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medicine worcester

Volume 90 • Number 3 Published by Worcester District Medical Society May / June 2021

JEDI or Die

NOT AN OPTION BUT A MANDATE At the intersection of Asian and American Hidden In Plain Site: Working with Medical Societies to Actualize a Just, Equitable, Diverse, Inclusive (JEDI) and Anti-Racism Healthcare System Small Practice Adaptations to Healthcare in the Pandemic Women Rise Up! Limitation of Opportunities for a Black Physician in Massachusetts

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Contents

on the cover

MAY / JUNE 2021

Illustration by Angelina Bambina

JEDI or Die: Not an Option but a Mandate Editorial 4

A Young Attending’s Perspective on LGBTQIA+ Representation and Inclusivity in Medicine 16

George Abraham, MD

Ahmed Salama, MD

President’s Message 4

Now We Turn Unto Our Calling: Medical Students During the COVID-19 Pandemic 18

Spiro Spanakis, DO

At the Intersection of Asian and American 5 Elisa Choi, MD, FACP, FIDSA

Hidden In Plain Site: Working with Medical Societies to Actualize a Just, Equitable, Divers, Inclusive (JEDI) and AntiRacism Health Care System 7 Darilyn Moyer, MD, FACP, FIDSA, FRCP

Calvin Schaffer, Sabahat Rahman, Sarah Ferreira, Bennett Vogt and Paula Whitmire

A Cautionary Tale 19 B. Dale Magee, MD, curator

In Memoriam Dr. Robert E. Maher 20 Sidney P. Kadish

Women Rise up! 9 Limitation of Opportunities for a Black Physician in Massachusetts 11

Society Snippets 225th ANNUAL ORATION “The Next Gen – The Physician Work Force of the Future” 22

Ronald W. Dunlap, MD, FACC

Melissa Boucher

Diversity, Equity and Inclusion in Health Care: The Time for Action Has Come 12

2021 Call for Awards Nominations 22

Alice A. Tolbert Coombs, MD, MPA, FCCP

Mark D. Johnson, MD, PhD, Marlina Duncan, EdD, Milagros C. Rosal, PhD, MS & Brian Gibbs, PhD

Nursing Notes: Concordance on the Front Lines of Patient Care Delivery 14

Melissa Boucher

Health Matters 22 Melissa Boucher

Kenneth Peterson, PhD FNP-BC, Jaya Rawla & Everlyne Njoroge published by

wdms editorial board

produced by

Worcester District Medical Society

George Abraham, MD, Guest Editor

Studio DiBella

321 Main Street, Worcester, MA 01608 wdms.org | mwright@wdms.org | 508-753-1579

Lisa Beittel, MBA Anthony Esposito, MD Anna Morin, PharmD Nancy Morris, PhD, ANP Thoru Pederson, PhD Joel Popkin, MD Alwyn Rapose, MD Robert Sorrenti, MD Paul Steen, MD Ram Upadhyay, MD Peter Zacharia, MD Alex Newbury, MD Resident Representative Parul Sarwal, MD Resident Representative Alexandra Rabin, Student Representative

wdms officers

President Spiro Spanakis, DO Vice President Giles Whalen, MD Secretary Marianne Felice, MD Treasurer B. Dale Magee, MD wdms administration

Martha Wright, MBA, Executive Director Melissa Boucher, Administrative Assistant

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Worcester Medicine does not hold itself responsible for statements made by any contributor. Statements or opinions expressed in Worcester Medicine reflect the views of the author(s) and not the official policy of the Worcester District Medical Society unless so stated. Although all advertising material is expected to conform to ethical standards, acceptance does not imply endorsement by Worcester Medicine unless stated. Material printed in Worcester Medicine is covered by copyright. No copyright is claimed to any work of the U.S. government. No part of this publication may be reproduced or transmitted in any form without written permission. For information on subscriptions, permissions, reprints and other services contact the Worcester District Medical Society.


WORCESTER MEDICINE

Editorial

President’s Message

George Abraham, MD

Spiro Spanakis, DO President, WDMS

JEDI or Die

T

his

may

sound

like

a

bizarre

title

for

an

issue

of

Worcester Medicine, in the current era of firearm violence, it might even be construed as a threat. The acronym JEDI stands for justice, equity, diversity and inclusion, an oft-overlooked concept that has plagued our society in general and medicine in particular. While each of these terms is self-explanatory, our consistent practice of them may be lagging. The authors who have contributed poignant articles to this issue of Worcester Medicine have spoken from experience, be it from the angle of women in leadership, Dr. Darilyn Moyer; the Asian-American perspective, Dr. Elisa Choi; the African American perspective, Drs. Alice Coombs, Ronald Dunlap and Mark Johnson, et al.; the LGBTQ and religious minority perspective, Dr. Ahmed Salama; and so on. Probably the most overlooked of the JEDI characteristics is inclusion. The Merriam-Webster Dictionary offers several synonyms for the terms “inclusion” or “inclusivity” such as “all-embracing, all-in, all-inclusive, broad gauge, compendious, complete, comprehensive, cover-all, cyclopedic, embrasive, encyclopedic, exhaustive, full, global, in-depth, omnibus, panoramic, thorough, universal, etc.” Diversity and inclusion expert Verna Myers, founder and president of Verna Myers Consulting Group and star of a TED Talk on overcoming bias, told the Cleveland Metropolitan Bar Association that overcoming prejudice starts with identifying our unconscious biases and trying to rewire our brains to welcome differences and think more inclusively. She then went on to say: “Diversity is being invited to the party; inclusion is being asked to dance.” If not JEDI, then what is the alternative? I propose “die” to mean “death” in terms of our growth mindset, the ability to appreciate the best in others, progress in our profession and perspective and a more inclusive medical community, indeed society in general, that we are all called to be. I invite you, through the subsequent pages, to walk in the shoes of the authors as they share their perspectives, aspirations, passions and experiences. I hope that after reading this issue, like me, you will be challenged to increase the JEDI within yourself and within our sphere of influence, be it at work or elsewhere. We have all been invited to the party, I hope we will have a chance to dance together and take our profession to further heights. The alternative is not viable, hence my tongue-in-cheek title above. +

of Worcester Medicine – which sheds light on racial, ethnic, and social injustices and inequities in our society – I hope you can do so with faith in the future. As clinicians, not a day goes by when we are caring for patients whose medical conditions were not worsened by the social determinants of health. These insults to the patient’s health can take many forms and are often the most difficult for us to address in our treatment plans for patients. But, no problem can be solved without first recognizing it and committing resources to it. I am pleased that institutions, employers and legislators are focused on making improvements in this realm. We must also do so in the way we care for patients. The medical and surgical home models are wonderful examples of how we can begin to address some of the real underlying barriers our patients face to their health and well-being. I hope that payers continue to realize the long-term benefits to our patients of such care models in the future. As a larger segment of the population becomes vaccinated for COVID-19, I look forward to a time when we can come together in person again to conduct the business of society and socialize like we once did. In the meantime, we will continue to conduct our meetings virtually. Please stay tuned as we adapt to what will, hopefully, be an easing of social distancing guidelines and a time when we can come together again as a society. +

STUDENTS:

“Not enjoyment, and not sorrow, Is our destined end or way; But to act, that each tomorrow Finds us farther than today”.

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A Psalm of Life Henry Wadsworth Longfellow 1807-1882

4

A

s you read this issue

On Page 22

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JEDI or Die At the Intersection of Asian and American Elisa Choi, MD, FACP, FIDSA

I

have to confess, this essay is very different than the original

piece I had written and planned to submit. We, as physicians, do not exist in a vacuum and recent events, specifically the terrible shootings in Atlanta, Georgia, on Tuesday, March 16, 2021, where eight people were murdered by a 21-year-old white man, and where six of the victims were women of Asian descent, four of whom were women of Korean descent, upended my original plans for this essay. What does this particular event have to do with diversity, equity and inclusion in medicine? Aside from the horrible tragedy of lives lost, how does that event relate to DEI efforts? For me, a self-identified physician, woman and individual of Asian/Korean descent, the events of March 16 struck far too close to home as I visualized the possibility that I could have been a target of the shootings based on my identity. The Atlanta shootings also led to numerous days of contemplation about the role that racism, bigotry and hatred can play in all of our lives, but also in our experiences as physicians and in the lives of our patients. DEI work cannot exist in isolation from addressing anti-racism. One of the most challenging aspects of being a physician of Asian descent this past year, while we all experienced the COVID-19 pandemic, has been the targeting and racism directed against those of us who self-identify as members of the Asian/Asian American/pan -Asian community. Ironically, the same day the horrific murders were committed in Atlanta, new data from “Stop AAPI Hate” (https://stopaapihate.org/) was released that reported approximately 3,900 incidents of discrimination, harassment, racism and violence directed at individuals of Asian descent in the U.S. since the beginning of the COVID-19 pandemic last year. That number is likely a significant underestimation, as many cases of antiAsian racism, bigotry or discrimination go unreported. What has this meant for our Asian community during this pandemic? First, some background information about our Asian/Asian American/pan-Asian community in Massachusetts and in the U.S. Currently, our community represents approximately 6% of the greater population in the Commonwealth and in America. We are also the fastest growing racial/ethnic group, but we have characteristics that can exacerbate health inequities. Our community has the largest proportion of limited English proficiency individuals and the greatest proportion of foreign-born individuals of any racial/ethnic group. Limited English proficiency is one of numerous social determinants that can further aggravate health disparities. In addition, there are numerous biases and stereotypes about our community that are harmful both to our physicians and clinicians as well as to our patients. Namely, that we are a “model minority“ but at the same time we are perpetually viewed as being “other“ or “foreign“ and “not really American.” Moreover, our community is often left out of discussions about race and health disparities or health inequities as often those discussions center around Black/white dichotomies or appropriately focus on Black/

