizzano:

I would agree. So I understand that the college has recently amended its mission statement to and include health equity. Could you expand on this a bit and the impetus for this change, which I think you're probably have already alluded to? 

Dr. Bud Isaacson:

Uh, right. So, you know, we have a, a mission at our school to train physician investigators, and that's really where our school started in 2004. A couple years ago, we really started to look at where we were in terms of how do we project ourselves both internally to our community, also externally to those who wanted to come and maybe apply to our school, and we thought there were definitely opportunities to update our mission statement. 

This was a process. It seemed simple, but it took a long time. It probably took us six months. We had various drafts. We had input from students, from faculty. And in the end, i- in our one-sentence mission statement, health equity has a role. That we wanna promote health equity, that's one of the key missions that we have, to do that, and I think it's really an important statement about where we are as a school. 

Dr. Tony Tizzano:

Yeah, I would agree. So awareness and illumination of health disparities is an important consideration. How are these precepts woven into the curriculum? 

Dr. Bud Isaacson:

That is a great question and one that does not have a simple answer. So, if you think that you're going to solve this problem with a lecture on health equity, you're wrong. So, I don't know that we have it figured out, but we have some ideas and some approaches that we've used that give me hope. We have really tried to integrate discussions of social determinants of health into our interviewing courses. So when a student is getting to know a patient, they look at their background. How are they coming to the clinic? Do they need to take three buses to get to clinic? Do they have health insurance? Those are things that are easy to sensitize our students to that I don't think I was when I was trained.

We are looking, in terms of our actual curriculum that we teach students, to integrate discussions of health equity, discussions of health disparities into existing curricula. So, we have curricula that uses a lot of small group learning, and we use cases, and so we've tried to examine the cases that we're using and make sure they are not perpetuating sort of false judgments about patients. We're trying i- insert discussions about health equity, social determinants of health in these cases so students start to realize that that's part of how you provide holistic health care. 

We, uh, are fortunate, as you alluded to, to have a strong emphasis on reflective practice. So we have students, they have the opportunity several times in our curriculum to reflect on their experiences, and we will actually try to prompt them to reflect on some of these issues that are relevant to health equity. Uh, we have an Art and Practice of Medicine course that I know you're a faculty of, and I appreciate that. And so, discussions with faculty, where you have time to explore these issues, I think is one important area. We also have an emphasis on the humanities. And so, I think that humanities, we find, is an excellent way to sensitize students to the perspective of a patient through art and literature and, often, to have a perspective of what the patient's experiencing that they were not aware of beforehand. And then finally, I think our diversity, equity, and inclusion initiatives, they really overlap significantly with health equity and, and provide some resources for us. 

Dr. Tony Tizzano:

Yeah, I would agree. And I must say, the APM through the Art and Practice of Medicine course has been an eye-opener. If someone said to me "reflective practice" in medical school, I wouldn't have had a clue. I'd, you know, where's the mirror? I would have no idea what they were talking about. And now, it's part and parcel of each time we have one of those courses, we have a didactic session, then we talk about it maybe, but at the end of the day, they write back their reflections around it. Some of them are really eye-opening. A- And you were so bent on getting the factoid down as opposed to taking a minute to think about this and what's the impact. So, kudos to the program. 

So it's great to teach it, but how do you teach the faculty? I mean, especially I look at my generation of training, you know, this wasn't front and center. So what do you do for that aspect of? 

Dr. Bud Isaacson:

That's another big challenge, and I think, as I alluded to, most of us didn't have this training. And also, most of us come at our roles as an educator or as a healthcare provider thinking that we're providing the best care possible, that we are not biased in our approach, but we have to raise awareness, I think, in, in a way that is not blaming in any sense of the word. I think we've integrated training around implicit bias. For example, we talked about we try to integrate that with our faculty. And that, when done well, is really can be an eye-opening experience, that you're trying to raise awareness and recognize really blind spots that we all have so that we can provide better care. I think, frankly, our students are a huge benefit in this regard. So we create forums where we have students and faculty together, and we rely on our students to help us point out areas, opportunities for us to get better, and they do a great job of that. 

Dr. Tony Tizzano:

Yeah, I would agree. I think in many ways, in this particular topic, the students almost carry the torch, and it's important to listen to them. So along these same lines within the college, you have your own assistant dean for Diversity, Equity, and Inclusion, Dr. Monica Yepes-Rios. What is the focus of her work? 

Dr. Bud Isaacson:

Well, Monica is a great ally in this work and, uh, she's done a terrific job. We started this process, it was actually just after the George Floyd episode. And Monica was not yet in her role, 'cause we hadn't created it, but we started discussions with our students and asked them, what are we missing here? What are we missing in terms of diversity, equity, inclusion? And they, again, really paved the way for us to see what we needed to do. We ended up identifying this role as assistant dean and recruited Monica to be in that role. 

