Marcela del Carmen, MD: Valuing Your Own Diversity
Episode #5 of the Charged podcast
PodcastJul | 22 | 2020
In the United States, people of color have long experienced inequalities in health care. And, throughout the global COVID-19 pandemic, these disparities in health care, and the systemic racism that prevents underserved and underrepresented communities from accessing equal care, have been brought to light even more. In this special episode, the new Charged host, Kelsey Damrad, and three previous Charged guests—Gaurdia Banister, PhD, RN, NEA-BC, FAAN, Allison Bryant, MD, MPH and Marcela del Carmen, MD—discuss inequalities and racism in health care.
Dr. Gaurdia Banister is the executive director of the Institute for Patient Care at Massachusetts General Hospital and director of the Yvonne L. Munn Center of Nursing Research. She is a champion for diversity, and she has long been recognized for her efforts to bring more people of color into the field. As a nursing leader, Gaurdia has worked hard to not only promote diversity within the workforce but also increase the retention and advancement of these nurses.
Dr. Allison Bryant is a maternal-fetal medicine specialist and the Department of Obstetrics & Gynecology vice chair for quality, equity and safety at Mass General. Allison’s work focuses on racial, ethnic and socioeconomic disparities in both obstetrical care and pregnancy outcomes. Most recently, Allison was awarded the 2020 Harold Amos Faculty Diversity Award from Harvard Medical School, which recognizes her significant achievements in fostering a diverse and inclusive community.
Dr. Marcela del Carmen is a gynecological oncologist and the chief medical officer at the Mass General Physicians Organization. Among the many responsibilities of her role as chief medical officer, one she considers as one of the biggest is working to mitigate provider burnout and help health care providers restore meaning and joy back into the practice of medicine. Marcela is originally from Nicaragua but fled with her family to the United States at the age of 10 during the country’s civil war in 1979.
MODERATOR: In the United States, people of color have long experienced inequalities in healthcare. And throughout the global COVID-19 pandemic, these disparities in healthcare, and the systemic racism that prevents underserved and underrepresented communities from accessing equal care have been brought to light even more.
I'm joined here today with three very special guests for an episode of CHARGED that discusses inequalities in racism and healthcare. You may recognize them from past episodes of CHARGED, during which they shared more about their specific areas of expertise, and the ways in which they have devoted themselves to increasing diversity, equity, and inclusion in healthcare.
Dr. Gaurdia Banister is the Executive Director of the Institute for Patient Care at Mass. General and Director of the Yvonne L. Munn Center of Nursing Research. She’s a champion for diversity, and she has long been recognized for her efforts to bring more people of color into the field. as a nursing leader, Gaurdia has worked hard to not only promote diversity within the workforce, but also increase the retention and advancement of these nurses.
Dr. Allison Bryant is a maternal fetal medicine specialist and the OB/GYN Vice-Chair for Quality, Equity, and Safety at Mass. General. Allison’s work focuses on racial, ethnic, and socio-economic disparities in both obstetrical care and pregnancy outcomes. Most recently, Allison was awarded the 2020 Harold Amos Faculty Diversity Award from Harvard Medical School, which recognizes her significant achievements in fostering a diverse and inclusive community.
Dr. Marcela del Carmen is gynecological oncologist and the Chief Medical Officer at the Mass. General Physicians Organization. Among the many responsibilities of her role as Chief Medical Officer, one she considers as one of the biggest, is working to mitigate provider burnout, and help healthcare providers restore meaning and joy back into the practice of medicine. Marcela is originally from Nicaragua, but fled with her family to the United States at the age of 10, during the country’s civil war in 1979.
So welcome, everyone, and thank you so much for joining me today. To start off, I would love to just go around the panel and learn a little bit more from each of you about your experience working and supporting these underserved communities, specifically during the COVID-19 peak. So Gaurdia, I would love to start with you, if that’s possible, and just hear a little bit more about your experience.
GAURDIA BANISTER: So when I was thinking about this question, I had this situation occur where I was watching TV one night. And as you know, we’ve all been masked as a result of the pandemic. And I heard this voice that sounded extremely familiar to me. So I kept listening to this nurse, kept listening to this nurse. And finally, the next morning, I sent her an email, and I said, “Did I just see you on TV last night?” And yes, I did.
She was one of the graduates from the program that I'm very proud of called The Clinical Leadership Collaborative for Diversity in Nursing. And she happened to be—her name is Cynthia Crispie—excuse me. Cynthia, I want to make sure I say this right. Barbosa. She is one of the nursing graduates from the program. And she speaks Portuguese, and also Spanish.
So she had been working very closely with an OB/GYN patient, who had been hospitalized with COVID. She had been that patient’s nurse. And she had really been the caregiver and translator and supporter while this patient was in the hospital. So she was being interviewed on TV. And also, in addition to that, because she is trilingual, she was also featured on Telemundo on that station as well.
So I felt like it was sort of full circle when I saw her. And I knew the importance of having clinicians and providers that look and sound like the patients that we serve. And she was certainly fulfilling that role.
MOD: Excellent. So tell me more about what that was like for you, seeing that, and seeing the representation, and what kind of different perspective that brought for you, in the work that you do?
GAURDIA BANISTER: So I think what it says is how critically important it is, particularly during a pandemic, when we know, as you said earlier, it disproportionately affected communities of color, particularly when I think about our LatinX community, and also African-Americans, that yes, all providers can provide great care. And I'm not minimizing that in any way.
But I also think culturally competent care, and care that’s really specifically suited, in terms of individualized care, that’s what we need to see when we have situations like this, not only during a pandemic, but certainly just providing wonderful exemplary care in general.