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African American, Latinx/Hispanic and Indigenous/ Native American communities. What are some of the implications of the stereotypes, biases and omissions of our pan-Asian community from conversations about race and health? Starting with the “model minority” myth, this harmful stereotype was initially coined by William Petersen in 1966 when a New York Times story profiled the successes of Americans of Japanese descent in their financial, economic and educational attainment. Unfortunately, this label as the “model minority” has persisted for many decades up to the present and has generated an erroneous assumption that those of Asian descent do not suffer from health inequities or health disparities. Importantly, stereotyping and characterizing our pan-Asian community in this way does real damage, overlooking the concerns and issues faced by many of the more economically or educationally disadvantaged Asian subgroups. The Asian/Asian American/pan-Asian community is the most heterogeneous of all racial and ethnic groups, representing approximately two dozen languages and more than four dozen nationalities without a predominating or unifying language or culture. The circumstances under which our community members made their way to the U.S. have also been varied, ranging from highly educated professionals from East Asia or South Asia who voluntarily immigrated to the U.S. to chase the “American Dream” to refugees from Southeast Asia fleeing from their war-torn home country arriving in America to escape from political turmoil. The experiences of such diverse communities cannot be homogeneously defined. Also, despite some groups of our larger pan -Asian community being in the U.S. since the 19th century, even in 2021 there is a presumption of Americans of Asian descent as being “foreign.” This had a particularly insidious and hateful outcome with the internment of Americans of Japanese descent who were sent to concentration camps and detention centers during World War II and this “perpetual foreigner” trope continues in the present day in everyday interactions when we as Americans of Asian descent are frequently asked “where are you from?” When we answer, “I am from Massachusetts,” that prompts the follow-up question, “But where are you REALLY from?” As physicians and clinicians, these stereotypes and biases can manifest as harmful assumptions about us and can impede professional achievements and attainment of leadership positions, and can also undermine our efforts to achieve success. The quiet, hardworking, docile, obedient “model minority”

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JEDI or Die At the intersection of Asian and American Continued Asian will not be seen as “leadership material,” but instead as a “worker bee.” We physicians of Asian descent have also experienced “racial microaggressions,” ranging from blatantly offensive racial slurs to less aggressive but still unacceptable jokes about our Asian foods or foreign accents. More concerning still are the instances of blatant racism and racially motivated violence directed against our community, as what happened in the Atlanta shootings. For our patients, these harmful stereotypes and biases can lead to under-recognition and under-diagnoses of medical conditions, and a failure to address some chronic medical conditions because of the assumption of the “model minority” myth as applied to Asian/Asian American patients’ health. The “model minority” myth of the “healthy Asian patient“ also belies the fact that our patients of Asian descent are often underdiagnosed with diabetes and will suffer from delayed diagnoses with various cancers because of poor rates of cancer screening. Poor language access, particularly for our patients of Asian descent who have limited English proficiency, is a significant and frequent barrier to care and our medical systems often are under-resourced to address it. Asian patients who speak primary languages which do not have corresponding interpreter services are significantly disadvantaged when it comes to their health care. COVID-19 has also led to the parallel pandemic of anti-Asian racism, which has had significant consequences for our Asian patients. They are not accessing COVID-19 vaccines to the same degree as white patients. Data from our Massachusetts Department of Public Health COVID-19 vaccine dashboard supports this health disparity. A more difficult outcome to measure is the impact from the targeting and stigmatizing of

Asian individuals on access to care. The racialization of COVID-19 may dissuade our Asian patients from seeking care for suspected COVID-19, or even other medical conditions, as a response to racial trauma and stigma. The events in Atlanta on March 16 and the horrific murders of eight individuals, six of whom were Asian women, did not happen in a vacuum. They occurred with the backdrop of Anti-Asian racism and COVID-19 ongoing over the past year. The COVID-19 pandemic has surfaced a parallel epidemic of anti-Asian racism and has revealed health disparities affecting our Asian community. The way forward must include active, anti-racist efforts as well as inclusion of our Asian community in those conversations about DEI and health disparities. Do not omit our voices and our lived experiences. We matter, we have been in America for centuries, but now more than ever, we must be seen and heard and accepted for who and what we really are. We Asian/ Asian Americans will stand up to racism, hatred and bigotry and together in solidarity with other Americans and will strive to create a more compassionate, tolerant and humane environment where we can all coexist as fellow human beings. + Elisa Choi, MD, FACP, FIDSA, Governor of the MA chapter of the ACP Conference and Councilor of the Asian American Coalition in MA

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JEDI or Die Hidden In Plain Site: Working with Medical Societies to Actualize a Just, Equitable, Divers, Inclusive (JEDI) and Anti-Racism Health Care System Darilyn Moyer, MD FACP, FIDSA, FRCP

T

he elevator story is compelling, the urgency never more critical. Organizational success, including for those in health care, is catalyzed and created by a Just, Equitable, Diverse and Inclusive, or JEDI, environment, free of harassment and discrimination (1). The imperative has never been greater as accrediting and licensing organizations in health care recognize, and require, that safer, higher quality patient care and medical education must be delivered in a JEDI environment. Inaction, or action without significant change, implies tacit perpetuation of the status quo. Despite more than 30 years of organizations trying to ensure that women and others underrepresented in medicine have appropriate representation at AHCs, the needle has barely moved (2). We should not suffer the tyranny of low expectations of just getting one woman and/or Underrepresented Racial Ethnic Group, or UREG, to a position of power but rather settle only for tectonic shifts that give appropriate representation proportional to patient populations. In 2015, 51%, 17.6%, 13.3%, and 1.2% of the U.S population were women, Latina/Latino, Black , and indigenous persons, respectively. In fact, there has not been an increase in proportion of Black men entering medical school since the late 1970s and the number of racial and ethnic minorities in U.S. medical schools only increased from 11.3% in 1980 to 13.7% in 2016 (3). Strong signals for patient-physician racial and gender congruity leading to improved patient outcomes are accumulating (4). Yet, despite the rapid, recent expansion of new medical schools and medical school classes, none of the last 30 have been in conjunction with a historically Black college or university (5). The first medical school opened in conjunction with Cherokee Nation in 2021 as the Oklahoma State University School of Medicine at the Cherokee Nation. The tsunami of data regarding

systemic disadvantages and barriers to women and others underrepresented in the health care workforce are incontrovertible. Women, UREGs and other traditionally marginalized and excluded groups in medicine are recruited, evaluated, promoted, advanced, mentored, sponsored and compensated differently (6,7). Women and UREGs in health care suffer more harassment and discrimination, including in social media (8,9). Now is the time to fix this as potential new physicians, and others in health care, cannot be what they cannot see. As the world’s largest medical specialty organization with 163,000 members, the American College of Physicians has a strong voice in representing internal medicine physicians, who comprise roughly 25% of practicing U.S. physicians. The “practicing” life of a physician is the largest proportion of a physician’s life cycle, hence the important interest, impact and role of physician medical societies in the discussion and solutions. Health justice, becoming an anti-racist organization, and achieving a diverse, equitable and inclusive health care environment are part of ACP’s strategic priorities and goals, as well as for many other medical societies (10). As I stated in a recent interview for the 2020 WIM Conference, “Every society should do the foundational work of systematically and

Every society should do the foundational work of systematically and comprehensively resetting its organizational vision, mission and goals through a JEDI lens.” comprehensively resetting its organizational vision, mission and goals through a JEDI lens. This foundational work should be directly accountable to the fiduciary board and governance body and should permeate every structure in the organization including committees, councils and local chapters. These new structures, informed by metrics, need to be transparent, evaluated, adjusted and continuously measured. Societies need to generously share their data through publications and presentations. There is excellent language in medical school, graduate medical programs, and health care accreditation and regulatory standards that recognize more JEDI health care environments lead to safer and higher quality outcomes for our patients. The Council of Medical Specialty Societies, comprised of 45 national, professional physician societies representing more than 800,000 practicing U.S. physicians, has Diver-