And our approach was to form action groups, not to be providing guidelines without any stimulus for change. But I like action groups because they really are defined by you have to be working toward something. And we've had a partnership between faculty and students on action groups that has been absolutely fantastic. I mean, some of the examples, we have a whole action group on the culture of equity. How do you build a culture of equity at our school? How do you address implicit bias? Microaggressions training, increase in the care for those disadvantaged patients. And then we've looked at our curriculum, too. We said, "Are we still continuing these same myths that have been passed down? Do we build certain stereotypes that we can really address?" So it's as simple as that, looking at some of the cases on paper that we have and saying, "We need to change those." And finally, we've tried to recruit faculty. We've tried to get a more diverse faculty in front of our students, and I think we're making inroads there. 

Dr. Tony Tizzano:

Yeah, I, I certainly would agree with that. So there's an importance of favoring integration of content over standalone presentations, and you alluded to that about lectures. This is getting more and more traction despite requiring a lot of energy. So what are the college's efforts to include, for example, LBGTQ content across the pre-clinical curriculum? 

Dr. Bud Isaacson:

You know that you pointed out a great example. That's been one of our great successes, I think, so far. So as you know from your role, this is a patient population that has felt disenfranchised in many ways. Uh, th- they come to a, a clinical setting, they don't know if they're gonna be judged in any way, they don't know if it's safe to talk about what they wanna talk about, and they've sort of been hidden in many ways. And I know that I was not sensitized to this at all in my training. 

Again, what we did was we had a group of faculty and students work together, and they've done a deep dive, really evidence-based, to try to identify what is the best care we can provide this group of patients. And it starts with our pre-clinical curriculum, and they've done the most work in that area. That's our classroom activities. So they've used the best evidence and gone to our different courses that we teach and integrated best care of this group of patients into our curriculum. And they've been enormously successful. They've published on this. They've gotten awards for this. They create tool sets now that o- other faculty and students can use and build from to become more comfortable and provide better care. They're not done with their journey. They really need to work on integrating this fully into our clinical curriculum, but very optimistic about the work they have done. This is a great example of something tangible that can come out of our efforts. 

Dr. Tony Tizzano:

Yeah, I've, I've got to look at some of the work that Jason Lambrese has done, and I, I, it's extraordinary. The students are actually extraordinary. And, you know, it's not just going and hoping you're not going to be judged. It's, will you even be recognized? And that takes some active thought, but it's easy to not pay attention and to miss it. So I, I think that the awareness coming out of that work is important, and as you said. 

Dr. Bud Isaacson:

Uh, uh, abso- I'll give you one tangible example that we were not doing. I was involved with our clinical training, as I said, early in the medical school, and part of that involved how do we start to train students to interview and develop rapport with patients. And we're now spending a lot of time on pronouns, just how do patients want to be addressed and the sensitivity to that right at the beginning. So we have first-year students being trained in that because they are starting their roles with patients now. And so, small things, but they can make a big difference. 

The other thing that's really nice about this is this sort of trains our faculty as well. So when we s- s- train a student, they go out into a clinical setting, and suddenly the faculty sees what the student is expected to do. It's training the faculty as well, and that's sort of a hidden part of this that's quite beneficial. 

Dr. Tony Tizzano:

Yeah, I would agree with that. I, I'm ears open when I listen to those students. And there's times that I will say in APM 3, "W- Why am I not doing that?" And, you know, you, I think it requires being a little bit humble so that you're receptive. So, we talked in earlier conversations th- the importance of humility and building trust. How does this come into play? 

Dr. Bud Isaacson:

Oh, absolutely. I have a h- heavy dose of humility approaching this. As I said at the outset, I don't think we have all the answers. I think we have to really look to our patients and we have to provide an environment in where they feel comfortable. And that really starts with how do you respect our patients, how do you talk to them about their prior experiences in an open way and a curious way, "Help me understand how this has worked for you before. I wanna do better," partnering with them. I think our students offer a great perspective. And I think it's possible, I've seen this happen in a positive way, that I think if you approach this knowing that you don't have all the answers, but helping be guided by your patients and by your trainees, it really can make a big difference. 

Dr. Tony Tizzano:

Do you think that the very nature of the curriculum at Lerner with the problem-based learning and not having the traditional exams and grading system is a more ripe environment for getting this accomplished? 

