Pamela Jones, MD, MS, MPH: Forging a Path to Neurosurgery
Episode #8 of the Charged podcast.
PodcastSep | 5 | 2018
Allison Bryant, MD, MPH, is a maternal-fetal medicine specialist in the OB/GYN Department at Mass General, where she spends her days caring for women with high-risk pregnancies. She is also a strong advocate for improving not just safety and quality of care at Mass General, but also the equity of care. Dr. Bryant explains how we might go about improving equity in health care and why it’s important for us all to examine our own biases.
In her work, Allison Bryant, MD, MPH, explores disparities in obstetric care and outcomes in low-income and minority women, including those in unintended pregnancy, interconception care and birth spacing, uptake of prenatal screening and testing and cesarean delivery.
Dr. Bryant received degrees in biology, public health and medicine from Harvard University, where she also completed her training in obstetrics and gynecology and fellowships in maternal/fetal medicine and minority health policy.
She spent five years as faculty at the University of California, San Francisco and served on the advisory board of California’s Black Infant Health Program and the San Francisco Department of Health Women’s Health Advisory Board. She returned to Mass General in 2010 where she is now the vice chair for quality, equity and safety in the Department of Obstetrics and Gynecology. In that capacity, she works toward equitable care and outcomes for all patients.
She currently works with several regional and national women’s health and equity improvement efforts, such as the Massachusetts Department of Public Health’s Perinatal Advisory Committee and Maternal Mortality Review Committees, ACOG’s Committee on Obstetric Practice and the Society of Maternal Fetal Medicine’s Disparities and Workforce Diversity Task Force.
Q: My guest on today's podcast is Dr. Allison Bryant, as a maternal fetal medicine specialist in the OB/GYN department here at Mass General, she spends her days caring for women with high risk pregnancies. Alison is also a strong advocate for improving not just the quality and safety of care, but also the equity of care here at Mass General.
During her training, Alison completed the Commonwealth Fund Mongan Fellowship in Minority Health Policy here in Boston. Her research focused on racial, ethnic and socioeconomic disparities in both OB care and in pregnancy outcomes. She continues this work today as the OB/GYN vice chair for quality, equity and safety.
In addition to being a busy obstetrician, Allison is also the mom of two young boys. So, welcome, Allison.
A: Thank you so much, nice to be here.
Q: Great. So I wanted to start off talking with you about motherhood. And I think we all learn about motherhood and what that means through our experience with our own mother. So can you talk about your experience as a child and what you learned from your mom?
A: My mom is amazing, my mom is great. I learned many, many things from her that I use both as a mother, but also as a professional woman. So the one time I had my mom in my head all the time is like I'm in the kitchen cooking and there's like a mess everywhere. And what I hear her say is, Have a plan, Al, have a plan. Like, that's what she would say to me all the time. And so, I do try to keep that in the back of my mind, sort of like try to figure out where we're going with motherhood, with work, whatever, and sort of lay out a little bit of a plan, totally understanding that plans can go awry.
I also feel like we talk a lot at work about equity and equality, and I feel like some of those messages I got from my mom, and I use at home, too. So what I try to emphasize for our teams at work is that there's a difference between equality, which is giving everybody the same thing, versus equity, which is giving people what they need. And so, at home, at Christmastime, everybody got exactly the same thing – the exact same money, the exact whatever. But for equity, I had trouble with subtraction, so she would teach me subtraction because that was what I needed.
And so, I use that at home with my own kids, that there are times for screen time or food or whatever where equality is the right thing, but there are other times when equity is the right thing. And so, we sort of translate that as well in the work that we do here at MGH, too.
Q: And where was childhood for you?
A: I grew up in the Upper West Side of New York City. So I am a New Yorker born and bred. I was there until I was 17, and then I came to Boston for 15 years. Then I went to San Francisco for five, and now I've been back here for about eight years. But being a New Yorker definitely informs who I am. I'm a fast talker, fast mover. Time is money. Like we just keep moving.
Q: Yeah. I'm one of those kids who grew up seeing that on TV and just thought, oh, man!