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JEDI or Die Hidden in Plain Sight Continued sity, Equity and Inclusion as one of its top two strategic priorities.” I urge academic health centers, hospitals, medical practices and other key stakeholders in health care to look to medical professional societies for collaboration and meaningful action to create the rapid-response teams that are needed to catalyze, synergize and diffuse this critical imperative in an actionable and generalizable fashion. Despite the tsunami of data documenting that “Houston, we have a problem,” there is a paucity of impactful and generalizable solutions. Here are a few suggestions: 1. Perform foundational work – review your organization’s mission, vision and goals with a JEDI and anti-racist lens and modify accordingly. 2. Review your policies and procedures for governance of your organization to remove explicit and implicit bias in all recruitment, retention, appointment, promotion, leadership, educational and advancement processes. 3. Ensure that your organization has JEDI, anti-harassment and discrimination policies – including those for patients/family members/visitors – and accessible mechanisms for activation of processes to enforce these policies. 4. Establish a body for ensuring a JEDI/anti-racist environment in your organization that is empowered in education and enforcement and can actively intervene in a rapid-response fashion, as well as have oversight with all governance and other germane policies relevant to establishing and maintaining a JEDI/anti-racist environment. 5. Review the allocation and prioritization of financial and other critical supporting resources to ensure that allocations prioritize creating/sustaining/augmenting a JEDI/anti-racist environment. 6. Institute deliberate practice in transparent data collection and review to assess your organization’s cultural environment, with a focus on safety, quality, JEDI and anti-racist principles. 7. Review and actively track total compensation, recruitment, appointment, advancement and leadership positions, and benchmark to rank and file of your organization and patient characteristics, if applicable. 8. Transparently publicize your organization’s data regarding your review of data in total compensation, recruitment, appointment, advancement and leadership in your organization. 9. Educate all in the organization regarding the benefits of a JEDI/anti-racist environment in terms of human and financial outcomes, safety and quality. 10. Review all local, regional, national licensing, accreditation and certification of JEDI/anti-racist standards and ensure that your organization is adhering to them – e.g., AAMC, ACGME, Joint Commission, state/local licensing boards and health departments. It is critical that we collectively make a difference for those who previously couldn’t see what they could be. Let’s work together to finally achieve

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the efficacious vaccine to eliminate systemic, structural and other barriers in our organizations that are preventing us from getting to a JEDI/anti-racist environment. ACP and other medical societies stand ready to meaningfully collaborate with other organizations to unleash a powerful collaboration to make meaningful and impactful progress, and not spend one day more hidden in plain sight! + Darilyn V. Moyer, MD FACP, FIDSA, FRCP EVP/CEO American College of Physicians Adjunct Professor of Medicine, Lewis Katz School of Medicine at Temple University references:

1. Why Diversity, Equity, and Inclusion Matters For Nonprofits, https://councilofnonprofits.org, 2021 2. The State of Women in Academic Medicine 20182019. AAMC. 3. Trends in Racial and Ethnic Minority Applicants and Matriculants to U.S. Medical Schools, 1980-2016. AAMC analysis in Brief, 2017 4. Capers et al, Perceptions on Diversity in Cardiology: A Survey of Cardiology Fellowship Training Program Directors, JAHA, 8/25/2020. https://doi.org/10.1161/ JAHA. 120.017196 5. Campbell et al, Projected Estimates of African American Graduates of Closed Historically Black Medical Schools, JAMA Network Open, 2020;3(8):e2015220. Doi:10.1001/jamanetworkopen.2020.15220 6. Serchan et al, Achieving Gender Equity in Physician Compensation and Career Advancement: A Position Paper of the American College of Physicians, Ann Intern Med. 2018;168:721-723.https://doi. org/10.7326/M17-3438 7. Silver, J .Physician Workforce Disparities and Patient Care: A Narrative Review. Health Equity,2019, 3.1 8. Viglianti et al, Patient-Perpetrated Harassment Policies in Patient Bills of Rights and Responsibilities at US Academic Medical Centers JAMA Open Network, 9/15/2020. Doi:10.1001/jamanetworkopen.2020.16267 9. Pendergrast et al, Prevalence of Personal Attacks and Sexual Harassment of Physicians on Social Media JAMA Intern Med, 1/4/2021. Doi:10.1001/jamainternmed.2020.7235 10. The ACP Commitment to Being an Anti-Racist, Diverse, Equitable, and Inclusive Organization, 10/21/20, www.acponline.org


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JEDI or Die: Not an Option but a Mandate Women Rise up!

Figure 1. The Massachusetts General Hospital Department of Anesthesia, Critical Care and Pain Medicine traces its roots back to the October 16, 1846 public demonstration of medical ether

Alice A. Tolbert Coombs, MD, MPA, FCCP Portions of this publication has been published in VSA Newsletter October 2020

A

pivotal moment in the history of anesthe-

is highlighted by a patient being anesthetized in the classic picture, “Under the Ether Dome” at Massachusetts General Hospital, on Oct. 16, 1846 (figure 1). While we are impressed with the historical significance of what happened under the Ether Dome, there exists another narrative. In a 19th century, male-dominated world, women understood the power of influence and basked in the appreciation of informal authority. While formal authority is expected in organizational structures, informal authority stems from relationships that are cultivated and which result in acquired influence. Informal authority or power is your brand and signature that ultimately impacts your organization and society. Female physicians are showcased in Figure 2, administering anesthesia in the operating amphitheater of the Woman’s Medical College of Pennsylvania in 1903. While women may be exhibiting formal authority, successful leadership development does evolve from informal authority. There are examples of positive and negative informal authority. As female physicians, we must understand the value of resourcefulness, empowerment, legitimacy and affinity as they relate to leadership development. Black women in medicine introduced the issue of intersectionality. Columbia University and the University of California at Los Angeles law professor, Kimberlé Crenshaw first coined this term more than 30 years ago in which she described: “the way people’s social identities can overlap, creating various forms of inequality and experiences of discrimination” (1). Intersectionality highlights the fact that not all inequalities are equal. The percentage of female Black physicians has steadily increased over the past 20 years and currently represents 59.1% of all Black physicians while the absolute number of Black female physicians has only increased minimally (2). Minority women in medicine may aspire to advance in leadership positions both in private practice and academic environments. Establishing some informal authority may offer a stepping stone into formal leadership positions. It takes doing the extraordinary and disruptive innovation to break through the glass ceiling. sia

Figure 2. Woman’s Medical College of Pennsylvania operating amphitheater, 1903. Legacy Center Archives, Drexel University College of Medicine

Dr. Elizabeth Blackwell was the first woman to receive a medical degree, doing so in 1849, and her role in mentoring and advocacy of the underserved was a constant theme in her life. She was a sponsor and mentor to her sister and other women. Dr. Blackwell demonstrated informal authority, but she had challenges that forced her to make career decisions based on an acquired physical disability (monocular blindness), infrastructure support, gender and her finances. At one point, she struggled to find work. She found strength in other women, who encouraged her. One of Dr. Blackwell’s closest friends insisted that if she were cared for by a female physician, she would have received better care. Dr. Blackwell’s empowerment allowed her to be decisive. Once she lost her vision, she could no longer be a surgeon, but she considered her next best alternative was to become a generalist. Her legitimizing body was her patients and other women. She recognized the reciprocal appreciation in this sector. Although she was forced to make decisions in the midst of uncertainty, she was empowered because a key element in her decision-making was her “connectiveness.”As female physicians, we must determine, “who is my legitimizing body?”In other words, who are not only my supporters but who shares a similar vision and therefore is a reciprocal relationship (3). Dr. Rebecca Crumpler was the first Black female to graduate from a U.S. medical school , New England Female Medical College in 1864. Sometime after graduation she traveled to Richmond, Virginia, where she cared for freed enslaved persons. The Medical of Virginia had so many marks of discrimination against Black people during this period. There are stories of procedures performed on Black individuals for teaching purposes (Medical Apartheid, Harriet Washington). There

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JEDI or Die Women Rise Up! Continued was a separate hospital for Black people and white people. In this city, she received comparable patient support that would have been rendered for a white male physician in Boston. Despite this fact, she and other Black physicians in Richmond still experienced intense racism. She published a book, “Book on Medical Discourses.” She was empowered because she recognized her legitimizing body was made up of other Black individuals having to relocate to practice medicine. Her informal authority and greatest influence were in the Black community. Female physicians sacrificed professional advancement because of their limited resources and lack of social capital. The struggle for female physicians was complex. Three years following the graduation of Dr. Crumpler in 1967, Dr. Rebecca Cole, a Black woman, graduated with her medical degree from the Women’s Medical College of Pennsylvania. These female physicians were resilient, focused and with dogged determination. But these qualities were only part of the solution (4). Firstly, it is affinity that opens the doors to success. I will define affinity as connectiveness. As a female physician, recognizing when we have affinity in an environment is essential to our success. Several questions are important. Affinity is influenced by personalities and tolerance. Can you increase affinity and, is there a secret sauce to making your colleagues be connected to you? For women, sometimes they recognize, when you first walk into a room, if you have a halo-effect. Other times your support from others, or lack thereof, may not be obvious. We must be creative in gaining access into the lock-out minds of decision makers. It will be an experience in understanding the value system of the environment. In some circumstances there will be obvious biases. I will caution physicians to hold steady and understand the perspectives of key players in your workplace prior to taking any stance or formulating conclusions. Once your homework is complete, seek not just mentorship but allyship – a person whose ideals resonate with yours although they may not agree with you on all issues. There is amazing value in divergent-thinking colleagues who are not paralyzed by terminal group think in the landscape. A strategy to gain affinity would be to engage in activities or work projects that result in the increase of connectiveness. Here are a few suggestions which are by no means complete. The role of mentorship cannot be underestimated. People who become your personal BOT are helpful for growth-propelling transparency. For example, for hospital-based