Dr. Bud Isaacson:

I think it facilitates that. The students don't feel like they're having to perform for a grade, and so I think they approach their learning with an openness to seeing how they can do better. We call it targeted areas for improvement. And that's a big part of our culture is approaching something knowing I can always do better, let me help figure that out. And as I said, I think it's a collaboration between the, uh, students and the faculty. The faculty have a lot to learn, too, and so the partnering works extremely well. 

Dr. Tony Tizzano:

And they have this mentorship, where they have someone who gives them feedback. I mean, in my training, you had your exam in 10 weeks, and that was the only feedback you were getting, period. There was nothing else to, to go by. So, switching gears just a bit, you know, climate change is a particular interest of yours, and I've listened to you speak around this. How is health equity impacted by environmental changes such as temperature, air, and water quality? 

Dr. Bud Isaacson:

Yeah, you know, I, I became interested in climate change and health, and I didn't really have a full appreciation of the intersection with health equity. And I think many people wouldn't. They'd say, "Well, the climate change affects everyone, right? It's hot. It's 95 degrees in Cleveland with a high hot index and everyone's gonna be affected." Well, uh, people of disadvantage in the social situation are disproportionately affected in so many ways by climate change. So you think about Cleveland in the summer. And if you're a resident of East Cleveland, there's very little tree cover. And if you're a resident of one of the rings, suburbs, like Cleveland Heights or Shaker Heights, we, w- we revel in our tree cover. The temperature difference in those two settings can be 10 to 15 degrees. The air quality often varies considerably, too. Many of the poorer neighborhoods, as a result of redlining, which sort of segregated poorer people into certain neighborhoods, are also closer to highways, they're closer to waste treatment plants, so the air quality is much worse in those areas. If you think about what's going on across the country with the hurricanes and floods, you will see that the people who are disadvantaged socially are gonna have harder times accessing care. 

And finally, when you think about who's on the front lines providing care, who's on the front lines doing construction work, who's doing sanitation work in the heat, that is critical. And they can be affected in their jobs when they're working out in the h- in the sun and the heat. And we see this more even in the Southwest, S- Southeast, the places like Phoenix, where the temperature may be over 100 for days on end, and you've got people working, who are usually of a, a lower socioeconomic class. So, this is another thing that we sorta had blinders on and we've been exposed to that we really need to pay attention to, the disproportionate effects of climate on our populations. 

Dr. Tony Tizzano:

There are so many parts and pieces. So, when you look at the topic in general, or, or perhaps even more specifically Lerner, what lies on the horizon? If you had your Dr. Stoller magic wand, what would you... 

Dr. Bud Isaacson:

(laughs) Well, I, you know, I'm a asset-based thinker, so I'm optimistic. I think that, again, if we come at this with the approach that we can't solve this in a day but we can get ourselves on a path to a better place, we have great opportunities. I think, as you alluded to, the environment that we have created for our school, which we hope is very collaborative between faculty and students, which is very open to the community, which is very open to issues of health inequities and diversity, w- and we have a primary emphasis on that, as we've talked about, all those things are assets that we have to try to address this. I think really engaging the community and trying to solve this, not in day, but get us on a pathway so that if we approach this saying, "We want our future students to be prepared to care for patients moving forward," whether that's climate change, whether it's disadvantaged patients, h- having a focus on these areas that have not been focused on in the past will help us allow our students to provide better care. 

Dr. Tony Tizzano:

Well, I could see that. I love the idea of reaching out into the community and offering experiences there. Well, Bud, is there anything that I didn't ask that you feel is important for our listeners to know? 

Dr. Bud Isaacson:

Well, no. I appreciate the chance. I think, uh, uh, raising awareness is probably the first thing. So if we can accomplish nothing else today but raise awareness, I think we've accomplished something. And then, for those in the audience who are involved with health care, get involved. We have ways for people to get involved at the school. Uh, we have sorta open invitations for faculty members, residents, nurses to get involved with our diversity, equity, and inclusion efforts. And Monica Yepes-Rios can provide a pathway for that. So, the more we get people involved with this, I think, the more chances we have to solve these problems. 

Dr. Tony Tizzano:

Absolutely. And, you know, we have a great course on microaggressions, and it's an opportunity to really look at implicit bias. And I think that it would be something that we would even go out into the public and do. So, you know, there are some great resources. Well, thank you so much, Bud. This has been a wonderfully insightful podcast. To our listeners, thank you very much for joining us and we look forward to you joining us on our next MedEd Thread podcast. Have a wonderful day. 

This concludes this episode of MedEd Thread, a Cleveland Clinic Education Institute podcast. Be sure to subscribe to hear new episodes via iTunes, Google Play, SoundCloud, Stitcher, Spotify, or wherever you get your podcasts. Until next time, thanks for listening to MedEd Thread and please join us again soon.