A: It's funny because when I got to college, I literally didn't have a real sense that people lived in houses. I thought that everyone lived in an apartment with, like, an elevator. So I'd seen houses on TV, but didn't really believe that they existed. [laughter]
Q: So it’s polar opposites because I grew up trying to imagine what it was to live in an apartment. I'm curious, too, to know, did your view of motherhood change when you became an OB/GYN? When you have this role that's so intimately connected to motherhood?
A: Yeah, I think it did. I think it could have changed more. I think as I think about people who go into OB/GYN, there's a group of people who go into it because they really enjoy sort of the physiology and the clinical and the medical portions of being an obstetrician/gynecologist. And then there are people who come into it more from a women's health advocacy space. And I feel like as we move forward, there are many more people coming in through the latter avenue. I would say that I was someone who was sort of jazzed about the clinical medicine, and I was so, like, desperate in residency to sort of understand the clinical implications, that sometimes I missed the boat on what was happening in the room.
And it was not until my later years of training or becoming a fellow, or certainly becoming an attending that I really, recognized that we are in this position of honor, to kind of bear witness to the beginnings of motherhood. And that really did then inform the rest of my care and how I work as an OB/GYN.
And I think that the opposite is certainly true. So once I became a mother, I became a much better OB/GYN. And part of that is just having a sense of the, like, the physical thing that the patient is telling you in the office. So you know, when I was a resident, people would say, "My feet are swollen," or like, you know, "I'm really tired." And you just sort of nod and grin. And now I understand what it is to be 36 weeks pregnant in the middle of the summer.
I also feel like, you know, we take care of a bunch of patients who have high risk pregnancies and sometimes we take care of them in the hospital as in-patients. And I feel like if there's anything that I teach the fellows, even if it isn't clinical maternal/fetal medicine, for the women who are in the hospital who have kids at home, who have family struggles and things outside the hospital, to totally understand the whole context of that woman and how difficult it is for her to be sitting in the hospital bed caring for this pregnancy when there's a lot going on out there
I really want the trainees and everybody who takes care of the patients to understand the whole package that women come into the hospital with or come into this pregnancy with. And that, I feel like I do because I'm a mother. Because if I had to be an antepartum patient and leaving my two kids at home, like I honestly don't know, there's not enough FaceTime in the world that would get me through that. So I just want people to recognize that.
Q: It's easy when you see someone in the hospital to just see that person and to forget, even when we're at work here you forget that there's this whole world outside of those walls. Are there practices that you use to encourage people to kind of broaden their view?
A: I think that what we know is that the period of time that people spend engaged in healthcare has a relatively small proportion of effect on their actual health. So there's many things that influence health and wellness, and so really understanding the social determinants of health, or what people are sort of now calling the seven disciplines of health.
Like, what is your life outside of this office? Like I tell you "you have hypertension, please go pick up this medication that you need to take four times a day." How hard is it for you to do that? (a) Do you have a pharmacy that you can go to? (b) Do you have the money to pay the pharmacist? Do you have the childcare to get there? Are you able to read the label?
And so, we actually have incorporated that now into our OB practice. We've started to screen for the social determinants of health. So every new OB patient that comes to us will fill out a questionnaire that asks about all of these, you know, conditions that may impact the way that they can engage in care with the idea that we can then, you know, point them to resources.
Q: And what are those seven determinants of health?
A: So they are more broadly known as sort of the social determinants of health, and depending on sort of what field you're in, probably depends on what exactly you screen for. But the things that we screen for are things like food insecurity. So, do you have enough food in your house to take care of you and your family? What we know is that there's lots of women who live in food deserts, right. So they, live somewhere where the nearest grocery store is sort of miles and miles away where you could actually get fresh produce.
Housing instability. So, where do you live and do you have stable housing?
Health literacy. So really, do you understand the instructions that I'm giving to you?
And we ask them about childcare; so, is childcare a barrier to getting to your visits specifically? Is transportation a barrier?
But those are the kinds of things that sort of plague women and families outside that keep them from being able to engage in healthy care and healthy practices.
Q: Sort of those external stressors that can get in the way of health and self-care?
So I think that if we can figure out the environment in which all of our patients live, we will do a better job of taking care of them here at MGH, or more broadly.
Q: So are there ways that you try to encourage patients to open up or things that you watch for?
