Episode 13: Implicit bias and health care disparities | Guest: P.J. Rochon

You see that it's appalling. What can you do, and what can we do as privileged human beings, to denounce this? To say that it's wrong? To not stand for it? To say, "You know what? That's not right and this is what I'm going to do about it."—Paul J. "P.J." Rochon, MD, FSIR

Warren Krackov, MD, FSIR, speaks with interventional radiologist Paul J. "P.J." Rochon, MD, FSIR, about health care disparities, our own implicit bias, the minority tax and the importance of taking a stand against racism.

Read Dr. Rochon's IR Quarterly article on health care disparities.

Note: This episode was recorded on Aug. 20, 2020.



SIR thanks Sirtex for its support of this episode.

Contact us with your ideas and questions, or read more about about interventional radiology in IR Quarterly magazine or SIR's Patient Center.

(c) Society of Interventional Radiology.

Transcript

The Kinked Wire – September 2020

Guest: Paul J. Rochon, MD, FSIR

WK: Thanks so much for being here, we certainly really appreciate it. Obviously we’ve got a ton of things that we could cover with you, and something that I’d like to delve into is something that I think is really long overdue for this podcast, and in some ways for the SIR and really all of health care in general, and that’s diversity and inclusion. I know you’ve been active, and I know you’ve got a forthcoming article coming out in IR Quarterly that we’ll be hinting at—I’ve had a chance to review it and I thought it was great. It’s just a huge issue. That and COVID are really the seminal issues now, and as you point out, they are not unrelated, they’re interrelated. So I’d like to start there. You talk about implicit bias, it’s such a great thing for all of us to hear about and talk about, and I know you talk about it in the article, but I’d like to get your take on it and what you mean by it and its implications.

PR: Yes Warren, thank you so much. In regard to implicit bias, whenever we have a discussion about diversity, equity and inclusion, it has to come to the forefront in terms of any type of workshop or education module that we are undergoing. Implicit bias is what we know as unconscious bias or implicit social cognition, and it’s our formed stereotypes and attitudes that affect our behavior in our every day lives. Personal lives, work lives, those are intertwined as well, but these are things initially that we are unaware of, and are likely due to the environment that we come from and the environment that we’re currently in. And a lot of us, especially those of us in health care, sometimes we are looking at it in a tunnel vision, because we are so focused on this disease process and this patient and this answer, and we need to take a step back and take our blinders off. What things are we doing that we are unaware of? There are some things that I have ideas about of how we can go about this. But the first thing is our awareness of our implicit bias. All of us have it, none of us are without it. 

WK: It’s great to mention that, and I think a lot of us, as you suggest probably all of us, operate without knowing it and it’s kind of in our subconscious and we’re not aware of it. I happen to be a white person, and I looked at, as a lot of people did, a lot of the things that happened in terms of the police and so on and so forth and was absolutely flabbergasted at the treatment of people of color and the African American community, and to me that seemed very obvious and overt. But as I started thinking about it, I thought—you know, I don’t ever think of myself as a racist person at all—but then I started thinking of it and thought, well, I don’t know. Are there things that I do and say or ways that I relate to people that are—unintentionally—but nevertheless, leading to someone feeling a racist type of vibe or feeling? I think there’s a lot of people who feel that way. And I know the last thing I or other people would want is to make other people feel that way, but when you mention education, or sort of inwardly looking, it sounds like that’s what you’re saying—is that you’ve got to tease that out and figure out what framed you or is going on inside you, so you can learn to act in a fully equitable way.

