Monday, April 27, 2015

Beyond Flexner: It is time to stop shoring up the bridge and figure out how to cross the river!

I recently attended the “Beyond Flexner 2015” conference in Albuquerque, NM. Originally titled “Beyond Flexner II”, it was a followup to the 2012 “Beyond Flexner” conference in Tulsa, OK, which I discussed in my June 16, 2012 post “Beyond Flexner: Taking the Social Mission of Medical Schools to the next level”. The first conference was itself in part stimulated by the 2010 publication of “The Social Mission of Medical Education: Ranking the Schools” by Mullan, Chen, et al. in the Annals of Internal Medicine.[i]  Fitzhugh Mullan, head of the Medical Education Futures group at George Washington University, was co-director of this recent conference along with Arthur Kaufman, Vice Chancellor for Community Affairs at the University of New Mexico Health Science Center. The organizing committee was a “Who’s Who” of leaders in the movement to make medical schools more accountable for meeting the actual health needs of the people of the United States, including Gerry Clancy, host of the 2012 conference in Tulsa, and several of the other authors of 2010 paper.

The attendees at the 2012 conference in Tulsa were captured in a posed photograph, crowded but with  recognizable faces. This would not be true of the nearly 400 people in Albuquerque, who also represented a much wider group. In addition to more university sponsors (including Florida International University, which will host the next conference in 2017), several other foundations have joined the Josiah Macy, Jr. Foundation, which helped sponsor the first conference as well. The bulk of the attendees were medical school faculty, with some residents and students, but others from a wide swath of those with an interest in the impact of medical school output on health were in attendance. Notably, this included people from the cooperative extension services based at our nation’s land grant universities, who have been collaborating with health sciences centers to create “health extension” programs in a number of states (The Primary Care Extension Service, July 12, 2009);  New Mexico’s HEROs (Health Extension Rural Offices) program is one of the national leaders.

There were a number of stimulating and provocative speakers, including Camara Jones, about whom I have already written, who spoke about racism and the Social Determinants of Equity. Don Berwick, founder and senior fellow at the Institute for Healthcare Improvement, and former interim Administrator of the Center for Medicare and Medicaid Services (CMS), gave a powerful talk about the direction of healthcare in the US. His most powerful metaphor was of the Choluteca Bridge in Honduras, which was so well built that it withstood Hurricane Mitch in 1995. Unfortunately, the hurricane relocated the river, so that now it no longer functions for its intended purpose! Dr. Berwick also noted that if the US spent 15% of its GDP on health care, instead of the current 18%, it will still be higher than #2, Switzerland. If the US had spent at the per capita rate of Switzerland over the last 25 years, it would have spent $15.5 TRILLION less. That is real money, and could have been used to address many of the social determinants we are always told there is not enough money to do.

Perhaps the most stirring talk was given by H. Jack Geiger, former Dean of the Sophie Davis (now City University) School of Medicine in New York. Accurately described as a “living legend”, Dr. Geiger founded the first two community health centers in the US, in Charlestown, MA near Boston and in Mound Bayou, MS. He was a founding member of the group Physicians for Social Responsibility (PSR), the US affiliate of the International Physicians for the Prevention of Nuclear War (IPPNW), and Physicians for Human Rights (PHR). In his introduction we were reminded that Dr. Geiger was once chastised by a federal bureaucrat for writing prescriptions for food for his patients in Mississippi, and told that the federal funds supporting his program were to be for treatments. His now-classic response was that “the last time I checked my medical textbooks, the treatment for malnutrition was FOOD!” He noted that the last decade might be called that of raising consciousness of the Social Determinants of Health, but that because many of these are determined by (and are currently being eroded by) the political process, called for the next decade to be that of the Political Determinants of Health. He did not mention, but I note, that while IPPNW won the Nobel Peace Prize (1985), the Nobel Prize for “Medicine” in fact goes exclusively to researchers in the basic sciences. How wonderful, fitting, and appropriate would it be to go to someone like Jack Geiger, whose life’s work had really made a difference in the health of people!