A: Yeah, I think that one thing that helps is having a continuity relationship with people, which also is not always possible. So if we see someone in the emergency with a gynecologic complaint, that may be the first time that you were seeing them and you want them to open up, but certainly from my OB practice where I have patients that I've known over time, building that trustful relationship is quite helpful in terms of getting them to divulge things that are important to their care.
I do often frame it in that way. For someone that I'm meeting for the first time and I suspect that there may be things that are going on that I'm not hearing about, the things that I will use sometimes as touchstones to say is, I'm asking about things that will help me to take better care of you. And also sometimes I'll sort of say, Some patients that I have seen have had this; has that ever happened to you? To open the door and maybe normalize some of the things that they may be eager to say, but are holding back.
Q: So put it in context, that it's not just me, it's other people like me.
A: Exactly. I have seen other people like you who have had the same struggle. Are there ways that I can help you get through this?
Q: I'm wondering, you're a maternal-fetal medicine doctor, which means you end up working with women who might have, I imagine, pretty tough pregnancies. How did you end up there? And what is it like to do that work day in and day out?
A: It is a privilege. It's an honor to be in that position. I came into OB/GYN fascinated by pregnancy and the physiology of pregnancy. I came to it from a very clinical place. And so, I liked the internal medicine approach of like, let's think about a problem, let's deconstruct it, let's look at the literature and have a little bit of time to devote to that. But also, let's sometimes fix things with our hands, so the little surgical piece.
Bringing those together, OB/GYN I think does that really beautifully, and then does that in the context of women's healthcare. I often point to an article in the Boston Globe that I have in my office that's been sitting there for years and years, literally since 2002, that said, "Infant Mortality of Blacks on the Rise."
And that was something that I had seen in my clinical training and knew was important to me, but wasn't something that I felt was necessarily going to get incorporated into my maternal/fetal medicine training. And so that's why I did additional work to try to help to figure that out. So that's how I got into that place of thinking about equality, thinking about equity, but also putting it in a context of at-risk pregnancy outcomes.
It is, as I said, sort of it's a place of honor to be with women as they are both having happy outcomes, but it also very much part of my job, and an important part of my job when things are not going well to understand with women how this is going to affect them, how we can help to support them and support their families, and how we can get them through it, and to eliminate a lot of the blame that happens.
So every good mother, when something happens that was not expected, even if they have not yet given birth to a baby, they think back to everything that they did that could have caused that. And so, my job, and I, like, get so angry with myself when I forget to say it at the very, very first thing when I interact with someone, is, in general, there's nothing that you did that caused this. And this was not your fault.
And I usually turn to their partner or their support person and say to them, “When you go home and she doesn't remember what I just said, and she says, ‘But what about when I took the plane ride; did it cause the miscarriage?’ Your job is to say to her, ‘Remember when Dr. Bryant said. There's nothing you did, there's nothing you could have done differently.’”
Q: Especially in this day and age, we have this feeling that we have science and medicine and it can and should explain all things. And it's hard to be faced with this, we don't know.
A: And OB is particularly tricky. We have some good evidence for some of the things that we do, but there's a lot of gaps. You know, we really don't even know what starts labor. And so, like whoever figures that out is honestly going to get the Nobel Peace Prize. There's lots of times when things happen that we don't or are not able to give a good explanation for and it's deeply unsatisfying. But we have to move on and get the patient to a place where they can sort of move on from that and sort of acknowledge the thing that's happened.
Q: I'm curious, you brought up the article about infant mortality being higher among black women. Can you talk a little bit more about that?
A: Yeah. So we know from many outcomes in OB, and OB/GYN in particular, adverse outcomes are oftentimes disproportionately borne by women of color; in particular African American women. That's not totally, vastly different than the rest of medicine. There's lots of disparities or inequities in outcomes. I always like to think of it both as outcomes, but also the care that's received so that we know that, yes, babies born to African American mothers are more likely to die in the first year of life. African American women are more likely to die in the context of pregnancy.
But also the care that people receive is differential. So lots of people want to talk about, is it biology? Is it access to care? Is it health behaviors? It may be some of those things but we in the medical field have to own the fact that once a woman enters the door of the healthcare system, we may be treating them differently, and that may affect the outcomes.
Q: How do you figure out how and when someone's being treated differently? You can't see care.