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physicians, seeking out the most visible and essential core committees and activities in a hospital may prove beneficial. Probably the best halo-getting action is to be a great physician. Lastly, it is important to engage in professional society activities: linking up with other like-minded individuals promotes connectiveness. February is Black History Month. What are the lessons learned from these historic icons?At the turn of the century, we had only a handful of women and Black individuals graduating from medical school. Today, Association of American Medical Colleges data reveals that in 2019, 50.4% of the graduates from medical school, and less than 40% in practice, are women but Black physicians in the U.S. only represent 5% of all physicians while Black individuals represent 13.4% of the U.S. population (5). How do female and minority physicians succeed in an evolving world? A complex question invites us to explore solutions that are multi-pronged. Being a GOOD DOCTOR is essential for advancement into leadership positions. No matter how much advocacy a physician engages in, her or his voice is strengthened by care for patients. Mentorship, allyship, sponsorship and understanding the importance of education and service are paramount for advancement. Over my more than 30 years of private and academic practice, I am eternally grateful for the role that others have played in my development. This includes: Wilbur Jordan, MD; Marlene Myer, MD; Bart Cilento, MD; Estelle-Stez Marcus, MD; James Devin, MD; Linda Healy, Corrine Broderick, Alex Calcagno, Robin Allie, Steve Phalen, the Hammonds, Elba and Roosevelt Tolbert, and of course my husband Albert Coombs, MBA. Together we really are stronger. Physicians rise up and take a place in society! + Alice A. Tolbert Coombs MD MPA FCCP Interim Chair, Department of Anesthesiology and Critical Care Medicine, Virginia Commonwealth University, Medical College of Virginia Richmond, Virginia references

1. What Is Intersectionality? A Brief History of the Theory | Time 2 Black or African American physicians by age and sex, 2018 | AAMC 3.Elizabeth Blackwell | National Women’s History Museum 4.US National Library of Medicine, 2015. Dr. Rebecca Lee Crumpler. Changing the face of medicine. https://cfmedicine.nlm.nih.gov/physicians/biography_73.htmlDate: 2015 5.https://www.AAMC.org/media/3866, Figure 20. Percentage of physicians by sex and race/ethnicity, 2018 | AAMC

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JEDI or Die Limitation of Opportunities for a Black Physician in Massachusetts Ronald W. Dunlap, MD, FACC

I

have been asked to provide some insight as a

Black physician practicing in Massachusetts. I switched from biomedical engineering to medicine after observing the disparities in the treatment of a devastating illness in my sister, a nurse, in Newark, New Jersey . My medical school experience at Tufts University was at the very start of a limited number of attempts to diversify medical schools. I will skip over that era, and my time in technology, given that it would require more time to describe the complexity of the situation and that journey. I will say that my focus in medicine was to train and practice in a community serving a diverse and underserved population. This led me to consider both Boston City Hospital, now Boston Medical Center, and Cambridge City Hospital. One of my colleagues from Mississippi spent one year at Boston City Hospital before he transferred to Meharry Medical College in Nashville, Tennessee. He cited the racism and attitude of the staff toward Afro-Americans in the mid-1970s. I opted out of Boston City Hospital, which was being re-organized at the time, and interned at Cambridge City Hospital. Fast forwarding 30 years and that same Boston institution became the leader in the care of the underserved and a leader in promoting diversity. For Black physicians wanting to serve a diverse population, the options for medical practice were limited by the academic- and hospital-based systems that provided care for Black citizens. This situation was unique as the care of this Black demographic in other cities was somewhat proportional to the Black physicians in private practice. This structural deficit was partially rectified by the deployment of Federal Qualified Health Centers in Massachusetts which offered positions for black physicians. The wealth gap between Black and white individuals in Boston limited the opportunity for Black practices in Boston. I chose to remain in Boston because my ties to technology, business and my post-graduate training were all in this region. Advancement in academics was inhibited by the lack of mentors for Black physi-

cians at that point, particularly in research. A conflict between salaried positions and surviving on grants made it even more challenging. Debt service inhibited both public service and career choices as it does today. During my cardiology training at the Brigham Women’s Hospital in Boston, then affiliated with the West Roxbury Veterans Affairs facility in West Roxbury, and for many years afterward as an attending cardiologist with a Harvard University appointment, I moonlighted in community hospitals in critical care and emergency medicine. This was common for many working in academic medicine at that time. A major reason for that exposure, other than income, was to see how the residents of suburban communities responded to a Black physician. Private practice was not a viable option at the time. The veterans were accepting of care from a Black physician. The number of minority patients grew as they made up an increasing number of the forces involved with the Vietnam War and the Gulf conflicts. An interesting phenomenon during racial turmoil in South Boston at that time was that it didn’t seem to stop patients from that area from generally accepting me as their physician. One common occurrence in community hospitals was that white patients in higher-income suburbs frequently questioned my education and training, seeking to determine if I were qualified. This process was described by Chester Pierce, a noted psychiatrist at Massachusetts General Hospital,as “microaggression.”In most cases, they were satisfied after I discussed their malady and the treatment plan. There was a minority of patients who were not happy or willing to be treated by a Black doctor. Thus, most of the patients were accepting of me as a treating physician and some called my home to see if they could arrange an appointment. I had several experiences with microaggression during emergencies. I was on a United Airlines flight which was halfway between Hawaii and the mainland U.S. when an 18-month-old had a severe allergic reaction to peanuts. I responded to the call for a physician and was not allowed to treat the patient until I produced my license and a business card showing I was an attending cardiologist at a Harvard-affiliated hospital. This resulted in a delay of the treatment of the patient, which required me to dilute the adult Epinephrine vial to a pediatric dosage, which I knew from my Emergency Department experience. On the other hand, the most striking phenomenon was that physician practices that I covered had full confidence in me but never spoke to me about joining their practices. When I decided to consider transitioning to private practice, I found that white physicians were concerned about the impact of a Black physician joining their practice – assuming their patients would object, which was not the case. When I explored practices in Washington, DC and other urban areas, I found that Black physicians practicing in mixed communities were also concerned about the practice marketing after adding a black partner . I had two resumes. One noted my membership in the National Medical Association and the Association of Black Cardiologists, the other simply showed my education and training. My name didn’t give any indication of my race. The worst experience I had was showing up for an interview and finding the practice manager shocked that they had invited a Black doctor to come in. They rapidly dispensed with me. After that I confined my search to areas where I was a known quantity.

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JEDI or Die Limitation of Opportunities for a Black Physician in Massachusetts Continued I finally accepted a hybrid position in a practice on the South Shore in 1992, which allowed me to spend one day a week teaching at Beth Israel Deaconess Medical Center for 15 years. I also spent a few years at Boston University Hospital on a per-diem basis. I switched practices in 1994 and was recruited to join two Irish cardiologists at South Shore Hospital. Brigham sent cardiac fellows to South Shore Hospital for a few years and, during that time, our exposure to the fellows allowed us to recruit a diverse group of highly talented young physicians from Brigham, Beth Israel and Boston Medical Center. We became a diverse practice with eight cardiologists with a racially, ethnically and gender-diverse perspective. During that time, spanning 25 years, I became acquainted with Dr. Alice Coombs who was very involved in health care disparities at the National Medical Association, American Medical Association and the Massachusetts Medical Society. She got me involved in organized medicine with a focus on health care disparities. Ultimately, she became the first Black physician to serve as president of the MMS. She recruited me, and others, from South Shore Hospital to the MMS. Although I had not intended to, I literally followed in her footsteps also serving as MMS president and became involved in the MMS and AMA’s Commission to End Health Care Disparities and other state-based initiatives. In 2013, we collaborated on a statewide study of patient access to physicians for Massachusetts Medicaid patients which showed marked access problems in communities with large Medicaid underserved populations. The Medicaid population size in a given area is driven by the wealth and income gap related to race between white and black individuals in Massachusetts. The MMS gave us a platform to pursue disparities and other issues involved with the role of physicians in governance in medicine. Unfortunately, those disparities have been magnified and increased during the COVID-19 pandemic. + Ronald W. Dunlap, MD, FACC Past President, MMS MA Health Policy Commission Advisory Council Past chair and advisor to MMS Committee on Diversity Board Advisor for DEI at Coverys Companies AMA Minority Affairs Section New England Medical Association, NMA Instructor in Medicine, Harvard Medical School

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Diversity, Equity and Inclusion in Health Care: The Time for Action Has Come Mark D. Johnson, MD, PhD, Marlina Duncan, EdD, Milagros C. Rosal, PhD, MS, Brian Gibbs, PhD shown clockwise