PR: Absolutely. And you’re absolutely right. A lot of majority white males, white females, are not racist. There’s a very small maybe percentage of people who are racist, and it’s overt and it’s out there. But when we look at it now, there’s hatred and injustice which, as you said, you were appalled by—how can it be happening? But what is the next step? You see that it’s appalling, but what can you do, and what can we do as privileged human beings to denounce this and not stand for it and say, “you know what, that’s not right and this is what I’m going to do about it.” A lot of us in this privileged state feel, “okay, that’s wrong, but I’m going to go about my own daily life because I’m comfortable. That’s not really affecting me, my kids are fine, they may ask some questions but they are provided for, they have all the resources they need.” That’s where it’s coming from, and the people it’s affecting personally, that’s the cry out that I believe is happening, and that’s what we need. It’s not about are you racist or not, and that’s something that we all need to look into, but it goes a little bit deeper than that. Why are we still seeing these acts of hatred and injustices? Health disparities? These pandemics that are uncovering things that we have been dealing with for hundreds of years. It’s just in a different scenario.

WK: Yeah, I think that’s really well put. And again, sort of getting into your article a bit, I know you touch on that a lot. But not even discussing the article, the data are very clear that in the COVID era, the African American population has been absolutely decimated by COVID, as compared to other populations. It’s clear, it’s scientific, it’s data, it’s just as clear as any other study you may read about heart disease or anything else. And similarly, I think we’ve seen—and I actually wrote a piece about this not so long ago in the wake of the police violence and such—the African American community seems to be constantly victimized by things, whether its violence, which could be argued is itself a public health crisis, whether it’s poor access to preventative health care and medicine leading to higher instances of diabetes, hypertension and staged renal disease cancer and so on and so forth, but COVID is really another example in a way of that. I think it’s really fascinating—and again I don’t want to give away your article—but I was really taken with your example of what happened in the ICU with CT scans of the chest, with patients both pre-and post-COVID. If you don’t mind walking our listeners through that a little bit, it might entice people to read the article rather than saying, “ah, I heard that already.” Because I think it’s just such an amazing example.

PR: Yeah, sure thing. This is how we as—we are IRs, but a lot of us are colleagues or under the umbrella of diagnostic radiology and we still practice that. We think about, well how can we as DRs also make an impact? And this was coming from one of my colleagues in internal medicine, just one account of –why are we limiting CT scans, which we said we were going to do during COVID because it was a means of, well we know what clinically is happening, it’s not going to change anything, we’re trying to decrease exposure to COVID with patients coming down for CT scans—a lot of departments had been doing this. And rightfully so, because it was a pandemic and we want to try to get it under control. But as you said, the data has that Black people, African Americans, were affected more than white Americans, and so were in the majority in the ICU. We have that data. And now that it’s turned, we have majority Black patients, and they may have other things going on. We talk about how COVID is related to a hypo coagulable state, ie: PE, venous thromboembolism. But we still need to know these things. In the past we’ve said, this patient has shortness of breath, has these signals for clotting, let’s get a CT PE, it’s going to change our management. But now we’re saying, this patient has COVID. Yes, they’re Black, but their demographic is COVID. That’s how we’re labelling these patients. That shortness of breath, the ordering team is concerned about that, but now they may have some resistance of getting this question answered, ie: getting a CT scan. So now it goes back to seeing how populations are being affected, and where these health disparities are. How can we change our global systemic protocols to not treat it as such? Yes, we need our protocols to protect our workers, but what are we really doing for each individual? The whole patient? And that’s where it’s not just an IR or a DR thing, it’s health care. It’s medicine, it’s how we should be communicating across the board about these disparities.

WK: Right. So it’s all the disparities along the way that led to that patient being more likely to having deleterious impacts of COVID, as opposed to a white patient of privilege, as you pointed out.