A: So it is really hard. I mean, I think we oftentimes cling to the outcomes, because the outcomes are the things that are the most important. But we then do try to back it up, to sort of say, Are there process measures, things along the way that we can develop that we truly as a field acknowledge should be happening for every person. And then look to see if those things have happened, if they're differential by race, ethnicity, insurance status, language.
Q: Can you talk a little bit more, I think if you're a person who doesn't feel like they've ever been treated differently, are there stories that stick out or particular patients that you've either met yourself or read about that had this experience of being treated differently?
A: Yeah, I think what's coming out a lot and that is really resonating with me is, certainly there's been a lot now in the lay press about the rising rates or the disparate rates of maternal mortality in African American communities. So African American women are three to four times more likely to die in the context of pregnancy– you know, I had a patient the other day asking me, "Dr. Bryant, are you going to have, are you going to try for the girl?" And I was like, (a), "No, I have two boys at home and I'm all set.”
But I do, in my mind, there's like a graph that the CDC has of maternal mortality rates separated by race, ethnicity, and also stratified by age. And there's this ridiculously high orange bar that I will never get out of my head that is African American women over the age of 40 have an astonishingly high risk of dying in the context of pregnancy. And so I'm like, that's me. Like, no, thanks, I'm all set. But that shouldn't be the case.
People have talked a lot about in the postpartum experience in particular– so maternal mortality is death in the context of pregnancy or up to 42 days in some definitions, or 365 days after the end of a pregnancy. And a lot of those deaths are happening in the postpartum period.
I have heard from my own patients and have seen reflected in some of these publications is women who come, who say, I told my doctor X, Y and Z, or I called on the phone and I said I wasn't feeling well, or I said I had a lot of edema, and they sort of pooh-poohed me and said, "Oh, you're fine." That has sort of come out as a sort of dominant theme in a lot of these investigations.
And my gut feeling tells me that we do that differently by race/ethnicity. I think that how we communicate with people has a lot to do with our own experience, with our own implicit biases. And so, I think that that is a real phenomenon. I think it's something that we have to sort of do a better, deeper dive into.
Q: So the first piece, it sounds, is acknowledging mistakes on our part, which is probably sometimes the most difficult thing to do.
A: Yeah, and we oftentimes don't frame the language of mistakes. We talk about adverse outcomes. And so, I, in my role as quality, equity and safety director, help to review the outcomes in OB, GYN, reproductive endocrinology, and we talk about the things that went differently than we expected. We oftentimes have a list of things that are adverse outcomes that we want to review. And when we do it, we always review things in the lens of “just culture.”
And what just culture really means is that we have this baseline assumption that everyone showed up to work on that day, to do their best for their patients, but that adverse outcomes sometimes happen. Sometimes they are infused by human error. Sometimes it's the systems in which we work. Sometimes it's what we call at-risk behaviors that there's not enough time in the day, so maybe I might be able to take a little bit of a shortcut and that's where the error happens. But really, our job is to understand the context of the system and how the system might improve to sort of help those outcomes.
So I think when we frame it that way, people are more open to sort of reporting when they themselves have had an adverse outcome because they don't feel like we're going to say, You made a mistake, you have failed the patient. But yes, there definitely needs to be a recognition of when adverse outcomes occur, for sure.
Q: Can you talk a little more about this system level piece of it. I think there's been writing lately about institutional racism and these ways that racism is maybe even built in in this insidious way, but when you step back and really look at it, you see that there might be some problems.
A: Yeah, I think it is not unique to health or healthcare, for sure. I think that institutional, structural racism are things that we need to acknowledge. It is hard in the one-to-one or when you're reviewing outcomes to sort of bring racism into it. There's no one who doesn't feel somewhat slighted or offended by that.
And so, what we oftentimes do is just to acknowledge the possible role of the race of the patient in terms of their outcome. And so, what I ask everybody to do when they're presenting their M&M or FQA is to say what we call the one-liner – so the age, the parity of the patient, but then that is followed by the race/ethnicity, the English proficiency status and the insurance status of the patient.
And it's not because there's necessarily a one-to-one correlation that what happened to this patient had something to do with her race/ethnicity, but I want everyone in the room to start to hear if there are patterns that go on.