D

isparities in disease prevalence, treatment and outcomes in the United States are widespread and disproportionately have adverse effects on certain racial and ethnic groups. Indeed, the Centers for Disease Control has amply documented that Latino, Black and Indigenous populations have been disproportionately affected by COVID-19 in the U.S., bringing the existing health disparities in these groups into the spotlight once again. The places where people live, work, learn and play affect the rates of COVID-19 infection, severe illness and death. The COVID-19 pandemic has clearly demonstrated how social factors such as race, ethnicity, education level, income, neighborhood, access to health care, physical environment, occupation and others shape the landscape of disease risk, health care delivery and patient outcome. Additionally, pre-existing disparities in the prevalence of medical conditions – e.g., obesity, diabetes, cardiopulmonary disease, renal disease and others – which correlated with worse outcomes among patients with Sars-CoV-2 infection, also have contributed to the greater burden of severe COVID-19 illness and death borne by some racial and ethnic communities. The observation that COVID-19 vaccination rates for Hispanic/Latino and Black populations have lagged far behind those for white individuals reinforces the notion that many of the health inequities that we see derive from societal policies, practices and institutions that perpetuate them, and are not solely the result of intrinsic biological differences among these groups. The interplay between all of these factors and the powerful impact that they have on the health of our communities are undeniable . Many health inequities mirror inequities in other areas of our society that are the result of decades of widespread, institutionalized and harmful discriminatory practices. Those of us in the medical profession must embrace the professional and moral imperative to correct the numerous health disparities that we see among different patient populations. The importance of doing so is underscored by the rapidly growing diversity in our society. Indeed, a recent analysis of 2019 U.S. Census Bureau data by William Frey of the Brookings Institution shows that our nation is diversifying faster than predicted. (https://www.brookings.edu/research/new-census-data-shows-the-nation-is-diversifyingeven-faster-than-predicted/). For the first time in history, the white population in the U.S. declined during the 2010-2020 decade, largely because the number of deaths among white individuals exceeded the number of births and because white immigration to the U.S. did not

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Diversity, Equity and Inclusion in Health Care Continued completely make up for the difference. Overall, the percentage of white persons in the U.S. declined from about 69% of the population in 2000 to about 60% in 2019. Importantly, nearly all of the 6.3% annual population growth during the nine-year span from 2010 to 2019 occurred among non-white racial and ethnic groups, with the Hispanic/Latino and Asian populations showing the greatest gains. Currently, four out of 10 Americans identify as non-white. Studies have shown that patients whose doctors resemble themselves in terms of race, ethnicity or gender are more likely to follow medical instructions, keep follow-up appointments and have better outcomes. As we work to rectify health inequities, we must therefore ensure that the diversity of our physician workforce reflects the diversity of the patients we serve. Data from the U.S. Census Bureau reveals that Worcester is already a diverse city, with a population that is roughly 69.2% white, 13.3% Black, 7.4% Asian, 0.6% American Indian and Alaska Native, and 0.1% Native Hawaiian and Other Pacific Islander (https://www.census.gov/ quickfacts/worcestercitymassachusetts). About 5.5% of Worcester residents identify as being from other races and 4%are from two or more races. Hispanics and Latinos of any race make up 20.9% of the population in Worcester and women make up a slight majority, 50.9%, of the population. Importantly, about 22% of Worcester’s population was born outside the U.S. This relatively large immigrant population originates from numerous countries, including Brazil, Puerto Rico, Vietnam, Ghana, the Dominican Republic, Albania, Mexico and others. Data on the racial and ethnic composition of the physician workforce in Worcester County was not immediately available. However, national data from the American Medical Association for 2019 indicated that about 51% of physicians in the U.S. are white, 5.5% are Hispanic/Latino, 4.2% are Black, 15.3% are Asian American and 0.3% are Native American. The race/ethnicity of about 22.3% of physicians is unknown. International medical graduates make up about 22.4% of physicians. Based on this data, the National Institutes of Health has defined Hispanic/Latino, Black and Indigenous physicians as “underrepresented in medicine.” It is very likely that Hispanic/Latino, Black and Indigenous physicians also are underrepresented in Worcester County just as they are underrepresented across the nation more broadly. Thus, efforts to optimize the diversity of the local physician workforce are critical for adequately addressing the health disparities that are present in our diverse city. According to projections by the American Association of Medical Colleges, the U.S. will face a shortage of up to 139,000 physicians by 2033 as the number of retirement-age Americans soars by 45%. As that time approaches, demand for two-thirds of the new doctors will be driven by the growth of racial and ethnic groups. For example, nearly 45,000 new doctors will be needed to care for members of the Hispanic/Latino community, which is the nation’s fastest-growing ethnic group. Are we on a path that will lead to the diverse physician workforce that we need now and in the future? Sadly, the answer is no. Women now outnumber men among matriculants to medical school and thus the need for more gender diversity among physicians should be met over the next few decades. However, the 2018-2019 AAMC data shows a continued and troubling lack of racial and ethnic diversity among medical school matriculants. In all, 7.1% of matriculants were Black, 6.2% were Hispanic/Latino, 0.2%

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JEDI or Die were American Indian or Alaska Native, 0.1% were Native Hawaiian or other Pacific Islander, and 9.5% were of multiple race/ethnicity. White individuals constituted 49.9% of the matriculants and Asians were 22.1%. Part of the challenge in increasing diversity in medical schools lies in the composition of the applicant pool. In 2018-2019, white applicants, 46.8%, and Asian applicants, 21.3%, made up the largest subgroups of applicants, while Black applicants constituted 8.4% of applicants and Hispanic/ Latino applicants were 6.2% of the applicant pool. Left unchanged, this pattern will perpetuate the disparately low numbers of Hispanic/Latino, Black and Indigenous people among the U.S. physician workforce. Since 12% of the U.S. population is Black and 18.5% of the population is Hispanic/ Latino – together they account for nearly one in three Americans – these groups are expected to remain underrepresented among physicians for the foreseeable future. However, that is not what the AAMC, the AMA, the Worcester District Medical Society or the public are trying to achieve and it is thus clear that the current racial and ethnic pattern of medical school admissions must change, just as it has changed with respect to gender diversity. To accomplish this objective, a broad-based, coordinated effort that spans K-12 and undergraduate education must be initiated with the goal of reinforcing efforts to effectively teach science, technology, art, engineering and medicine disciplines at an early stage to all students, including those from groups that are unrepresented in medicine. In addition, physicians must engage as mentors with learners more purposefully and at an earlier stage, helping disadvantaged students successfully navigate the path to medical school and serving as a counterweight to the many societal forces that would throw them off that path. Medical schools must develop better methods for successfully selecting potential matriculants from the applicant pool that rely less heavily on tools and metrics that introduce bias against individuals that are underrepresented in medicine including those from low income backgrounds and members of racial and ethnic groups. Addressing disparities in health and health care that have historically plagued our communities must include, but is not limited to, strategies to diversify our physician workforce so that it reflects our patient population. The time has come for the medical profession to actively work to ensure that

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JEDI or Die Diversity, Equity and Inclusion in Health Care Continued diversity in health care reflects the diversity of the communities we serve and to accept nothing less than that. This will benefit the lives and the livelihoods of our patients. Identifying and developing talent from an early age is a necessary step toward eliminating the myriad health disparities that are exacerbated by the structural and systemic inequities which are so pervasive in our society and so damaging to the lives and well-being of all of our patients. Additionally, addressing systemic and structural inequities in under-resourced communities is tantamount to eliminating racial and ethnic disparities in STEAM education. Eliminating structural inequities in education, ranging from K-12 all the way through medical education and residency training requires partnerships and collaborations with community-based organizations, including outreach and funding support from local hospitals and community health care foundations (Increasing Diversity in Science and Health Professions: A 21-Year Longitudinal Study Documenting College and Career Success | SpringerLink). A collective and coordinated effort from every segment of our community will be required to redress the original wrongs of our country, i.e., slavery, oppression, segregation and racism, and the long-term destructive impact that systemic racism has on K-12 education, health equity, generational wealth and cultural exposure. +

References 1.Mark D. Johnson, MD, PhD, FAANS Maroun Semaan Professor of Neurological Surgery, Chair, Department of Neurological Surgery, Senior Consulting Vice Provost for Mentorship, Leadership and Transformation 2.Brian Gibbs, PhD – Chief Diversity and Inclusion Officer, UMass Memorial Health Care 3.Marlina Duncan, EdD – Vice Chancellor for Diversity and Inclusion, University of Massachusetts Medical School 4.Milagros Rosal, PhD, MS – Vice Provost for Health Equity, University of Massachusetts Medical School Mark D. Johnson, MD, PhD, (1,2) Marlina Duncan, EdD, (1) Milagros C. Rosal, PhD., MS, (1) Brian Gibbs, PhD (2) 1. University of Massachusetts Medical School, Worcester, MA 2. UMass Memorial Health, Worcester, MA 14

Nursing Notes: Concordance on the Front Lines of Patient Care Delivery Kenneth Peterson, PhD FNP-BC Jaya Rawla Everlyne Njoroge shown left to right

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e a r e a u n i q u e g r o u p o f n u r s e s i n the worcester

community leading change and improving health and well-being for many patients. We are nurses, on the front lines of care delivery, modeling effective actions through our commitment and dedication to the values, beliefs, attitudes and behaviors supporting sociocultural, ethnic and racial diversity. In these tumultuous times, where serious health threats and poor outcomes for minoritized and marginalized people in our communities continue to escalate, we need to call attention to essential provider qualities likely to mitigate the inequities of unequal care. In this short piece, we share our thoughts on what we believe matters most in the provider-patient relationship. on concordance