MOD: And you mentioned the disproportionate challenges for these communities. Can you talk a little bit about, you know, what those are, sort of in general care, and then how those were amplified during the pandemic?
GAURDIA BANISTER: So I think what’s really important, and we've been talking about this for a long time, it’s really related to the social determinants of health. I feel like community of color, when you think about the social determinants, it’s really the environment in which you live, and you work, and you thrive. And so what kinds of supports are available to you from a healthcare perspective? What opportunities are available when you're going to school?
Do you have a healthy environment in terms of, whether they're manufacturing around you, and the air that you breathe? What kinds of supermarkets are in the neighborhood? All of those come together, in terms of what a healthy environment looks like. And we know that communities of color are disproportionately affected by these social determinants of health.
Now I do want to make a statement, because I was thinking about this, that while we’re talking about the challenges to the communities that we’re talking about today, they are incredibly resilient. I think it’s so important for us not to forget, at any point in time, during this conversation, is how resourceful they are, how resilient our communities are, how hard they have worked to get to where they are.
So, while we’re talking about some of the challenges that they face during this pandemic, and really, it’s grounded in the social determinants of health, we need to also focus on their successes, their strengths, their capabilities, and what they contribute to our society.
MOD: And that resilience, can you talk a little bit about what that looks like, what maybe examples you’ve seen that are specific to COVID, how that really manifests?
GAURDIA BANISTER: When I think about some of the challenges, that resilience is risk-taking, that I know that, in some communities of color, they don’t necessarily feel like healthcare institutions and organizations, are safe places to go. But you have to take a risk, if you want to take care of yourself, if you want to take care of your family, if you want to take care of your friends.
And so I saw our communities coming together and saying, “Yes, I'm frightened. Yes, I'm scared. I may go in, and perhaps I'm not going to feel welcomed. But I want to take care of the communities where I live in.”
MOD: And I know, too the pandemic, it illuminated disparities that have always been there in healthcare. So I'm wondering if you can explain a little bit, too, about how those disparities have been recognized in the past, specifically as it relates to your work?
GAURDIA BANISTER: So, in my work, I'm very focused on having particularly nurses, which is what I'm focused on, nurses that look like the patients that we take care of. Sowe’ve been talking about this in the nursing profession for a very long time. When you look at the predominance of nursing, in terms of racial and ethnic background, they're primarily Caucasian. I mean that is the truth.
And so we feel very strongly the importance of having nurses that are diverse. And that’s whether they're LatinX, whether they're African-American, Filipino, whatever that might be, because we know that we have a very diverse patient population. And it’s only becoming even more diverse.
So I see this as fundamental to providing the kind of care that we want for everyone. And when I think about some of the nurses that have participated in our program, they talk about the fact that some patients are looking for people that look and sound like them, because they have a connection. They have a commonality.
Perhaps they're thinking about the cultural sensitivity and competency that is really important. So that’s how it intersects with what I've been working on. And that’s what I've heard a lot about in regard to this pandemic.
MOD: And I know so much of your career has been devoted to creating this culture of diversity, so that your healthcare providers represent patients that they're serving. How do you see this either strengthening the work that you're doing, or just impacting it in general?
GAURDIA BANISTER: Well, I'm hoping it will be a catalyst. I'm hoping it will shine a light on the importance. I'm hoping that the momentum that we have seen.
But I'm hoping that there's going to be a continued recognition of the importance of these kinds of pipeline programs and the funding that’s necessary to continue them. I know in this very challenging time, many organizations are feeling the financial strain of having gone through this pandemic. But I truly hope that, as this has shined a light on the importance and necessity for this kind of work, that it will only help us and strengthen us.
MOD: And I think that there's general recognition that this did shine a light, and this did illuminate a lot of the disparities in these communities. How was this experience, the COVID-19 pandemic, how was it different than past experiences which also might have shown a light?
GAURDIA BANISTER: Oh, I think it’s completely different. First of all, we’re talking about a worldwide pandemic. And I think about the fact that so much happened, that the entire country was affected. Then, as a result of the pandemic, we know that people then began not being able to go to work, not being able to go to school. And soit had financial and economic consequences that were profound.
We saw, the impact on healthcare providers, whether it’s nurses, physicians, physical therapists, respiratory therapists, I mean it had such a profound effect, we’ve never seen anything like this in our past. So I think that this is a situation that we need to continue to learn from, we need to continue to watch. And we need to continue to prepare for, because we know that it’s not over. So there's been nothing like it.
MOD: Absolutely. That’s great. Thank you so much. Marcela, I’d love to turn the tables to you. Could you tell me a little bit about your personal experience and professional experience in this situation?
MARCELA DEL CARMEN: Sure. SoI think, I would say, from a professional experience, because I have two domains of work, both as a clinician, but also as an administrator, the pandemic obviously hit both of those spaces for me. If I were to start with the clinical space, as a GYN-oncologist, we knew that there was going to be some cancer care that had to be delayed or postponed because of the pandemic, and the need to actually close down some of our clinical services that were not urgent or deemed to be essential, to create capacity to care for our COVID patients.
But also, importantly, because we don’t want to expose patients unnecessarily by having them come to the hospital or to the ambulatory setting unless we felt that it was really essential to their wellness and wellbeing.
So, as a GYN-oncologist, I would say probably about 50 percent of my baseline clinical volume sort of went away. And that became more virtual care. So we were doing a lot of our surveillance visits over a virtual care platform. But about 50 percent of my clinical practice continued to be in person, primarily seeing new patients that were being diagnosed with gynecological malignancies, who couldn’t wait, or patients that were coming in for chemotherapy, or surgery.