But the other thing that we've asked people to do more globally is to really understand the role of implicit bias in the way that we care for patients at the one-to-one patient level. Because I think that there is nobody on this planet that doesn't have implicit biases. Biases organize our brain so that we can, you know, see something and make a snap judgment, which sometimes is helpful, but sometimes is not helpful.
There are tools out there, some of which have gotten criticism about whether or not they actually work, but that can sort of assess someone's own implicit bias. And so, that's something that we asked everyone in our department to do, the implicit association test, which is a computerized test that was developed at Harvard University, where you look at images and you pair them with constructs that are positive or negative.
And depending on sort of the speed at which you're able to put things together, it gives you a score of your preference for whatever the two sort of constructs are. And like, literally I've taken it eight times and I have a moderate preference for Caucasian Americans every since time, which as an African American woman makes me sad, but it makes me understand that we all have these biases.
And so, when we did that we asked for feedback from our faculty. And I think that most people thought it was a positive experience. It's definitely a little bit of stages of grief, right. So some people who never thought that they had any of these biases uncovering that was very challenging for them. It's been a nice dialogue. I think if we don't have the conversation going, we can't do anything to fix it.
Q: One other thing I'm curious to ask you about. You talked about surveying your own bias. You know, once you learn your own biases, is there work that you've done to try to correct for that within yourself?
A: So I think it really is just a recognition and then understanding when the next patient comes in the door sort of keeping that in the back of your mind – is the way that I'm relating to this patient, does it have anything to do with my preconceived notion of them. And I think what the literature would suggest is there's all kinds of ways to undo that a little bit. So think about positive references; if it is an African American patient and you know that you have some sort of bias, can you think about other African Americans in your life that have been positive influences and sort of bring that to bear.
Can you then just sit with the patient and sort of unpack their experience. We had a grand rounds speaker who came and I asked to talk about bias, and I asked whether we should be, in our social determinants of health screening, should we be asking if people have had adverse experiences with the healthcare system on the basis, do they think of race. We haven't included that yet, mostly because we were worried that like what would we do with that information? But I think that that information is key.
And I think that if every provider saw that in the problem list – this is a patient who previously has the perception that they were treated differently on the basis of X, Y and Z – that clues everybody in. I think awareness is the key. There's no panacea, but it's got to start with an awareness and acceptance. So I feel like, that, I have done that for myself, is really the first step. And then I really do, on the one-to-one clinical encounter, try to make sure that I am not infusing those biases, now that I know about them.
Q: Yeah, I know I get this where I want to say something or do something, but then maybe I'm not sure if I'm doing the right thing, saying the right thing. And then you freeze, because rather than make a mistake, maybe I should just be quiet. But how do you encourage people to have that really hard conversation?
A: So I think it needs to happen in a safe space. I hope that our department feels like that space. I sit on a couple of AGOG committees and we have the honor of revising the committee opinion on racial and ethnic disparities in healthcare. So we were able to relook at sort of national statistics, and things really haven't changed a whole lot. There's still lots of disparate outcomes in all of the ways that we take care of patients and in their outcomes.
And so, one of the calls from that, as well a couple of other national organizations, is just making people aware. I think that that awareness is important so that we keep talking about it over and over again. It's sometimes hard to have on the one-to-one patient encounter, but like the conversations that happen in the hallway may help to sort of break down some of those walls.
And ask each other. Come ask me how you should go talk to your patient. Like those conversations can be very natural and empowering, and hopefully will help then get back to the clinical encounter to help us all take better care of the patients.
Q: I've noticed a lot of articles in the press, as you said, about maternal mortality, and particularly among black women. Do you think it's helpful that it's becoming something that's more in the cultural popular zeitgeist?
A: Yeah, I think it is great that it's now out in the open. And ProPublica, I think, gets a lot of the credit for – and NPR – for their sort of popularizing this. So they started this series on Mother's Day last year to really talk about maternal mortality and what a big problem it is in this country. I mean, we have a maternal mortality rate that is ridiculous as compared to other developed countries.
And it's something we don't really talk about in the public spaces and we try to tend to keep quiet. I sit on the Massachusetts Maternal Mortality Review Committee, which is a group that looks at all maternal deaths in the state. We always tend to kind of keep things hush-hush. We don't say the name of the patient. We don't say the name of the institution. And that I think is because we have previously come from a place that was not particularly “just culture.” It was a lot of blame, blame, blame.