Patients deserve respect, dignity, peace of mind and improved health when they participate in health care. Unfortunately, health disparities reveal this isn’t always the case. How we behave and what we do to relate to and engage our patients is key to successful encounters and outcomes of care. These actions are especially important in situations where concordance in the provider-patient relationship is not possible. Concordance – matching gender, race or ethnicity and other patient characteristics to that of the provider – is a popular practice improvement strategy. [1,2] It became popular following the 2003 release of the Institute of Medicine’s report “Unequal Care.” Unfortunately, achieving concordance remains a challenge given the limited sociocultural, racial and ethnic diversity of care providers in the health care workforce. Despite challenges in achieving concordance, we believe that providers can improve in their behaviors and actions supporting respectful, equitable and health-producing care. This improvement process first begins with becoming aware of the unique identities of our patients and ourselves and second from appreciating the learning that results from valuing difference. on identity and difference

Identity is an evolving amalgamation of demographics, beliefs and lived experiences in the context of a broader sociocultural landscape. Identity is multidimensional; it can be fluid and invisible. The complexity of identity has profound implications on the provider-patient relationship. We, and nursing colleagues, as members of minoritized racial, ethnic and sociocultural groups recognize racial, ethnic, linguistic and/ or sociocultural concordance with patients as important factors in building trust, creating patient buy-in and setting up the potential for implementation of effective relationships to improve health and well-being. MAY / JUNE 2021


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JEDI or Die

Nursing Notes:Continued In the United States, the context of identity is often one where those with dominant identities hold disproportionate power, often at the expense of those with minoritized identities. Matching every aspect of identity is improbable, if not impossible. Concordance of some aspects of identity is not always possible. Consequently, the provider-patient relationship is not simply informed by a mere matching of identity. We, other colleagues and our patients, having lived experiences of being minoritized and marginalized, value interactions that are collaborative, respectful, nonjudgmental and emanate from an awareness of the effects of bias, discrimination and racism on health. on visibility and trust

We know that marginalized and minoritized groups have a need to build trusting relationships with their health care team due to the historical injustices that have plagued their interaction with health care institutions. Our experiences suggest a concordant provider-patient dyad may eliminate the anxiety that arises from fear of being misunderstood or judged, which in turn facilitates fuller discussions of health problems and treatment decisions. The perception of similarity can lead to higher levels of trust and rapport. Equally, once trust has been established, patients are more likely to follow recommendations, be adherent to medications and increase health care utilization. Providers with high social intelligence have the innate ability to connect to others and are able to empathize easily with patients and their families who may come to health care encounters with challenging diagnoses and treatment against a background of anxiety. Effective listening and respect for cultural differences can be honed, but our experiences reveal that marginalized and minoritized groups are socialized to listen and entertain perspectives that are different from their own. What follows from this includes provider’s appreciation for understanding patient preference and needs and increased visibility for difference. Patients in concordant dyads feel listened to and may disclose information to their providers that is pertinent to their care and which they may not have otherwise disclosed. For example, they might identify drug interaction implications regarding herbal supplements they are consuming along with their conventional medications. The evidence suggests that there is no statistically significant benefit of sex/gender or race/ethnicity concordance. (1,2) However, there is consensus that distrust between patients and their health care teams will further increase the existing gender and racial disparities in health care. Provider-patient concordance might be important in helping patients to understand and navigate the health care system which empowers the patient and allows them to become active participants in their care. It is not feasible to achieve concordance 100% of the time. However, providers who have developed qualities such as cultural competency, language competency and a general understanding of patient beliefs, values, preferences and roles have greater potential to make the health care system less threatening to marginalized and minoritized patients. on leadership and change

Our experiences on the front lines of care delivery suggest to us that skills and abilities leaders use to influence others can evolve from the relationships we have with patients. Benefits are gained from concorMAY / JUNE 2021

dant and non-concordant relationships alike. When we are open to the learning that occurs in our interactions with others, we engage and enhance our social and emotional intelligence. This allows us to see others as they are through respectful relations and trust-building actions. When we all value the differences among us, health care delivery will change. +

References (1) Jerant, A., Bertakis, K., Fenton, J., Tancredi, D., Franks, P. Patient-provider sex and race/ethnicity concordance: A national study of healthcare and outcomes. Med Care 49 (2011): 1012-20. (2) Hsueh, L., Hirsh, A., Maupome, G., Stewart, J., Patient-provider language concordance and health outcomes: A systematic review, evidence map, and research agenda. Med Care Res Rev 78 (2021): 3-23.

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JEDI or Die A Young Attending’s Perspective on LGBTQIA+ Representation and Inclusivity in Medicine Interview with Ahmed Salama, MD (right) by Parul Sarwal, MD

please tell us a little about your background and what drew you toward this cause.

I

was privileged to work with minority groups

throughout my career – serving in remote areas of Egypt, I worked to help vulnerable migrants and victims of trafficking from several African countries who ended up being stranded in Egypt. When I came to the United States, I worked with the Black community in Harlem, New York . These experiences taught me to respect each patient’s individuality, appreciating their unique journey and the struggles that they faced. During my residency training, I noticed that pre-exposure prophylaxis, or PrEP, could only be provided through a consult placed to the infection disease team – this is something I believe should be accessible through any primary care provider. I was fortunate to have a wonderful preceptor during this time with whom I worked to develop a strategy for more comprehensive care for our small panel of LGBTQIA+ patients. Another time, during an emergency department rotation, I had a patient whom the staff were not sure how to address – this was very distressing for the patient. Entering the patient’s room, I realized that they were transgender – in fact, they were my first transgender patient. They were tearful and scared, so I approached them and gently inquired how they identified. This eased them up a bit and, as the conversation flowed, we talked about how far they were along in their hormone therapy and if they had any surgeries. Within the next few minutes, the patient became much more comfortable, allowing me to address their present medical concerns. I then passed this information over to the rest of the team. We were able to change the patient’s emergency department experience from one of uncertainty, vulnerability and fear to something much more like a safe zone where they could feel respected and cared for.

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are there any challenges you faced as a physician

during your training years, either back home in egypt or here in the u.s.?

We all face multiple challenges in our lives – that is what makes life interesting and worth living! I think the biggest challenge for any foreign medical graduate is getting an interview for residency. Unfortunately, many programs use automatic filters for interview selection, which may sometimes miss the unique stories of these applicants. I believe a significant challenge that minorities may face is microaggression– subtle, hidden and happen on a daily basis. Microaggressions can be more powerful and hurtful than visible aggression. Unfortunately, you might sometimes face patients and coworkers who question your knowledge and skills, based on your sex, orientation, age or skin color instead of your work or level of training. how can we empower physicians who identify as

lgbtqia+ so that there is better representation and

inclusivity in medicine? how do you think this would help?

Almost 18% of percent of Gen Z identifies as LGBTQIA+. That is nearly one in six people in that demographic. In light of this fact, I believe reinforcing workplace regulations that protect all minorities would be a major step toward establishing a safe work environment for all. Minority groups are not asking to be favored or receive special treatment – they just want to feel equal. Making sure that every staff member is treated with respect and professionalism, making sure they have access to the same opportunities and career progression, regardless of their individual gender, sexuality or color – these steps would go a long way in achieving these goals. It is not enough to just have this written on websites and pamphlets – it must be incorporated into the fabric and culture of any organization. Even today, we sometimes see leadership positions among many organizations lacking representation for most minority groups or have representation just for the sake of it without actual advocacy for the minorities in question. True representation is especially important and is needed to break the yokes that shackle our communities and divide us for artificial, nefarious reasons. do you think self-identification among lgbtqia+ physicians in leadership and faculty roles can help normalize workforce diversity among the newer

trainees? are there existing mentorship programs or support groups dedicated to this?

During residency, one of my favorite attending physicians used to be incredibly open about their life and personal experiences as an LGBTQIA+ physician. Seeing them so comfortable in their skin while being well-established made me feel confident myself – as a member of multiple minority groups, not just one. This is just one example of how representation for minorities in leadership positions can be impactful in medical training.

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A Young Attending’s Perspective on LGBTQIA+ Representation and Inclusivity in Medicine Continued Being different is scary – it makes you feel constantly monitored and endlessly judged for being who you are. Representation and allies in leadership can make you feel safe, present and strong. The Massachusetts Medical Society has an LGBTQIA+ chapter and before COVID-19 there used to be two major events each year where residents and students would get to connect with their peers as well as established attending physicians, make connections and get advice. The chapter also has a wonderful mentorship program which absolutely needs to be advertised and utilized more.

of Transgender and Gender Nonconforming Adults: www.fenwayhealth.org/documents/ the-fenway-insti­tute/policy-briefs/TheFenway-Institute-MTPC-Project-VoiceReport-July-2014.pdf. are there any resources you would recommend for improving awareness and sensitivity among health care providers

what aspects or nuances are overlooked by physicians who have limited experience working with these populations?

Affirming your patient’s identity is one of the main things that a health care provider needs to emphasize . A first step is using the patient’s preferred name and pronouns. LGBTQIA+ patients face a lot of trauma and rejection from both family members and society at large. Placing their care in the hands of a doctor involves a feeling of loss of control for any patient and only adds to their vulnerability. So, acknowledging the patient’s orientation, gender and preferred name is a great way to initiate the therapeutic alliance and offer a safe space to patients so that they can work with us to address their concerns, both medical and otherwise. Some useful resources to start with for this include: • Collecting Sexual Orientation and Gender Identity in Electronic Health Records available at www.lgbthealtheducation.org/lgbteducation/publications/. • Do Ask, Do Tell: A Toolkit for Collecting Data on Sexual Orientation and Gender Identity in Clinical Settings: www. doaskdotell.org. what are the major problems faced by your patients? what are some rapidly implementable solutions to these problems?