I think that we, as a community, came together nationally to quickly try to identify some guidance, as to how we define essential cancer care versus nonessential. And I think it's very hard when you're seeing a new patient with a cancer diagnosis, even if the cancer is more indolent and maybe not as life-threatening as another cancer, how do you explain to a patient and decide uniformly across the practice or across the discipline, that someone can wait and someone can't?
We definitely, over the course of the last three months, have done more chemotherapy. So for many of these patients with metastatic ovarian cancer, who would otherwise be eligible for surgery upfront, we've delayed their surgical care. It gets very complicated. Those are very big procedures that oftentimes require patients who care unit, we need to have access to a lot of resources, chemo blood bank. Because just the nature of the radicality of the surgery.
So we gave a lot of these patients chemotherapy upfront to treat their cancer, and then had them back, or are bringing them back for what's called an integral surgical. So their surgery is going to be done in the middle as opposed to the beginning of care. Because, as you know, we were also charged with having to keep access to our intensive care unit, our blood bank, and things like that, resources that go beyond what you think of traditionally medicine, to be able to think of our COVID patients.
I think that because I am from Latin America, I'm originally from Nicaragua, as you said, and I'm bilingual, I also felt that I was not, as a clinician, going to sit this one out. And even though the care of COVID patients does not really intersect with the clinical care that I've been trained to do, I did participate in the training program that was put together by the Department of Medicine and the Leadership Care. And I was lucky enough to be able to serve in the Respiratory Illness Clinic at Chelsea.
So, in that setting, I took care of patients who had symptoms of respiratory illness and were coming in to Chelsea to get tested, or appropriately evaluated for their symptoms. And I would say that, in the course of my career, I've been in practice for 20 years, it was one of the most rewarding experiences, to really be able to get out of my comfort zone as a clinician, but really be able to serve the community that I come from.
In a way that, you know, as Gaurdia said, you know, these patients are incredibly resilient. Many of them have defied all kinds of odds to be able to pass the border and come to the U.S. They don’t speak the language. Many of them if you talk to them, they're working three or four jobs to be able to support their families here, but also send money back to their home countries.
Many of them live, two families in a single family home. So the challenge for them to isolate or to shelter in place is even much more profound than in some of our other communities. I think many of us who provide clinical care, we've been catalogued as heroes in the pandemic, and actually think we get so much more back from the care that we give.
Sometimes I think the biggest benefit to a patient with just having somebody who spoke their language. And I think Gaurdia said this earlier, you know, the ability to provide culturally competent care, I think, was critical when patients are feeling very vulnerable.
Many of them are afraid, we said earlier, to come into a hospital setting, because of issues of, that range from not having language proficiency, to being worried about their legal status, and the ramifications of presenting for care that may have on them, or the impression that it may have an impact. So I would say that was incredibly rewarding.
And then, my administrative role, obviously we were charged with having to stand up services very quickly under the guidance and leadership of our command center. But the intersection between that charge and vulnerable patients was real, in that we saw early on, in the pandemic, that our patients—for example, at Chelsea, were disproportionately being affected by COVID. Forty percent of our COVID—of patients admitted to the hospital for COVID care came from those communities of color.
And so making sure that we, again, got freed up. And I was in charge of organizing the labor pool for our clinicians, primarily our physicians and APPs. So trying to identify bilingual staff that could serve those communities and reassigning them to those geographies, making sure they had the appropriate training, including PPE, to be able to serve those communities.
And then, within the hospital, under the leadership of Elena Olson and Joe Betancourt, we organized a group of clinicians who are bilingual, who actually served as translators. So these were, for example, physicians that would come in, and actually do a 12 hour shift, and help in our ICUs, not with the direct clinical care of the patient, but they would be in charge of, for example, getting back to the families, communicating updates.
We forget about the fact that these patients not only were really sick, but they were also isolated from their families. And that creates another level of vulnerability that I think was very significant. And thankfully, we had enough Spanish-speaking clinicians that could help with that work of translating.
And then I think the third thing that we did under the leadership of Misty Hathaway, was to take a lot of the documents that were generated by some of our experts in infection control, and this care medicine, for example. And her team did a terrific job of translating those documents to Spanish, including some documents that came from the Department of OB/GYN, led by Dr. Bryant.
But to be able to share that with some of our colleagues in Latin America, I think is something that the MGH should be very proud of. And certainly, through Misty’s leadership, I was able to participate in some Zoom meetings, where we actually had that change of information to share with countries that maybe have access to less than we did, certainly less expert care than we had at Mass. General.
MOD: Well, that's incredible, all the work that happened, and how it happened so quickly. And this raises so many more questions for me that I'm going to remember. Because Allison, I’d love to hear you as well, and what your experience was like, as Marcela mentioned, working in OB, and what sort of unique challenges you saw women facing in these communities, and how that impacted you personally and professionally.
ALLISON BRYANT: I think that one of the things that I think was remarkable to me, is just that OB is one of the areas in the hospital that both had to deal with COVID, and sort of how to keep patients and providers safe. But also, at some measure, had to do business as usual, because we really were not physiologically able to just stop the ongoing pregnancies that are happening.
And so, the outpatient spaces, caring for women throughout their pregnancies, we had to make some modifications. But we had to continue at the same pace and the same volume. And then, really, on labor and delivery, daily, women were coming through for deliveries, we needed to keep them safe. So that was sort of really a unique experience. And I think our teams worked beautifully together to sort of, again, there were so many ever-changing policies. And sort of to keep up with that, keep up with amplifying the message.
