By Sonya Tang Girdwood (@STangGirdwood)
With the recent killings of Ahmaud Arbery, Breonna Taylor and George Floyd in the United States, our society has not only been challenged to reflect individually on our own personal racist views and biases, but also to assess the effects of structural racism on the lives of Black members of our communities.
For physicians and other healthcare providers, this call has led us to (re)consider the effects of structural and institutional racism on healthcare, particularly in the care of Black patients. While I had learned about the injustices suffered during the Tuskegee syphilis experiment and in the procurement of HeLa cells during medical training, addressing structural racism as a practicing clinician was something I had never considered. I also had no idea where to start.
In response to the racism epidemic in healthcare, the Journal of Hospital Medicine published two articles about racism – one regarding the two pandemics that Black physicians and patients were currently experiencing1 and another about systemic racism in medicine and the call to dismantle it.2
The journal hosted a Twitter Journal Club, #JHMChat, moderated by authors from the two articles, Drs. Kimberly Manning and Ndidi Unaka. During this public forum, we discussed the topic of racism in medicine and the lack of diversity among physicians. Two physicians, Drs. Vignesh Doraiswamy and Anika Kumar, discussed their practice of conducting “Equity Rounds” while they are on clinical service.
During Equity Rounds, they would deliberately spend time with their team discussing why certain patients are unable to receive optimal care and how social determinants of health play a role in patient care.
I was intrigued, as well as saddened, that I was not already doing this regularly on rounds. When the #JHMChat moderators asked what we planned to do differently after participating in the Twitter chat, I stated that I would implement Equity Rounds the next time I was attending on my pediatric hospitalist service.
Having declared my plan publicly on social media with multiple people holding me accountable, I had to follow through with conducting Equity Rounds when I was on service in early August. However, going into my week of service, I did not have a concrete plan. Before starting the week, I sent the senior residents my resident expectations document, added a couple of sentences that I would be testing out Equity Rounds, and stated that I was open to feedback and suggestions on how to conduct them throughout the week.
Having now completed my service week, I am reflecting on what I learned from Equity Rounds:
Come to Equity Rounds with humility and an open mind.
Not being sure about the logistics of Equity Rounds or how well it would be received by my team, I was honest about both concerns during my first day of service with the medical students and residents when we discussed expectations.
I explained my reasoning for conducting Equity Rounds and that we should be identifying barriers that prevent our patients from receiving the best care possible. I told them I did not know if we would address these barriers after every patient encounter or at the end of rounds, whether we would conduct them every day or only a few times over the course of the week. I explained that it would be a learning experience for us all and that I hoped they would be engaged and provide feedback on how Equity Rounds went. I prepared myself for the possibility that my first implementation of Equity Rounds could fall flat but felt convicted that I needed to put aside my pride and learn how to make the experience better over time.
Equity Rounds are everyone’s responsibility.
I initially placed a lot of pressure on myself to be the one primarily responsible for Equity Rounds–to be the one to lead the discussions and summarize available literature. However, I quickly learned that all of my team members had recognized that addressing equity was a shared responsibility.
On admission of new patients, the senior resident discussed with the intern any social determinants of health that may have led to the admission and that would affect quality of care. During our daily pre-round huddles, when we typically discussed resident schedules, potential discharges, and patients at risk for decompensation, the senior would bring up concerns about patients she termed as an “Equity Watcher.” By naming these patients out loud, she allowed us to explore and address some of the issues before seeing the patient.
The medical students on my team were eager to participate and contribute to Equity Rounds.
When one of our patients had a reaction to vancomycin and it was described in the notes as “red man syndrome,” I asked a medical student to read a short article that was recently published about replacing the racist term3 while the senior resident and I went to examine the patient. The student summarized the article for the team, and we discussed other medical terms with racist origins. We decided that we would individually commit to stop using the term “red man syndrome” in the future and replace it with “vancomycin flushing reaction.”
Similarly, I learned on Twitter from a colleague about the movement to remove race-based estimation of glomerular filtration rate (GFR). Given that I had just talked about acute kidney injury with the acting intern, I asked him to look into the GFR literature and present a short didactic on rounds. He found several papers on the topic, as well as on the effect of including race in risk estimation for urinary tract infections in infants. He summarized the literature for us on rounds then followed up by forwarding the articles to us for our future reference.
Though interns were often too busy to read papers during the week, they found ways to address equity when caring for their patients. When we admitted a patient for poor weight gain in the setting of multiple missed medical appointments, the interns spent time to understand the barriers that prevented the family from seeking care, rather than relying solely on our social worker to uncover the details. We worked with the family to address those barriers and assisted them with scheduling all their appointments on the same day to minimize the need for transportation.
Every member of the team had a role in addressing equity for our patients and ensuring Equity Rounds led to change in our clinical practice and in the care of our patients. Providing excellent patient care and teaching medicine are the responsibility of all members of the care team and addressing equity should be as well.
Prepare for Equity Rounds ahead of time.
I realize now, even though I may not know ahead of time the exact barriers faced by the patients I will be seeing on service, I can expect having patients with common diagnoses such as failure to thrive, asthma and inadequate pain control.
With all these diagnoses, there are structural inequities that lead some patients to be admitted for care and others to be treated at home.
There is structural racism in place that causes some patients to receive certain treatments in the hospital, but not others.
I will certainly see patients who have their oxygen saturations measured with a pulse oximeter, which are usually calibrated for patients with light skin color. I will likely care for patients with rashes, which are often taught to medical students using only images of patients with light skin color.
These biases must be recognized, and their implications must be discussed. Just as I prepare trivia cards to teach about antibiotics on rounds, I can and should prepare ahead of time to teach about these inequities. I can and should continue to collate articles addressing these issues and identify gaps in our knowledge. I can and should be prepared for Equity Rounds.
I look forward to conducting Equity Rounds again the next time I am on service, applying the lessons learned from my first attempt. My goal is to help chip away at the structural and institutional barriers that lead to inequitable care.
My ultimate hope, though, is that I no longer have to call them Equity Rounds in the future because these practices have been naturally integrated in rounds as we continue to more fully recognize the need to teach and address health inequities and structural racism the same way we teach about diagnoses and disease management.
- Manning KD. When Grief and Crises Intersect: Perspectives of a Black Physician in the Time of Two Pandemics. J Hosp Med. 2020;15(9):566-567.
- Unaka NI, Reynolds KL. Truth in Tension: Reflections on Racism in Medicine. J Hosp Med. 2020;15:572-573.
- Austin JP, Foster BA, Empey A. Replace Red Man Syndrome With Vancomycin Flushing Reaction. Hosp Pediatr. 2020;10(7):623-624.
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