In writing about the 2012 conference I suggested that certain goals be the focus of the “Beyond Flexner” movement:
·         Diversity: How does the school produce a health workforce that looks more like American by enrolling, and supporting, a group of students that is truly diverse in ethnicity, gender, socioeconomic status, and geographic origin?
·         Social Determinants of Health: How does the school teach about and train students in, and carry out programs aimed at addressing, the social determinants of health? How does its curriculum and work invert that of the traditional medical school, which focused most on tertiary hospital-care, and emphasize instead ambulatory  care, community based interventions, and interventions on the most important health determinants including housing, safety, education, food, and warmth?
·         Disparities: How does the school, through its programs of education and community intervention, and its research agenda and practices, work to reduce disparities in health care and health among populations?
·         Community Engagement: How does the school identify the community(ies) it serves and how does it involve them in determining the location of training, kinds of programs it carries out, and in identifying the questions that need to be answered by research?
I believe they are still valid. The Social Determinants of Health (SDOH) were discussed everywhere in the conference, and Health Disparities are the central focus of addressing them, or in Dr. Jones’ phrase, the Social Determinants of Equity. Community Engagement was emphasized through the broader participation in the conference (such as the people from Extension services) and one of its highlights was an afternoon of tours of such community-engaged programs in Albuquerque. I went on a visit to the city’s International District, and the East Central Ministries, which operates an innovative clinic driven by community health workers, an Urban Farm, and a small factory manufacturing ollas, unglazed clay jugs used for low-water-use irrigation.

Diversity was certainly addressed by many of the conference speakers, including Dr. Jones and Marc Nivet, Chief Diversity Officer for the Association of American Medical Colleges (AAMC), who pointed out how poorly our schools have done. In the 1990s The AAMC had a goal for minorities of “3000 by 2000”, but in the last 35 years African-American applicants have increased by 1000 and admissions by only 250. Jose Rodriguez and his colleagues writing in Family Medicine note that African-Americans peaked at 8.1% of medical students in 1994, and was down to 7.23% in 2010, Hispanics are up to 8.25% despite a much higher % of the population, and underrepresented minority (URM) faculty in medicine has increased from 7% to 8% from 1993 to 2010 despite an increase in those same groups in the general population from 23.1% to 31.4% in the same period.[ii] In the accompanying editorial, which I wrote, I call for an immediate, dramatic, and comprehensive effort to change both the socioeconomic and racial makeup of our medical school classes.[iii]

If anything was a little disappointing to me at the conference, it was the degree to which the audience was less willing to pick up on the issue of lack of diversity. While there was applause for the comments of Drs. Jones, Nivet, and others, most of the questions and comments focused on the SDOH. These are extraordinarily important, and emphasizing the need to teach them in medical school is as well, but poverty will not be solved quickly. Diversity, on the other hand, could be; our medical school class next year could look dramatically different if we changed the criteria by which we admit so that half the class came from the lower 50% of income and we had double the percent of minorities.

Many of the conference attendees were from newer medical schools, whose goals are more tied to SDOH, Community Engagement and Diversity, and they were celebrated from the podium. But while they may deserve this celebration, the older medical schools need to be held responsible as well; unless they change their admissions practices and their goals to serve the communities, the impact of the newer schools will be only at the margins.

There is a lot to do, and to accomplish it will take a movement. Hopefully a movement growing from “Beyond Flexner” can start the process.

[i] Fitzhugh Mullan, MD; Candice Chen, MD, MPH; Stephen Petterson, PhD; Gretchen Kolsky, MPH, CHES; and Michael Spagnola, BA. The Social Mission of Medical Education: Ranking the Schools. Ann Intern Med. 2010;152(12):804-811. doi:10.7326/0003-4819-152-12-201006150-00009
[ii] Rodriguez JE, Campbell KM, Adelson WJ, Poor representation of Blacks, Latinos, and Native Americans in Medicine, Fam Med 2015;47(4):259-63.)
[iii] Freeman J, Diversity goals in medicine: it’s time to stop talking and start walking, Fam Med 2015;47(4):257-8.

Sunday, April 19, 2015

Racism and the Social Determinants of Equity: Camara Jones at Beyond Flexner 2015

At the recent “Beyond Flexner 2015” conference in Albuquerque, one of the featured speakers was Camara Phyllis Jones, MD, MPH, PhD. Dr. Jones, a family physician and epidemiologist, is Senior Fellow at the Satcher Health Leadership Institute at Morehouse School of Medicine in Atlanta, and formerly with the Centers for Disease Control and Prevention (CDC), and is currently President-Elect of the American Public Health Association, APHA. (Her election site contains a good biography, and this segment from “Unnatural Causes” a superb interview.) I was truly honored to meet her the day before (we were in the last row of a van headed to visit a clinic in Albuquerque’s International District; she told me her name and I responded with “the Camara Jones?!”) because I have long admired her work, and have used her “Cliff Analogy” for the Social Determinants of Health (SDOH) regularly in lectures to medical students, as well as in this blog (e.g., “Delmar Boulevard, Geo-mapping, and the Social Determinants of Health”, August 16, 2014; ACA after the election: Is it is the "fiscal cliff" or the social cliff that matters to people?”, November 17, 2012).