I was very impressed with the work that the hospital did, in terms of thinking about equity on the early side, so understanding that the communities that were going to be affected were very specific. And we really needed to get messaging and interventions out to those communities. And we did a lot of that work in our department as well. And then I think, as Marcela said, I think that what was really valuable and helpful to me, was helping to amplify that message.
So the work that we were doing at Mass. General, I think, was great and extraordinary. But being able to pass that on at sort of the community level, or at the state level, or at the national level, was something that many of us had the opportunity to do through ACOG or Perinatal Quality Collaboratives, to really understand, particularly for geographic areas around the country that had not yet had their surges, to sort of prepare them for where the equities or considerations were going to be.
And so that was rewarding to me. It was, a tiring time for so many of our providers. And we heard from so many providers, again, who take care of a number of women who deliver from Chelsea, and from Revere, and from Everett, those areas that were so hard hit, that the providers in the office just were weary, and fatigued, and sort of so emotionally invested in the care of their patients.
And it really drove home the sort of equity message, as just that, equity is not about providing equal care to everybody, giving everybody the same thing. But it’s about giving people what they need. And so for those communities, they needed so much more, even though maybe we did a few fewer visits, the contents of those visits were so lengthy, and emotionally charged, and understanding, as Gaurdia said, the social determinants of health, and how we as a health system could sort of step up and help to provide the things that people needed to get themselves through this tough time.
MOD: Mm-hmm. In talking about what you saw these communities, their specific and unique needs were, can you just give an overview of what kind of unique needs these women were experiencing and expressing?
ALLISON BRYANT: Well, I think it really does come down a lot to the social determinants of health. I really think that this disease, like no other, was very much a social disease. And sothe preventative mechanisms were really all about what you could do in sort of your communities and your social environments. And so I think, in OB, we had already been screening for social determinants of health. And I think what this pandemic taught us, is that social determinants of health are not static. So they are really dynamic.
And so the family, the woman that was not food insecure at the beginning of her pregnancy, for sure, two months into this pandemic, might have been food insecure, or might have had challenges with transportation, or with childcare, as we were limiting the visitor policy. A woman that might have brought her child to her prenatal care visit could no longer do that. And there might not have been anyone at home to sort of take care of her kids, or anyone who was healthy at home.
And so I think that all of those things, the food insecurity, housing insecurity, transportation, childcare, also for our patients in, unfortunately intimate partner violence is a very big part of many people’s lives. And this pandemic put that in the spotlight. And the fact that people were isolated in their home environments, and maybe not being able to reach out in the way that they otherwise would have been, with the impact of telehealth, and our sort of asking questions that then get broadcast on speaker phones in homes.
I think we learned a lot about privacy, and trying to keep people safe. And the fact that hospital was able to stand up, sort of our haven or our domestic violence program’s 24/7 access was really quite important in understanding what the unique needs of many of our patients face, including, particularly, in the OB space.
MOD: And I think Marcela and Allison both mentioned what you were hearing, and Gaurdia as well, from your staff, and sort of the fatigue, the learnings that were coming out of it. And this is kind of a question to the group, so anyone who would like to answer, what sort of testimonials were you hearing from the staff? What common feelings were being expressed? And how was that managed?
GAURDIA BANISTER: I certainly can go first. I mean absolutely, there was definitely fatigue, anxiety, stress, fear, because we, as both my colleagues have already mentioned, we were learning as we were going, or we were sort of flying the plane while we were making adaptations the entire time.
But I have to say, I'm incredibly proud of my nursing colleagues, my physician colleagues, PT, OT, speech. And I also want to just also make sure I reference the importance of food services, and environmental services, and everyone that came together to care for our COVID-positive patients.
I truly believe that most everyone that was involved felt it was a privilege to serve. It was a privilege to be able to take care of these very complex patients, from whatever perspective, or whatever role you were playing within our organization, the teamwork, the collaboration, the innovation that happened as a result of all of this.
Because everyone needed to think very differently because of what we were experiencing it was a privilege and an honor to care for these patients and to care for each other, and to care for our community, and even broader.
ALLISON BRYANT: I think that I would agree. Everyone, although we’re tired and in some ways emotionally spent, no one complained about it. Everyone understood their value as an essential worker, and really understood what the role of an essential worker was. And I think everyone showed up to do their best, every single day. And I was so proud to sort of work here at MGH.
I think also, as Gaurdia had mentioned before, I think people recognized the value and the resilience in the communities that we were serving, so really understanding, the Chelsea Collaborative, and sort of collaborations with that group, and really sort of arranging for, you know, food services, and masks, and things that we sort of couldn’t even think of on the fly, that the communities were sometimes prepared to sort of step in.
And so I think our staff really very much appreciated that, as we sort of think about wellbeing of our families, we are not alone in this. That the communities can sort of help to take care of themselves. And I think that that was really for everyone.
MARCELA DEL CARMEN: I mean, I think that absolutely, and we actually sent a survey to our clinicians. And many of our respondents were, nurses and physicians and some of our trainees. And what we heard were the things that have been true across the country. People are worried about their personal safety, that they have provided enough PPE.
I think that we heard a lot about fatigue, and also the feeling of being isolated, we’re people. You know, we like those personal connections. And I think people were deprived of that and starved from that very quickly.
With new challenges, in terms of learning technology, to quickly, for example, do virtual care, to keep up with the number of communications that were coming out, literally multiple times a day, to keep people informed and updated. The challenges of young parents having to now be faced with homeschooling their children. So these are all things that came to many people, simultaneously, without any real heads up or time to really be prepared.
I think the resiliency of our staff, I think that all 27,000 employees of the MGH have much to be proud of. And I think that everyone really came together. People were asked to work in a different clinical space. And the anxiety that comes from that, we also heard. But again, places like the Department of Medicine quickly put together training to help clinicians feel comfortable in the new job they were being asked to do.