But if we truly believe that there is a just culture and that everybody who is showing up to work on the day that that mom died, showed up to do their best and still things went awry, and then we can start to figure out what happened, why not be more open and more transparent?
I feel like one of the most powerful things in that ProPublica was really, like, you can drill down on those faces on this website and sort of say, This is the woman who died, this is her picture. This is what her family said about her. This is her obituary. Here's her Go Fund Me site. And it really, I think, has personalized it for people in a way that I hope is going to galvanize a movement.
Q: Yeah. It's easy to look at a number and be overwhelmed by the number or just appalled by it, but it's, at the end of the day, just a number that you can eventually close the screen, put your phone down.
A: Exactly. And I think that what humanizing it does is also, I mean, I think there's a little bit of a narrative that what happens to black women is in some way their fault, or because they are poor, or that they don't show up for care, or they're not educated. And what we know about some of these disparities is they affect college-educated, experienced women who are professional women in the same way that they affect everybody.
And then we really do have to own the impact of race, I think, in and of itself, not confounded by socioeconomic status and all the other things I think people want to point to.
Q: Do we know why? Why is it black women?
A: So I don't– it is multifactorial, which means it's really hard to get your hands around. We had a working group on something trying to work on disparities and someone was like, This is like solving world hunger. And so they went to then walk away from it. But I think we can't walk away from it just because it's hard.
There may be some very small part that's related to biology, but it's weensy. I think that there's very little that is deterministic about someone's genes that is explaining this huge disparity. I think that there is probably a difference into how women come into pregnancy and whether they are truly physiologically, socially ready for pregnancy.
I think we can do a much better job in this country about doing preconception and interconception care; so, what we call reproductive life planning. So why is it the case if I go to my primary care doctor's office as a reproductively potentialed person, shouldn't you be asking me what's my plan for pregnancy? And if I don't have a plan for pregnancy, let's enable me not to get pregnant. And if I do have a plan for pregnancy, let's check me out and make sure that I actually am ready for pregnancy.
The probably happens differentially in populations. So maybe the medical causes of maternal mortality have to do with things like hypertension or cardiovascular disease, and those are things that I have a suspicion that there are women who are coming into pregnancy not quite ready to be pregnant and then pregnancy presents an additional stressor on them.
There are also differences in terms of the way that women are cared for. So once they hit a labor and delivery unit, or once they've hit the door of their prenatal care provider, we certainly know that African American women, and women of low income, are more like to get care in ways that are a little bit more fragmented, right. So you go to your doctor's office who's here, and then your labor and delivery is across town over here, and then you may go have a postpartum visit somewhere else and your primary care doctor is somewhere else.
We are blessed at MGH that largely our patients are cared for in one place, with one medical record, where I can see what happened to you five years ago. But if that's not the case and I'm relying on someone to, like, get on the bus with a stack of medical records to bring to the hospital, then maybe I can't care for you quite as well once I see you if I've never met you before.
Then we also know that women of color are more likely to be cared for in settings where we think that maybe care quality may be not quite as good. And whether that's just because they're under resourced hospitals or other reasons that probably makes a difference in terms of outcomes.
That has led nationally, I think, to a call for thinking a little bit more about what we call maternal levels of care. And hopefully that that will sort of help to impact some of the disparities and inequities that we see.
Q: Yeah. I was reading about this concept of weathering and how it affects people of color but in particularly black women. Can you talk a little bit about that and your perspective on it?
A: Yeah. Weathering is something that was made popular by, I think, Arline Geronimus, who sort of argues that women's sort of lived experience really is cumulative over the life course. So part of the problem in healthcare in general is that we all sort of live in our silos, right. So I take care of you in pregnancy and then postpartum I'm sort of done with you until you come back.
But really, I should be looking at the long game. I should be looking at you when you were a child, and even, frankly, when you were a fetus, to kind of figure all of that experience is important. So the idea of the lived experience, particularly of African American women in this country, may sort of compound stressors that were, you know, on you in your fetal life, in your childhood experience, as a young woman. And then when you get to be the 40-year-old African American, you are sort of in a worse shape than is perhaps a woman who's had a different experience than you.