In brief, the Cliff Analogy portrays the healthcare system as a cliff face, which may or may not have a fence to keep people from falling off (primary prevention), a safety net part-way down to catch those who fall before they hit the ground (secondary prevention), and an ambulance to take them to the hospital at the bottom (tertiary “prevention”). The presence or absence of these, and how fast the ambulance comes, impacts access to health care. But along the top of the cliff, the nearness to the edge represents the social determinants of health, how vulnerable people are to falling off, how their life circumstances (poverty, housing, food, education, dangerousness of where they live) make it much easier for a gust of wind, or tripping (or a disease) to not just knock them down but throw them over the cliff.

It is a powerful and effective method of illustrating the SDOH, but Dr. Jones has other allegories that are also effective, in particular in describing the various forms of racism that exist within our society, and the impact of them on the lives and health of people. Several of these are presented in her wonderful TED talk, given at Emory University in 2014. She describes 3 levels of racism: institutionalized racism that, whether through laws or common practice, keeps its victims down in the underclass with less opportunity and hope; personalized racism, the actions and attitudes of people that perpetuate racial victimization; and internalized racism, by which members of the oppressed group come to believe in their own inferiority, that “the white man’s ice is colder”. All of these are important; efforts to demonstrate that “black is beautiful” and “I am somebody” can work to combat the psychological stigma from internalized racism, but without structural change can go only so far.

Dr. Marc Nivet, Chief Diversity Officer of the Association of Medical Colleges (AAMC), gave an earlier speech, in which he also provided a powerful metaphor, of opportunity in America being an escalator or a staircase. In it he describes the children of the privileged as having an escalator to take them to the top; even if they “bump their heads” or otherwise falter and fall back, it will continue to bring them quickly back up. Others, the children of the poor, have to climb the stairs, and when they fall it is a long and difficult way back up; they have to run very fast and are unlikely to ever catch up. This is a great way of illustrating not only the social determinants of health but of opportunity; it provides a dynamic metaphor to accompany the famous quote from former University of Oklahoma football coach Barry Switzer that “some people are born on third base and think they hit a triple”. Dr. Nivet includes his own children in those who are on the escalator; since he is African-American, this might be seen as support for the argument that the difference in opportunity is due to class (or as Americans like to call it to make it sound more random and less generational, “socioeconomic status”) rather than race.

But Dr. Jones asks us why people of some races are disproportionately represented in the lower class; she coins the phrase “the Social Determinants of Equity”. She helps illustrate this with “the Gardener’s Tale”, beginning with a (possibly true) story of when she and her husband bought their first house, with a lovely wrap-around porch with many flower boxes. In Spring, they discovered only some had soil, so they went and bought potting soil to fill the others, and planted marigolds in all of them. But some weeks later some plants were doing great, and others were struggling; it was clear that those in the old rocky soil were not on a par with those in the new soil. To be sure, some seeds in each box were stronger and doing better than others, but the strongest flowers in the poor soil could barely keep up with the weakest in the good soil.

And what if the gardener decides to plant red and pink flowers, but likes red better, and plants them in the good soil? And when they do better, s/he says “See? I knew red were better!”. And, if the flowers were perennials and went to seed and regrew each year, they would perpetuate, if not worsen, the difference, the inequity. And if the gardener said “these pink flowers are going to do poorly anyway”, and deadheaded the weakest, allowing them no chance at all? And in future generations if her children and grandchildren always grew up knowing that red flowers did better than pink? But why, someone asks Dr. Jones (not in this conference!) should the red flowers give up or share their soil?

Because, she answers (obviously, at least to many of us), the soil does not belong to the red flowers, although they have benefited from it, but to the gardener. It could easily be redistributed by her, and the flowers would have an equal chance to grow. Maybe generations of selection would take a few years to compensate for, or maybe because only the stronger pink seeds survived, they would do even better than the red given the chance to have the same opportunity to grow. We cannot be sure until that opportunity is comprehensively and completely available.

Dr. Jones’ allegories are very helpful in increasing our understanding.
  • We cannot truly improve health without addressing the Social Determinants of Health.
  • We cannot address the impact of racism without recognizing its many faces and forms, and its self-reinforcing nature.
  • We cannot adequately remediate the effect of class upon health without changing how some people and groups are disproportionately represented in the underclass, the Social Determinants of Equity.

Dr. Jones’ allegories can help us understand, but real change will take concerted and sustained action.

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