The history of the pandemic has been written as we speak. But when it’s all said and done, I think that the MGH will be very, very proud, and should be very proud, that once again, it will have left a very important mark in American medicine, and, I would say, in global medicine. And that includes for the way that we dealt with the disparity that we've been talking about.
I think that we recognize none of us were shocked, that we saw the pandemic manifest disproportionately in our underrepresented and under-served communities. But services like even, you know, the collaboration with the City of Chelsea and Revere, with the hotel, to actually be able to shelter our patients who could not do so at home safely, I think was just another example of that response.
MOD: Marcela, I’d love to go back to something you said earlier about not wanting to sit back when you had a background and history that felt applicable in this situation in some ways. And speaking another language, wanting to offer that kind of support for the patients. So I wonder if you can talk a little bit about how communication was used with patients differently during this time, to support them and address sort of those concerns you were hearing about people who were afraid about this impacting their immigration status, or, not speaking English as a first language. How was that approach taken?
MARCELA DEL CARMEN: I think it goes back to something that we heard earlier from Dr. Banister about providing culturally competent care, and also something Dr. Bryant said, is that you have to meet people where they are, in terms of their need. I can tell you that, personally, I think that being able to speak to somebody in their native language, where they can actually communicate with you, and you can ask, and get a response from them, that actually articulates what they're worried about.
I can tell you that, for a lot of the—a lot of the communications sort of behind closed doors, when you were seeing these patients in the Respiratory Illness Clinic at Chelsea, they had questions like, “How did I get this?” or, “What can I do to keep my family from getting the virus? How do I stay healthy? What does it mean?”
Just even being able to tell them how we’re going to communicate the results of the test back to you. Somebody’s going to call you. When are they going to call you. Making sure that we have the right venue to contact patients back. So simple things that sometimes, if you have, for example, access to Patient Gateway. It makes communicating about your healthcare much easier, because we can actually enter that information into your electronic chart. And you can access it on the other side.
But many of our patients either don’t have access to those tools, or they don’t know how to use them. Or they're not available. For example, you know, I’ll just give you something else. Patient reported out. Not available in other languages than English. So these things become much more profound and critical when you're in the middle of a crisis, and you really have to notify people, let them know if they're positive, that they need to shelter in place, and try to use some contact tracing.
I would say the reception from all of the staff at Chelsea for these patients was so warm and welcoming, that I think that walking through the door, immediately they felt a sense of comfort, which is what we’re here to do as healthcare workers. We’re supposed to provide comfort and that feeling of safety and reassurance to our patients.
But I would say a lot of it hinged on being able to communicate effectively with these patients, and have a plan of care that would allow you to remain in conversation in the community with those families, make sure that no one to follow up.
MOD: And Allison, this is triggering something from a past CHARGED episode that I know you have expressed about how important dialogue is in maintaining team morale as well, and creating change within the team structure. So just like the communication was important for patients. I wonder if you can talk about keeping an open dialogue with people on your team, and how that really impacted the approach to care.
ALLISON BRYANT: I think it was very important in this day and age, I think particularly, around COVID itself, sort of having an open mechanism for sharing new protocols and things like that, and understanding where people were going to get the information. One of the things that we did in our department early on is that our Chair started to have town halls, and sort of allowed time for people to come back together even though we couldn’t physically come together. And those were super well attended. And I think everyone was starved for information, and sort of being able to talk with one another. And allowed some space for some open dialogue.
I think particularly around the equity piece, we never let that message go unsaid, each time we sort of talked to our staff and our team. And really understanding where those disparities in equities were coming from. We have had a legacy of doing that in our department. So I think people felt very comfortable with that sort of conversation.
But I think one of the things that we learned from this epidemic is providing information about who’s affected sometimes leads to stigma and bias. And I think that it was really important to sort of nip that in the bud, as we were starting to hear some of those messages as well. I think they were very well intentioned made assumptions about who might be infected, and who shouldn’t have been infected, particularly when we started universal screening.
And so being able to sort of say to someone, “Hey, that’s not what we meant when we were saying who’s affected,” it’s so that we can provide resources to the community. It’s not so that we can provide targets, one-on-one. And so I think having that open culture, sort of chatting one another, is that I know your intent was good. But here is how we might have reframed that, I think has been really sort of very important in this pandemic, especially as things were moving so quickly.
MOD: And that stigma and bias that was coming up in these conversations, were those things that you’ve always sort of maintained this open dialogue about? Or is this new in the midst of this pandemic, these sort of expressions of stigma that you were hearing?
ALLISON BRYANT: I think that we’ve always tried to talk about—sort of, because we talked about what's the role of, you know, etiologies of inequities. We’ve always talked about the role of the healthcare provider and the healthcare system, in terms of perpetuating some of these inequities. And some of that comes down to unconscious, or sometimes conscious bias.So those were conversations that we had already had.
I do feel like I was a little bit surprised at how the demographic information that we were providing, that sort of turned around a little bit, in terms of people’s assumptions and expectations. So I had not seen that happen to date. And so I was a little bit caught back by that. But it makes sense, right. We were saying, over and over, for example, that women in Chelsea who come here to deliver are much more likely to be affected by COVID. And the intent behind that was so that we could stand up more resources in Chelsea, or understand how we could screen better on the individual basis.
But it wasn’t so that, if a woman came from Chelsea on labor and delivery, that anyone would assume that she had COVID. And so I think it was just a learning piece about how epidemiology and demographics can sometimes sort of be turned around, and just sort of nipping that in the bud again.