And then when you add on the stressor of pregnancy, that may be the thing that sort of tips people over. But I think that that spirit of being a black woman in this country also probably explains a little bit of why women of high socioeconomic status don't do as well as you might expect.
Q: Yeah. You think you have all the resources in the world so you should be fine.
A: Correct. And I think there's, you know, people have talked a lot about the difference between income and wealth, and I think that we need to dig down on that, too.
Income is just how much money you bring in on a daily/weekly/annual basis. But wealth is sort of the accumulated wealth that you have had over time. And I sort of think back to that Boston Globe series several months ago, looking at race in the city of Boston. And one of the first articles sort of pointed out the sort of relative differences in wealth between African Americans in this city and Caucasians. And it's ridiculous.
So I think it was something like the mean accumulated wealth of an African American is about $8. So that's taking into account, you know, all of the debt that folks have. And you know, it's just different families, like some families maybe passing on things, passing on equity, passing on homes, passing on jewelry that doesn't necessarily happen in every family. And so, my income may be the same as someone else, but my accumulated wealth probably has a lot more to do with how I will do in a health context, and education and criminal justice, and all kinds of other fields.
And so, you know, whether you are in debt or whether you sort of live in a neighborhood that makes it difficult for you to get a good job or to save, or whether you are using that money to help all kinds of family members who sort of also rely on you, that becomes a drain on your wealth as opposed to what happens to your actual income.
Q: Yeah. So this thing that feels really positive, the family atmosphere, can also have these negative impacts.
A: Yeah, I think that everyone has their, it's not baggage, it is the village in which they come to care. And so there may be lots of needs to take care of adult family members, older adults, younger kids. And so, that oftentimes comes with it, the need to disperse what you have amongst many, many people. And like any good mother, what you get goes to your kids. What you get goes to everybody else. And sometimes in the context of the pregnancy, that's not so great.
Q: Yeah. So it's really a time when you kind of need to cocoon and–
A: You do. And take care of you and your fetus. But, that's easy to say as the clinician, say, Oh, go take care of yourself, go to a spa. But if you live in a neighborhood where like getting from here to the spa is actually fraught with all kinds of danger, that's sort of a ridiculous thing for me to say. So I think that that's again what we need to understand, where people come from and what their needs are.
Q: Hearing you talk about all this, just hearing it overwhelming. So how do you keep the motivation and the positivity to keep going, to keep fighting, to keep looking?
A: It's interesting. When we did that Minority Health Policy fellowship, Joan Reede, who is the dean for diversity and community partnership here at Harvard, said on the very first day, ‘You learn a lot in medicine about the one-to-one clinical encounter, but you have don't have to use those skills to be a clinician.’ And many people go on from that fellowship to like never practice clinical medicine again.
For me, I felt like I needed to come back to clinical medicine because it is my touch stone. And that, it is the thing that keeps me going, is that I can talk about all these things today and sometimes feel discouraged, but also feel like I am hopefully helping to move the needle. So both locally in my practice, also at a regional level, or even at the national level, that hopefully, if there's enough voices, we'll move this mountain. But then I will leave here and go to my patient office and see the one-to-one patient, like look in their eyes and know that I'm doing a good thing for that patient that day.
So I can go do a prenatal visit, and then I feel like I've gotten my fix for the day. And then I can kind of keep moving.
So I really enjoy those efforts where I feel like I come out of the one-to-one clinical encounter and I'm doing something beyond just myself and the patient. And those are the moments where I feel like, okay, this is the work that we have to do, and this is why I'm doing it.
Q: What do you think, when you think of your career, what does success look like for you?
A: I used to say like what I wanted on my tombstone was that, like, "she made people laugh." But what I really to be there now is that I fought for equity. Like that is going to be, if can get anybody or get this nation to move towards health equity for women's healthcare and for women's health, I will have felt like I have done any little piece. Because I think we're coming from a place where there's lot of work to do. There's lots of opportunity. So I feel like that will be success for me at the end of a career.
I also feel like it's success in a super way if I get home at 6:30 and have dinner with my kids. Like that for me is also a success that I have compartmentalized a little bit, enough to be able to like put the word behind me for at least, you know, a window time, and then I'm like, you know, on my couch with my computer and Scandal and a glass of wine and moving forward.