PJ: Exactly. And you mentioned about how COVID has uncovered health disparities, more Black patients are being uncovered with COVID. We have that data now—it’s still being uncovered in this pandemic—and this is going to go away. We know that. We will have to take our time to do that. But what’s our next step? We have more Black patients that are affected, and people may say because of other comorbidities, such as diabetes, hypertension, and that goes down the road as to why these patients have diabetes and hypertension. Why are they uncontrolled? Why can’t we get them under control? And now more patients COVID positive, they know most are Black. So what’s happening to the Black population? Just as we saw 50 years ago, 100 years ago, it’s going to be a distrust in health care. We’re not going to be able to get our Black patients for follow up. We’re not going to be able to get them the treatment they need because, ‘hey, COVID is around, I need my health care, I need my meds, but I’m at higher risk of contracting COVID and getting to the ICU and dying.” What kind of effect is that going to have down the road for this vulnerable groups to have a distrust in our health care system. And that’s that vicious cycle we see every pandemic, every few years that we’re trying to fight for. But when we’re done, we can’t forget the things we’re talking about right now. This has to be present day in and day out, through the years, in every initiative and effort we have to combat this.

WK: I think those are some great words of wisdom, and everyone is really into population health these days, and I can’t think of a better population health project to look into in terms of, at least looking at racial demographics and such. And yeah, you’re right, COVID will lift, and as you said, it’s important for us in health care to have heeded the lessons of COVID. And there’s a lot of lessons, it’s not just racial lessons, but in terms of the racial disparities in health care, to make sure that we’re not unintentionally or intentionally closing the doors to health care, and it becomes as you said a vicious cycle and we don’t want that.

You mentioned, certainly radiology, we’re IRs, but getting into bias and maybe even overt racism in terms of IR itself—I think it’s fair to say that though many of us now would never consider ourselves racist, I think traditionally IR has not been thought of as the most diverse or inclusive specialty. What’s your take on that? What do you think about how that might be or how we’re doing now?

PR: Yeah. We’ve come a long way, and I’m so proud of my colleagues who have come before me who have started the D&I effort. I’m just a small piece of this pie sharing their knowledge and learning more and more every day. But the society has done great things across the board of developing the D&I advisement consul, having multiple groups come together, having it more perpetuated throughout our society and meeting, having different groups be represented such as our new underrepresented minority section. We have a Women in IR section that has flourished, and we’ve really worked together and learned a lot and all of the groups that have discrimination and can actually increase the diversity of our specialty.

And as to why were we not as diverse as we are now? I think in the past we just weren’t intentional in our efforts. Seeking more diverse residence class, more diverse faculty, you name it. We have to go out and get it. We have to show others, those URMs, women, all these groups of why IR, why radiology can be their specialty. What things we are doing to improve our diversity and inclusion. But we have to be intentional about it, we have to show them. We just can’t check a box and say “okay, we believe this.” What efforts are we trying to do, what curriculum workshops are we going through, what changes in our interview process to develop a more diverse class? What safe spaces do we have to listen to others and make those changes and not rest on the culture that we already have, and changing it as we move forward? And listening to people at different tiers—not only the leadership, they need the training as well, but also students, residents, administrative staff, everyone plays a role in making it a more diverse and inclusive specialty. We have all the tools in IR. We have the DR expertise, we can see patients, we have the ability to have a clinic and do it all. And I believe that’s what most people—and maybe that’s my bias—but URMs are coming in because, and I am one as well, we want to help people. We come from a background where there’s an incident where we want to make a change. We want to go back to our communities and make that change. Well we need the resources to do that. But in IR we can do that, plus we are leaders in innovation. We treat every disease. And with health disparities, every disease is affected by that. So there are a lot of options for a more diverse and inclusive population to be involved in our specialty. There’s no secret of why we have been the number one specialty since we’ve been deemed a specialty and not a subspecialty. That is something we need to keep pushing for. And SIR has identified this, people who work closely with me and have come before me they saw it and initiated this, and now is a ripe opportunity to make this happen.

WK: I think that’s a phenomenal call to action, and I really like the concept of bringing this to the trainee level. Especially now that we are running an IR residency, that should be part of the curriculum as you mentioned, and a lot of the things you’ve talked about, including racial demographics and inclusion, that should be part of the curriculum. Why isn’t that patient getting the CT scan, what are the implications for that and so on? I think that’s, as you say, how to move the needle forward. And things like the WIR section have helped, and I agree that the SIR has made strides. And I think we all want to and I think it’s fantastic that we’ve got voices to help guide us in the right direction.