MOD: And question for you, but also for the group, if anyone else experienced this in their work as well, but how did you manage those conversations to try to dispel some of that stigma and create change?
ALLISON BRYANT: When I hear those things, when I overhear them, it’s sometimes challenging. But I think the people know in my department that I don’t back away from those conversations. It’s not something that needs to happen in public, again, just culture. I know that you sort of intended well, but I pulled that person aside and sort of said, “That’s really not what we meant. You know, it is very true that that patient had a higher a priori risk of having COVID. But her negative screen is what tells us that we are not going to treat her any differently. Soit’s really important to keep those messages straight.”
And so I think that that was a well-received message. And it wasn’t out of the blue. It’s something, again, that we talk about a lot in many of our clinical spaces these days. And so I think it was well received in that particular case.
MOD: And so one thing, too, that I know Gaurdia mentioned at the very beginning, is one thing that’s intersected with the pandemic or the Black Lives Matter protests. So a question for the group, and Gaurdia, maybe we can start with you, what has this intersection been like for you? How have these protests sort of amplified the disparities that are being discussed in the conversation of COVID and outside of it?
GAURDIA BANISTER: You know, so what I've seen from my colleagues, which I'm encouraged, but I am also—And I don’t want to say skeptical, but I'm encouraged, and I'm hopeful. I feel like, as a result of what happened in our country, shining a light—I mean not only had COVID shined a light on these healthcare inequities, but then we had the death of George Floyd.
And I feel like it was a perfect storm, because we had people that weren’t working. They were at home. They were watching television. And that was played over and over and over again. And I felt like there was this a-ha moment that happened in our country, that even though, as an African-American woman, I feel like I had been very aware of this for a very long time, in terms of the injustices and what happens to African-American men.
I mean, when I think about my brother, my nephews, my cousins, I mean it’s something that we've all sort of—at least I can speak for myself—it’s been a part of our culture, and it’s been a part of our community. But I felt like there was this awakening of the country, in terms of these inequities, these problems, these issues around race inequity.
So I felt like it provided a lens to begin to have a dialogue, an open dialogue in a way that at least I would feel, at Mass. General, we've never had before. I had a number of people reach out and say—which I think is really important and positive—“How can I learn more? You know, what are some of the resources that are available to me? Because I feel like I just was unaware. I didn’t know. I was blinded. Maybe I was ignorant, whatever it might be. But I want to improve myself. And by improving myself, I know that I can be an ally and an advocate for my patients, for my colleagues, and in my community, and beyond.”
So I felt like it provided a lens to be able to help people understand the inequities that both Dr. del Carmen and certainly Dr. Bryant have talked about. And then, what was their responsibility? What was their ownership? What was their role? And what could they be doing differently?
MOD: I think allyship is a big conversation and a big hopefully long-term outcome that’s come out of this. So I wonder if you could talk about the importance of that in anti-racism work, in healthcare, specifically.
GAURDIA BANISTER: So I’ll give an example. A very beautiful letter was recently written by one of our nurses that talked about, really, the importance of allyship. And it talked about the fact that we do have these instances in our organization, and they're everywhere, where you may be disrespected because of your race. And something may be said by either your colleagues, something might be said by a patient, and we certainly have policies and practices in place to address these issues with our patients.
But allyship, what it means to me, is that when you see injustice, or when you see something that is absolutely inappropriate, that’s said to a colleague—and I'm just going to use that as an example—it’s not the opportunity to turn away or to say nothing or to do nothing. Allyship means that you're going to step in. You're going to lean in. You're going to support your colleague. And you may need to bring voice to what is happening.
“This is inappropriate. Perhaps this should not have been said. We’re not going to tolerate that within our organization.” And also, at the same time, care for your colleague who has just been, in my opinion, harmed and hurt in some way, by this experience. And I do feel like earlier, when we were talking about the Black Lives Matter Movement, that there were more and more people who began to say, “I want to be an ally. I want to reach out. I want to have a more active involvement to help facilitate the change.”
And I think we saw with the crowds across the country, they weren’t primarily only African-Americans or Blacks. It was a cross-section of young and old, White and Black, you name it, everyone was out really bringing voice to the importance of some change.
ALLISON BRYANT: And I would love to echo that notion that I think allyship can come in many forms. Sothere is the reactive allyship, where you just saw something happen, and you're going to be an upstander, and you're going to help to protect the person who’s just been aggrieved. But there's also the proactive allyship, that I think people are coming into now, which is just that this is going to take a lot of work. And people of color cannot do all of the work. They’ve been doing much of the work so far. But we really need everyone to be engaged, and everyone to understand how this is so destructive.
So we can stand up on the committees, and do all of the, like, research and the work that needs to be done, to move this mountain. And so I think that that’s another way that people can sort of show their allyship.
MOD: Personal bias, too, I know that plays a big role, and being able to look inward, and be introspective, and sort of deconstruct some of those personal biases. How do you encourage people on your team, people in your life, you know, anyone, to sort of do this type of hard work, in order to be a better ally?
ALLISON BRYANT: So I think that there are, you know, formal ways that people can sort of really recognize their own biases. So there are things like the implicit association tests, which we really have encouraged. And, in fact, a couple years ago, sort of mandated that all of our clinicians complete within our department. I think that that’s one way that you just at least recognize that, indeed, I carry these. I harbor these biases. It doesn’t really teach you what to do about them.
So I think it does need to be paired with some kind of training and education, which I know that the Institution is now hopefully committed to doing across the entire Institution, is how do I mitigate those biases? It’s not like you're going to get them to go away. But what can I do when I recognize them in myself? And I think third, if you don’t recognize them in yourself, but an ally standing by recognizes them, then we have to have a culture where we can sort of call each other out, again sort of in private, if that’s appropriate, to sort of say, “That thing that you just said, that may have been interpreted by that person in a way that you did not intend. And so let’s think about how we could change that the next time.”