Q: Yeah. I think it's so helpful, finding those little pockets of success for the day, that even if the finish line looks really far away, you know those tiny wins along the way.
I think that's such an interesting point, too, that the core often of this challenge is that it's one person's perception of their experience. And from the outside, you might look at it and say, well, I know that you received the same care, but it doesn't really matter if that person didn't feel it.
A: I think that that's the key, is it doesn't really matter. And actually, even as I said it, I hesitated to use the word perception because I think that that is sort of how we framed it when we look at big databases of perceived racism. It almost doesn't matter. So if you perceive it, then it is true.
Q: You've spent a lot of time at work thinking about equity and disparities and fighting biases and all of these things. How does that feed back into your own life? How do you bring those lessons from work into sort of raising these two young people?
A: There were moments where I thought that I could compartmentalize and sort of say, this is what I do at work and it doesn't happen at home. And clearly, that's not the case; we all live in the same world. And so, you know, my kids are young. They're seven and nine. We do, you know, we talk about race, not infrequently. We talk about how different people may be perceived based on the color of their skin. But we talk about, you know, culture and how that influences things. And so, I try to give them some frame of reference in understanding.
Recently there was a talk in the Lexington Public School system about the fact that there is differential in terms of how kids are treated in school in terms of suspensions and other things, which actually turns out to be a regional and national problem.
And that became sort of clear to me that I was like, okay, well, we can't just leave this at work. Like, what I know about and what I studied about at work has relevance here in my community so I'm going to have to sort of like jump in and get into this conversation, too. It's a little bit exhausting, right. So then that means I don't ever leave the work that I do at work. But it's just because the work that I do at work has relevance across all that we do.
Q: Yeah. So to wrap up, what advice would you give to, other moms, other families who are, you know, trying to find their way in this landscape?
A: I look at the world probably through rose-colored glasses. I do a lot of laughing. I do a lot of sort of mirthful activity. I tend to be a very positive person. I tend to be, you know, try to see the funny side of things. And so, I ask women to do that as well.
I also would ask for women to advocate for themselves. We are not all asking all of the right questions. And so, if you come in and you have a concern for your health or a concern for your kids' health or a concern for your partner's health, speak up, speak up, speak up. So the squeaky wheel gets the grease every single time around many places.
Women know their bodies. They know their pregnancies. They know often when things are wrong. And so, they should consider themselves to be partners in their care team.
Q: Yeah, I love that. Speak up!
Q: So the very last thing, before I let you get out of here, I have my final five questions that I ask everyone. What's the best advice you've ever gotten?
A: My dad used to always say "go for the gold." Go for the gold is like always, set your sights high and just go after it.
Q: This podcast is called Charged. What does that word mean to you?
A: It means fired up. It means go, go, go, go, go. Be passionate about something. Get your charge on. Like I think a lot about electronics, my kids are always into electronics. But it is about getting your power going and using it to, like, move forward.
Q: How do you recharge?
A: Hmm, it's funny because I am a very loud introvert. So I am on labor and delivery singing all the time and sort of walking around and making a lot of noise. And yet, I find my center by myself. And so my favorite place is like the bathtub with a book. And so, that is the place that I sort of recharge. And then I'm ready to be fired up again.
Q: When and where are you happiest?
A: Hmm. I would say definitely with my family. So getting out of here and, like, sitting down with a family dinner, like we did when I was growing up, and sitting down and hearing about everyone's day, that makes me super happy.
Q: It's a great place. What rituals help you have a successful day?
A: So I, unfortunately I'm a little bit wedded to technology. So like literally the first thing I do when I wake up is I do four things on my phone, is that I check my work email, I check my personal email, I check Facebook, and then I check the electronic system at the hospital. And those are the things that just sort of settle me, is that I know what's going on in my world, and then I can move forward.
Q: Yeah. Great. Well, that concludes our discussion. So thank you so much, Allison, for being here today. It's really been a pleasure talking with you and hearing about your work.
A: Excellent. Thank you so much for having me.
Allison Bryant Mantha, MD, MPH
Charged is a podcast devoted to uncovering the stories of the women at Mass General who break boundaries and provide exceptional care.
Episode #8 of the Charged podcast.
Episode #10 of the Charged podcast.