I think the LGBTQIA+ community faces a lot of discrimination from society and this extends to health care. Even simple changes such as medical records reflecting the patient’s preferred pronouns and name can help to narrow the gap between patients and physicians. A fear of the unknown, and of something being different from what one is used to, can become fuel for unconscious microaggression and bias. For many providers, there has not been enough of an emphasis on education about LGBTQIA+ health. Introducing LGBTQIA+ issues in the curriculum in medical schools is particularly important for ensuring that future providers are sensitive to these concerns. At the same time, providing education to the current generation of practitioners is important as well. This could begin with requiring relevant CMEs during license renewal or increasing the number of LGBTQIA+ questions in the board certification and recertification exams. These steps would help present and future providers understand and familiarize with the issues and concerns that these communities face. I’ve included some resources that touch on this topic below: • National Transgender Discrimination Survey: www.transequality. org/issues/national-transgender-discrimination-survey • Discrimination and Health in Massachusetts: A Statewide Survey MAY / JUNE 2021

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– perhaps a podcast or guide

that you favor for quick and easy access?

Fenway Health has lots of resources available for both providers and patients online at www.fenwayhealth.org, as well as publications – for example, there is The Fenway Guide to LGBT Health by the American College of Physicians, available here: www. amazon.com/Fenway-Lesbian-Bisexual-Transgender-Health/dp/1938921003. Other resources that are available, and this is not an exhaustive list, include: 1. The National LGBT Health Education Center: www.lgbthealtheducation.org 2. Institute of Medicine. The Health of Lesbian, Gay, Bisexual, and Transgender (LGBT) People: Building a Foundation for Better Understanding. Washington, DC: National Academies Press; 2011. Available at www. nap.edu/catalog.php?record_id=13128 3. World Professional Association for Transgender Health Standards of Care: www. wpath.org 4. Center of Excellence for Transgender Health Primary Care Protocols: www.transhealth. ucsf.edu 5. Massachusetts Transgender Political Coalition: https://www.masstpc.org/health-care/ 6. Transgender Law Center: Health Care Issues: www.transgenderlawcenter.org/ issues/health A resource for insurance and billing issues: Human Rights Campaign: Finding Insurance for Transgender-Related Healthcare: www.hrc.org/ resources/finding-insurance-for-transgender-related-healthcare. Resources for patients on legally changing their name and gender: 1. The Name Change Project from the Transgender Legal Defense and Education 2. Massachusetts Transgender Political Coalition: https://www.masstpc.org 3. Transgender Law Center: www.transgender17


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JEDI or Die A Young Attending’s Perspective on LGBTQIA+ Representation and Inclusivity in Medicine Continued lawcenter.org 4. Health Care Rights and Transgender People: www.transequality.org/know-your-rights/ healthcare

Now We Turn Unto Our Calling: Medical Students During the COVID-19 Pandemic Calvin Schaffer, Sabahat Rahman, Sarah Ferreira, Bennett Vogt and Paula Whitmire shown left to right

there is a lack of representation of these populations in research

studies. do you see this gap being bridged in the near future?

As a matter of fact, there has been an increase in LGBTQA+ research in recent years. Unfortunately, there is still a gap in the number of published studies – something which is common with research studies revolving around other minority groups as well. I hope to see an increase in well-designed, published research in the near future. + Dr. Salama is a graduate of Cairo University Faculty of Medicine and trained in Health Care Management at The American University in Cairo, Egypt. He then spent time at the International Organization for Migration, a branch of the United Nations, providing care to vulnerable migrants and victims of trafficking. He did part of his medical training at Harlem Hospital Center in New York City and completed his internal medicine residency at Saint Vincent Hospital in Worcester, before joining Fenway Health in Boston in 2018. With a focus on the LGBTQIA+ community as well as people living with HIV/AIDS, Fenway Health provides comprehensive and equitable access to health, in addition to research, education and advocacy for these communities. Dr. Parul Sarwal is a PGY-III internal medicine resident at Saint Vincent Hospital.

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W

e came to medical school with the desire to address social issues.

But as the pandemic devastated our community, we often heard the best way we could help was to stay home and study. However, we felt our physician identity, our lifelong oath and commitment to serve our patients, began when we put on our white coats. With countless health care providers risking their lives every day to continue to uphold their own oaths, we felt compelled to do the same. While the authors were involved in many of the student volunteer efforts, we cannot begin to take credit for the magnitude of the projects taking place. However, we wish to share some of these projects to emphasize how impactful mobilizing the often untapped medical student population has been to a public health response. Despite lacking a framework for student action, students at UMass Medical School were able to create a COVID-19 Student Task Force. In collaboration with mentors, school administrators and community partners, the group supervised over 25 student-led projects across two hospital systems and several counties in Massachusetts (1). Within a few months, students helped collect and deliver over 20,000 pairs of gloves and 1,000 N95 masks to local hospitals, performed respiratory fit testing of over 1,000 hospital employees, created 130 gallons of hand sanitizer and trained an entire hospital network of 850 staff across 60 outpatient clinics on telehealth technology. Students supported local nursing homes by partnering with elders to provide social connection, aided schools by helping students navigate digital learning, assisted in contact tracing efforts, raised money to provide food and drinks to front-line staff and volunteered at a field hospital (1). Through these experiences, as students got a more nuanced understanding of community needs, addressing inequity became a key focus of student efforts. Medical students worked to transform their in-person, free clinic program to telehealth to ensure patients had access to care. Organized Medicine at UMMS and the Massachusetts Science Policy Network advocated on a state and national level to address policy issues related to COVID-19, including promoting the establishment of fellowships for medical students to participate as science policy advisors to leaders in state government. Lastly, students engaged with the Sustainable Health Equity Movement, an international movement pushing for a health equity-focused approach to the global COVID-19 response, presented a review of health inequalities in the United States. With the emergence of vaccines, students have again stepped up and hundreds have joined efforts across the city and state in partnership with Commonwealth Medicine. Through many of these efforts, we have had the opportunity to directly work with and learn from vulnerable and marginalized communities. Medical students and health care workers have risen to the occasion and worked countless extra hours and done a miraculous amount of work in the face of

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JEDI or Die

Now We Turn Unto Our Calling: Medical Students During the COVID-19 Pandemic Continued a chaotic and deadly pandemic, sometimes while dealing with personal tragedy. However, we are left wondering if the need for such sacrifices could have been avoided, not just in our field, but in all sectors of society. Would addressing systemic inequalities have lessened suffering and dependence on emergency action by an overstretched health care system and community? Prior to this pandemic, too often medicine and public health were considered to be separate entities. This crisis has shown the dangers of that line of thinking and how medicine is the most downstream net for addressing health sequelae caused by inadequate public health interventions upstream. As current health professional trainees, we are not surprised that the gaps of health care, especially regarding health inequities, have been put in a harsh light during this pandemic. We have seen the disproportionate health and economic impact that this pandemic has had on people of color, people in the service industry, low-income families, and vulnerable populations, exacerbating inequalities that social scientists have been warning us about for decades. It is an unfortunate reality that our collective failure to take adequate action on these warnings has cost people their lives. Going forward, it is essential that we treat health inequities as an urgent public health issue and that we recognize the role of socioeconomic inequalities in health disparities. As public health becomes a more significant shared concern, there is a greater need to include a wide range of equity-minded experts representing the various concerns of the community when making decisions dealing with life and death . We must guarantee public health officials are given the credibility they deserve and have a seat at the table when decisions that will affect the health and safety of our population are discussed. We must commit to funding public health and community organizations that can address systemic issues plaguing our country from its foundation, including racism, access to care and uninformed leadership. We must empower individuals from diverse backgrounds to lead these efforts and ensure that equity is at the forefront of all levels of medical education, practice and leadership. Invigorated by these tenets and the work we have contributed over the past year, we look forward to building better representation in medicine and being a part of creating a more equitable future.

Acknowledgments: Thank you Drs. David Chiriboga and Michael Hirsh for their early guidance on this perspective piece. We’d like to acknowledge and thank the leaders of the COVID-19 Student Task Force and the faculty for their guidance and support. We’d also like to acknowledge all of the 170-plus students, community members and faculty who volunteered their time to participate in these efforts. Finally, we’d like to thank all health care workers and essential workers who risk their safety and well-being to keep Worcester going during this pandemic. +

Reference: 1. University of Massachusetts Medical School Collective Student Response To COVID-19. https://icollaborative.aamc.org/ resource/11059/. Accessed August 16, 2020.