So I think it’s going to take the entire community, and I think the criticism of unconscious bias training is that it feels like it’s a one-and-done, and it can't be that. It has to be one, and then you move on, and you continue to use that, and you continue to—like every time you have an interaction, consider how your biases make.
MOD: And you mentioned that institutional piece of this, where there are trainings being implemented, and that kind of thing. What other sort of changes have you seen amongst leadership in healthcare, or changes that need to happen that haven't yet, to continue some of this work?
ALLISON BRYANT: Yeah, like I said, it’s moment. And I think that it has been very encouraging to see, frankly, leadership just listen, and to take a pause, and to understand from people of color, in the leadership levels, as well as throughout the entire hospital, about what people’s personal experience has been. I think that that has been refreshing. I know that there is this sort of the 10 point plan that has been put forward, that really has a lot of good foundational elements to it. And I am enthusiastic and hopeful that the Institution will take them, and sort of put the resources into it that are needed.
But they are things like, having an educational mission. Or there are things like being able to report things that you see, and be confident that they're going to be taken seriously, and looked into. But they're also things like making sure that everyone who works here, works at a living wage, so that the people who work here know that they can continue their own wellness, and so really taking care of our workforce.
And so I think all of those things are going to be so important. And again, lastly, I just think that we are MGH. We are man’s greatest hospital. And we can't be man’s greatest hospital unless we are providing the very best and the very most equitable care to every man, woman, and child who comes in here. And then we take that, and we amplify what we have done, because people do listen to us here.
MOD: Great. And I want to circle back to a broader question. And it’s for the group. Anyone who wants to answer. But how does racism and systemic racism, how has it historically and currently impacting public health?
MARCELA DEL CARMEN: Well, I think that, when you look at the pandemic, you know, I think, you know, you can think of racism as being another public health crisis, right. I mean I think that, when we talk about the social determinants of health, that drive the outcomes that we’re seeing, if you were to go upstream of that, why are those social determinants of health different for one population than another, in my opinion, it stems from structural racism in this country.
It is in the domain of responsibilities that each of us takes, when we decide to go into healthcare, to understand why one patient has an outcome, and a different patient, who just looks different, will have very different outcome. For example, in my field, we know that African-American women with endometrial cancer have a much higher mortality than their white counterparts when you control for everything, right. And we know those data for years. We just haven't done anything to fix it, right.
And so one of the things that I worry about is that, as we look to the future, whether it’s the COVID pandemic, or innovation in therapeutics in cancer—I’ll give you another example. You know, we do not accrue minority women to clinical trials the same rate that we accrue white women. So, until we do that, we’re not going to understand how therapeutics are going to improve the lives of these other populations. And that gap is actually getting wider.
So I worry a lot about, once we have a COVID vaccine in place, how are we going to make sure that we are equitable in the delivery of that vaccine, and that we can actually not leave anyone behind? So I think that there's always been a manifestation of racism in the delivery of the access of healthcare in this country.
We have 40 million people in the United States who don’t have access to any care. And countries like my country, who are extremely poor—Nicaragua is second poorest in Latin America to Haiti the right to healthcare is a human right. And this country hasn’t recognized that, right.
And so I think that this is an opportunity to actually think of racism as really a public health crisis. And it is incumbent in each of us to actually figure out a way to remedy it, to actually not just talk about it, but actually look for opportunities to change the history of his country. And I hope that the murder of George Floyd is not just a moment, but is actually a movement. It continues to be a movement that drives change.
MOD: You mentioned the clinical trials, the research part of it, making that part inclusive. Are there other areas of healthcare that we need to be thinking about sort of piecemeal, and making it more inclusive? And what would those be?
MARCELA DEL CARMEN: We need to make sure that we represent the patient population that we serve. And I think that there are spaces within our institution where that’s been done more successfully. I would say that nursing has done it better than we have on the physician side.
So when you look at, it’s not a pipeline problem. When you look at Harvard Medical School, and the enrollment of under-represented minorities to each entering class, the numbers are 23-25 percent. But then, those physicians who graduate from Harvard Medical School, they're not staying. The numbers begin to decrease as you get further into your career development, whether it’s residency training, fellowship, faculty appointments. And then, over across the spectrum of academic promotions.
And so I think that that’s another place where we have an opportunity to actually begin to make a difference. We need to create an environment and a culture where our under-represented minority staff feels welcome. They feel supported. They feel comfortable being here. And they thrive here.
And that’s when they, and try and create an environment that will become even more conducive for these providers from these particular segments of our community, to also want to be part of that.
ALLISON BRYANT: And I feel like there's probably no space in the healthcare environment that couldn’t benefit from more diversity. So certainly, the patient-facing roles, for sure, but I really like the 10 pointplan, this call that like everybody in leadership is going to have to sort of have a plan for how they're going to improve diversity. So what will we look like if our marketing workforce was much more diverse, or if our police and security was more diverse, or if the folks who are thinking about buildings and grounds or architecture, or like where we’re going to stand up our next clinic, like all of those things are going to benefit from diversity. Because that, I think, is how we’re going to better care for our communities.
MOD: I know infant and maternal mortality outcomes are higher amongst black women and babies. So I'm just wondering, specifically in your specialty, how you could see this movement making a true impact there.