You’d had an interview a little while back with Hope and you’d mentioned something about the minority tax that sort of burden of extra responsibilities in the name of diversity. What did you mean by that, if you don’t mind going into that for a second?

PR: About the minority tax?

WK: Yeah.

PR: Sure. So a lot of minority and inclusiveness endeavors, ideas, initiatives, are maybe brought about by those who are underrepresented. Those who have taken a different pathway, or who went through obstacles to get where they are and may not have had the resources others did to get where they are, and identify those burdens that are actually affecting them. And they want to be in these leadership roles. But when they’re called upon to do this, they also have to bear other things that the majority and everyone has to do—such as other things for promotion, research, a clinical team. They also have to educate. And that takes time, and to do it well you have to take the time. But now we’re throwing in diversity and inclusion, which brings upon even more. But it’s a passion that all of us have, and maybe the minority whose leading this has as well, but she or he has to carry all of this along with D&I. And the workshops that are being developed, curriculum being developed, bringing in different people—all of these virtual calls that we’re doing these days because of the pandemic—that takes time. And not to mention, as human beings, we have lives. We haven’t even talked about the wellness. We are, as IRs, that’s another topic that we’re going to talk about soon. We have our homelives and we need to be able to operate and function at a high capacity. We are working under stress 24/7. So going back to the minority tax, that’s what it is—it’s an extra layer of stress on people who want to lead, and it’s typically going to be a minority. I would love it to be other people helping and engaging, forming committees so this minority tax can be lessened. Giving the person who is leading this endeavor the time necessary, the same time that hospitals and systems give presidents, give chiefs, give program directors. Give the leader—or even go as far as to say the vice chair of D&I in that group—give them the time and maybe the resources and finances necessary to make this happen. This shouldn’t be placed on the backburner, but it usually is because we all have other things to get done—get that paper written, get this protocol done. Our patients will come first. But now when we’re putting in this D&I—which most institutions are pushing, and not just to check a box but to be intentional about it, so that medical students who are coming in, other faculty, other partners who are trying to recruit, they see that we mean something, and we’re putting the effort necessary, and our money where our mouth is. Because this takes effort and time. And that goes into what the minority tax is. 

WK: I think that’s really well put and I think the language is fantastic and really cuts to the point. And as you suggested the era of box checking and saying “we did this for diversity so we’re set”, but clearly as uncovered by COVID, but having been in existence for hundreds of years, saying, “sorry, it’s just not helping.” So we really need to take a step forward.

Unfortunately we have to wind down now, but I want to personally just say that I’ve gotten so much out of this session. I’d like to have you back, I’d like to have more people on. I think this is just a huge issue and I want to continue to educate myself and it strikes me that we all, as you suggested, we all need to be leaders in this. As said, I happen not to be a person of color but it strikes me as important to have my voice heard, and I really appreciate you educating me, the other IRs listening and to keep pushing on this. So as I close that off, I’m going to ask you probably the hardest question that I ask all our guests, which is: if you had the power to change one thing in health care, what would it be?

PR: Wonderful question. And in regard to health disparities, I would say health care for all and that’s equity. There’s a lot of political backing to this, but it starts with us as human beings. And we who are in health care have a privilege. Whether we are of color, a member of the majority, we all have to fight for it because we live it. And going back to your initial question, we need to be aware of our implicit biases, we need to be willing to speak up for what is right, and not turn the other cheek. So if I could change one thing in health care, it would be health care for all. Equity in health care.

WK: That’s great. And such a simple answer but would really fix a lot of things. So let’s hope a lot of people can get together and do it. Again, I want to thank you, for educating me and also a lot of folks listening. I wish you all the best, and thanks so much for being here.