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A Cautionary Tale B. Dale Magee, MD curator

I

t is well-known that elizabeth blackwell

was the first woman in the United States to earn an MD degree in 1849. Her roundabout path to formal medical education included spending a few years making contacts and gathering allies among recognized physicians as well as studying medical subjects informally. Having applied and been rejected by dozens of medical schools, including all in Philadelphia and New York City, she resolved to approach schools located in the country, where the weight of tradition may have been less. Her application to Geneva Medical College in 1847 came accompanied by a letter of recommendation from a Philadelphia physician. The faculty, not quite knowing how to respond, turned the decision over to the students stating that it was their decision and a single negative vote would result in rejection of Ms. Blackwell’s application. They voted her in more as a source of entertainment than a commitment to equality of the sexes. Once enrolled, her sober presence and focus on study immediately quieted the normally boisterous classes. She finished first in her class and went on to blaze many more trails in medicine. Three years after her application, in 1850, three prospective Black students; Daniel Laing Jr., Isaac Snowden, Martin Delany and a woman, Harriot Kezia Hunt; applied to Harvard Medical School. Ms. Hunt —who already had been practicing medicine without a degree, like about half of physicians at the time — had previously applied and been denied admission. The then-dean, Oliver Wendell Holmes, approved the admission of all four. When the students and faculty got word of this, they voted to protest the admissions — the actual votes were a little more nuanced, but the end result was the same. Mr. Holmes was able to advocate for two of the applicants, who were subsequently admitted to Dartmouth, but, in the end, he relented to the will of the students and faculty. Mr. Holmes’ career was among the most distinguished in the country. His intelligence, critical thinking and advocacy resulted in uncovering the cause of child bed fever and drew attention to the ineffectiveness of homeopathy as well as traditional medical treatments. He was extensively educated in both the United States and Europe and brought a professor’s perspective to medicine. Beyond 19


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JEDI or Die providing good care for his patients, he helped to change the face of medicine from one based on tradition to one focused more on science and results. Medical school in the mid-19th century was not what we have come to expect today. There were no significant prerequisites; courses were lectures with little or no patient contact. Medical schools were completely dependent on income from student tuition and, thus, a protest could be ruinous. Examinations were oral in the case of Harvard, and others, since a significant percentage of the students were illiterate. Boisterous activity, sometimes leading to complaints by neighbors of the schools, was not unusual. A member of Ms. Blackwell’s class described the student body as one made up of the sons of farmers, tradesmen and mechanics. A common saying ... was, “a boy who proved unfit for anything else must become a doctor.” In 2020, Harvard Medical School students circulated a petition protesting the name of the institution’s Oliver Wendell Holmes Society. The petition stated that “As dean of HMS in 1850, [Mr.] Holmes was challenged by students and faculty to revoke the acceptances of three Black students that had gained admission to HMS. Holmes responded by expelling the Black students and wrote, ‘This experiment that the intermixing of the white and Black races in their lecture rooms is distasteful to a large portion of the class and injurious to the interests of the school.’” Many other points are made in the petition, but no mention made of the fact that Mr. Holmes was responsible for admitting the three Black applicants, and a woman, in the first place. Over 650 signatures were obtained from faculty and students. The name of the Oliver Wendall Holmes Society has been changed. The faculty of Geneva Medical College may have shown foresight in dodging a potential student revolt, but, by today’s standards, the students made the right decision for the wrong reasons. Mr. Holmes, condemned by students and faculty in 1850 for admitting Black students and a woman, now stands condemned by students and faculty for not succeeding in overcoming the ethos of the times. +

References: Blackwell, Elizabeth. 1977. Pioneer Work in Opening the Medical Profession to Women. With New Introduction by Mary Roth Walsh. Schocken Books, New York. Podolsky Scott, Bryan Charles. 2009. Oliver Wendall Holmes, Physician and Man of Letters. Science History Publications, Sagamore Beach. Nolan, LaShyra. 2020. Renaming the Holmes Society At HMS/HSDM. Webpage Accessed 2021-2-10. [https://docs.google.com/forms/d/e/ 1FAIpQLSeGz-HFs9NGE1vQxGSuAbaJQh_LRap8jzkvNadrtL1PtrMX-A/viewform]

In Memoriam Dr. Robert E. Maher

Dr. Robert E Maher, an obstetrician and gynecologist, who practiced in Worcester for over 35 years, died Feb. 3, 2021. Dr. Maher was born in Pittsfield, Massachusetts, and was educated locally. He attended The College of the Holy Cross and medical school at Tufts University. Later, he served in the U.S. Navy. Following naval service, he worked as an attending OB- GYN at Saint Vincent and the former Hahneman and Worcester City hospitals. In 1978, he ended his private practice and became the chiefOB-GYN at the Fallon Clinic. Dr. Maher was certified by the American Board of Obstetrics and Gynecology. He was a fellow of the American Congress of Obstetricians and Gynecologists, a member of the Worcester District Medical Society, the Massachusetts Medical Society , and served on the board of directors of the former Marillac Manor in Worcester. He was a faithful communicant at the Immaculate Conception Parish, a member of the Order of the Purple Knights of The College of the Holy Cross and a member of the former Alumni Sodality of our Lady at Holy Cross. Dr. Maher’s life was described as incredible; enriched by faith, love and humor. + Sidney P. Kadish, WDMS Memorials Committee

20

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Society Snippets: Wednesday, February 10, 2021

225th ANNUAL ORATION “The Next Gen – The Physician Work Force of the Future”

Health Matters

Health Matters is a television program produced in collaboration with The Worcester DistrictMatters Medical Society and WCCA Health TV in Worcester. Offering valuable information on disease Health Matters is a television program produced in collaboration with The prevention, options, current public healthOffering issues Worcester Districttreatment Medical Society and WCCA TV in Worcester. valuable information on Matters disease prevention, treatment current public and more, Health is produced in a ½ options, hour interview health issues and more, Health Matters is produced in a ½ hour interview format and the program airs on WCCA TV Cable Channel format and the program airs on WCCA TV Cable Channel 194: Wednesday194: WednesdayNoon and 7:30 Thursday– Noon and 7:30 pm, Thursday– 7:00 pm pm, and Friday – 9:307:00 am. pm and Friday – 9:30 am.

Orator: N. Lynn Eckhert, MD, MPH, Dr PH Professor of Family Medicine and Community Health UMass Medical School of Health Matters please visit: www.wdms.org view episodes of Health Matters please visit: www.wdms.org Senior Lecturer Harvard Medical School To viewToepisodes Show Number 206 "COVID 19 Vaccine Trial"

On February 10, 2021, Dr. Lynn Eckhert delivered the 225th WDMS Oration, with approximately 80 physician and student members in attendance. It was an interesting and informative talk about the next generation of physicians. Dr. Eckhert’s research revealed fascinating data and trends and the group participated with engaging questions and comments. The following word cloud was generated when asked “What are your thoughts and hopes for the physicians of the future”? + Visit Our Website: https://www.wdms.org/ Event Calendar >Past Events

(L-R) Guest- Dr. Robert Finberg, Host -Dr. James Broadhurst, Guest- Dr. Matilde Castiel

2021 Call for Awards Nominations

Show Number 207 "Urinary Incontinence, It May Be Common, But You Don't Have To Live With It"

31st Annual Dr. A. Jane Fitzpatrick Community Service Award Established by WDMS to recognize a member of the health care community for their contributions beyond professional duties, to improve the health and well-being of others and to commemorate the life-long community contributions and exemplary efforts of Dr. Fitzpatrick in the Worcester Community.

(L-R) Guest- Dr. Cynthia Hall, Host -Dr. James Broadhurst

2021 WDMS Career Achievement Award

Show Number 208 “Skills to Sustain Caregiving”

Established to honor a WDMS member who has demonstrated compassion and dedication to the medical needs of patients and/ or the public, and has made significant contributions to the practice of medicine. To nominate an individual please include: 1) A letter of nomination 2) A current curriculum vitae of the nominee 3) Letters of support are encouraged DEADLINE: August 06, 2021 E-Mail: MBoucher@wdms.org Mail: Worcester District Medical Society Mechanics Hall 321 Main Street, 2nd Floor Worcester, MA 01608

(L-R) Guest- Dr.Tina Runyan, Host -Dr. James Broadhurst

If you have an idea for a topic or guest, or wish to be a guest, If you have wordmsa@massmed.org an idea for a topic or guest, to be a please contact or or callwish 508-753-1579.

guest, please contact mboucher@wdms.org or call 508753-1579.

Any questions call: 508-753-1579 or visit our website 22

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EQUITY

OUR RELENTLESS COMMITMENT “UMass Memorial Health is taking a stand for equity, both within our community and throughout our institution. We aren’t simply talking about it, but we’re actively listening and putting processes in place to be sure that every community member, every patient and every employee is treated with dignity and respect — and that everyone has direct access to the highest quality of care, along with the environmental factors that contribute to their overall health. Sometimes that means that as health care providers, we need to go above and beyond to ensure equity for under-resourced communities that have been disproportionately underserved by the health care industry. Our commitment is to go that extra mile.” – Eric Dickson, President and CEO, UMass Memorial Health What does equity look like to your patients? Is it access to a good education, a safe home and healthy meals, no matter what neighborhood they live in? Is it the opportunity to secure a reliable job or be considered for career advancement, no matter the color of their skin? Or is it simply the privilege of receiving excellent health care, no matter how much money they have in their bank accounts? Likely, it’s all of the above. Through our Anchor Mission work, UMass Memorial Health is committed to ensuring opportunities are afforded equitably to each and every one of our community members — so better, healthier lives aren’t just for the privileged few, but for all. Relentlessly.

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