ALLISON BRYANT: Yeah, I think if anything, turn a light on, is just how little healthcare necessarily impacts patients’ health and overall sort of wellbeing. And so how much, the social determinants, how much your environment really impacts and shapes how you show up, and how you are cared for. And soI think that, to that extent, we certainly know that maternal mortality is influenced by so many things that have nothing to do with the care that is delivered. Much of it does. So we certainly want to make sure that our care is top notch, and our care is equitable.
But we truly, you know, I sit at the pleasure of chairing Massachusetts Maternal Mortality Review Committee. And we spend a lot of time really talking about the public health correlate. What was the patient’s access to healthcare? How did she have access to community resources and community services? And so can we, as a healthcare institution, help to prop those up in the community?
And so I think that this will help healthcare providers understand how much more impacts how women do, in terms of their care and their outcomes. And so I think that that will be a moment, hopefully, that we can continue to capitalize on.
MOD: Gaurdia, I know you mentioned earlier that you're feeling hopeful about all of this, and that you’ve got a sense of optimism. And I'm wondering, what's different about sort of the anti-racism protests that are happening today, versus how it’s been talked about in the past, from your perspective?
GAURDIA BANISTER: First of all, they're huge. I mean it’s the largest movement ever, in terms of the kind of protests that we've seen, not only in Massachusetts, but in this country, but around the world. And the fact that there is such diversity, in terms of those that are really outin the streets, really raising their voice and saying that change needs to happen.
And I'm hopeful and optimistic, and I'm hoping that that kind of energy, that kind of enthusiasm, that passion, that recognition that we can't continue with our focus that we’re all in this together. And what I do impacts you. And what you do impacts me. And the importance of equity, of inclusion, of fairness, how diversity is advantageous for our country, and advantageous for all of us, versus a deficit.
I think with that growing awareness, that if we can keep this momentum going, that we can hopefully see substantive change. And I say change in a very broad way, from healthcare to policy to education, you name it. The criminal justice system, change, systemic change throughout every system that we have, going back to the structural racism comments.
MOD: And Marcela mentioned earlier that nursing tends to be an area where this is done very well, the diversity and inclusion within the team. How have you seen that sort of changed the way patients receive care?
GAURDIA BANISTER: So I would say a couple of things about the importance of diversity in nursing. I think that all of the disciplines within Mass. General are really trying very hard. It’s been something that's been on the agenda of our Chief Nursing Officers, Jeanette Ives Erickson and Debbie Burke, for a very long time, in terms of advancing diversity, and really looking to our partners in the community, the schools, in terms of how we can do things better.
So there's been really very much of a focus around that, and a commitment, and a passion. And they have recognized the need in regard to the importance. And I would say, as we started off in the beginning, this initiative that I have been involved in, is something that actually was sanctioned by our entire Mass. General Brigham System, over you know, 10 to 12 years ago, when they began to recognize that the demographics of our patients, and the demographic of our demographics of our nursing staff, didn’t match.
So there has been an ongoing recognition. And it’s not only the program that I'm a part of. We have Houseman Fellows. We’ve also recently gotten some funding from another family that wants to advance diversity. So we’ve been very fortunate to have the resources and the leadership that says that this is something that we have to do. And we’re seeing that overall. I certainly believe our CEO of Mass. General, and also the Physicians Organization as well. They’ve all said, this is something that we need to focus on and are committed to.
And we have our first, as Dr. del Carmen said, our first Vice President and Chief Equity and Inclusion Officer here at Mass. General, who created this 10 point plan that we've been talking about. And so his efforts have been astounding, in terms of how he’s been able to jump in, in a relatively new role, and really shape what kind of conversation that we’re having, moving forward.
MOD: Great. Thank you, so much. Does anyone have any other final thoughts or anything you’d like to say before we wrap up?
MARCELA DEL CARMEN: I think we’re living unimaginable and unprecedented times. The COVID pandemic would have been enough of a crisis in anyone’s lifetime. And I think that we’re also facing challenges with leadership at the national level. And I would even say globally, there are countries that have dealt with the pandemic better than others.
And then I think in this country, we have an opportunity to really, make some changes that will be transformative, and will make all of us better people. And certainly, I would say it would be a wonderful legacy to leave behind to the next generation. But I think it’s going to take a lot of thoughtful people working together, to make those changes realized.
I'm hopeful that, just given the experience that we’ve seen internal to our community at Mass. General, and at the Mass. General Brigham level, both in how our organizations have responded to the pandemic, and also to a civil, you know, crisis, and the challenges that surround all of the conversation on racism, to see leadership really stand up and be supported.
The kneeling event that we had here, that as you know, occurred across the Mass. General Brigham, I have to say, I've been here for a long time. And it’s single-handedly, one of my proudest moments. To see everyone really come together and say, “We’re here. We’re in this together.”
To go to any one of the units, and see this very hybrid group of clinicians coming together to care for our patients, nurses that were coming from different geographies, talking, to orthopedic surgeons who were working to support the care of COVID patients, under the guidance of an intensivist, is just, I would say, that resiliency, that spirit of help that has characterized this institution from its origin, I think is what gives me hope that we’re going to come out of this better than what we went into it.
MOD: Thank you so much Gaurdia, Marcela, and Allison, for being here today, and sharing your experiences and perspectives. It’s been so valuable, so informative. And I really appreciate your time. So thank you so much.
MARCELA DEL CARMEN: Thank you.
ALLISON BRYANT: Thank you.
GAURDIA BANISTER: And a pleasure being with my colleagues.
MARCELA DEL CARMEN: Agree. Thank you.
GAURDIA BANISTER: As always.
Allison Bryant Mantha, MD, MPH
Gaurdia Banister, PhD, RN, NEA-BC, FAAN
Charged is a podcast devoted to uncovering the stories of the women at Mass General who break boundaries and provide exceptional care.
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