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Palliative Care’s Diversity Problem: A Podcast with Lindsay Bell, Tessie October, and Riba Kelsey

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Palliative care has a diversity problem.  The workforce of palliative care looks nothing like the patient population that we care for in the hospital and in our clinics.   For example, in 2019-2020 academic year only 4% of Hospice and Palliative Care fellows identified as black, compared to 12% of the overall US population using the most recent census information.   These issues are similar for hospice and geriatrics.

On today’s podcast we talk about this diversity problem with Lindsay Bell, Tessie October, and Riba Kelsey. Lindsay, Riba, and Tessie recently published an article in JPSM that found that trainees at historically black colleges and universities and residents at institutions with the highest percentage of black medical students lack access to palliative care training. 

Riba Kelsey is the Family Medicine residency director at Morehouse School of Medicine, and we talk with her about the implications of these findings at historically black colleges and universities (HBCUs), as well as what we can do in the field of palliative care in general to improve our workforce issues.

One shining example we discuss in depth is the ongoing collaboration between the University of Pittsburgh Palliative care group and Morehouse School of Medicine.  We hope that collaborations like these will lead to a wider pipeline of palliative care informed trainees from diverse backgrounds, and someday soon, greater diversity in the palliative care workforce.

You can also find us onYoutube!

 

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TRANSCRIPT

Eric: Welcome to the GeriPal Podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, we’ve got a full house today.

Alex: Yeah.

Eric: Who do we have with us?

Alex: A full house. We are delighted to welcome to the GeriPal Podcast Lindsay Bell, who is a researcher and program coordinator in Palliative Care Research Center at the University of Pittsburgh. Welcome to the GeriPal Podcast, Lindsay.

Alex: And we have Tessie October, who’s a pediatric palliative care physician; first pediatric palliative care physician on the GeriPal Podcast. And a critical care physician at Children’s National in DC. Welcome to the GeriPal Podcast, Tessie.

Tessie: Thank you. Thank you for having me.

Alex: Then finally, we have Riba Kelsey, who is a family medicine physician in Atlanta, at Morehouse, which is one of the Historically Black Colleges and Universities in the United States. Welcome to the GeriPal Podcast, Riba.

Riba: Thank you. Thank you for having me.

Eric: We’re going to be talking about, and the framing around a recent Journal of Pain and Symptom Management, JPSM, paper, on the lack of exposure to palliative care training for black residents. A study of schools with the highest and lowest percentages of black enrollment. This is absolutely fascinating paper.

Eric: Lindsay was the first author, Tessie was the senior author. Love to get into that. But before we do, we always have a song request. Lindsay, I think you got the song request this time around.

Lindsay: I do. Our song request is going to be Run the World by Beyonce. And we chose this because Beyonce — I don’t know if anyone’s seen the Netflix special, but she pays homage to HBCUs, which is a large part of our paper.

Alex: HBCU stands for the Historically Black Colleges and Universities.

Lindsay: Yes. And we have three ladies from our team joining us today, so we thought it was appropriate.

Alex: And also to torture me. [laughter] Female diva singer-songwriter, which I’m pretty far from, but it’s all fun. Here we go, just a little bit.

Alex: (singing)

Eric: Nicely done, Alex.

Tessie: That was pretty good, I have to say that.

Eric: I was not expecting that.

Eric: Yeah, that was great. I almost had a joke about Beyonce could probably keep her job. Like, “Yeah, you’re not going to take it over.” But that was pretty darned good. [laughter]

Eric: I think Beyonce’s still pretty safe, though.

Alex: Thanks, pal.

Eric: Let’s start off talking about this paper. We usually do, before we even jump into the paper, how you got interested in this subject. I’m going to start off with Lindsay. How did you get interested in this as a potential research project for you?

Lindsay: In my role as research project coordinator, I am working on a project that partners with Howard University, Morehouse School of Medicine, which is how I met Riba, and then the University of Puerto Rico to implement a palliative care educational intervention.

Lindsay: Importantly, Howard and Morehouse are both HBCUs, and the University of Puerto Rico is a predominantly Latinx-serving institution.

Lindsay: It was interesting that these three major institutions that serve under-represented students didn’t have palliative care training. So we were curious to know what the state of this type of training looked like at other institutions that serve predominantly under-represented students.

Lindsay: For myself, I was aware of the disparities that exist in palliative care, and I was learning more about the issues in the workforce with diversity. And was curious to know what factors that might contribute to these issues are found in the medical education system.

Eric: Tessie, how about you? How did you get interested in this? Pediatric palliative care doctor, critical care…

Tessie: Yeah, I mean, when Lindsay came to me with the idea, I was like, “This is something we have to do.” I teach communication skills as a consultant with VitalTalk; your audience will know VitalTalk. It’s one of the platforms, I would say probably, one of the gold-standard platforms out there that teaches communication skills to clinicians who are taking care of patients who have serious illness.

Tessie: As a facilitator, I’m constantly struck by the lack of diversity in the facilitator pool. And I know this lack of diversity is equally present in the clinical setting. Not only do we not have black clinicians teaching this material, we also don’t have black clinicians at the bedside.

Tessie: And we know from the literature that race matters, and that racism exists. That racial concordance matters. That patients are more comfortable with doctors who look like them. They’re more likely to report their symptoms, more likely to be compliant with their medications, and so on and so forth, when they’re communicating with a doctor who looks like them.

Tessie: So it made me sad to think about the fact that me, a black woman, that many patients who look like me, they never have the experience of connecting with a black physician while they’re at their most vulnerable time: dealing with a serious illness.

Tessie: It became important to me think of, “Where is the problem? Is it that we’re in the pipeline. Are we not recruiting palliative care physicians who are black and brown people?”

Eric: And Riba, in your experiences as an educator and a clinician, is this something that also resonates you as far as palliative care workforce and the lack of diversity in it?

Riba: Sure, absolutely. That’s exactly it: as a clinician and as an educator and as an administrator, I direct the Family Medicine Residency Program. So curriculum is very important to me in how we build out our curriculum.

Riba: Understanding first that there is under-utilization of palliative care services among African Americans and Latina persons. Then secondly, understanding, “Well, wow, we are here at an institution where we’re training people who will ultimately likely be the ones who are going to take care of patients who are from that population.”

Riba: Not only that, at an institution where our goal is to help to eliminate health inequities. And understanding that as people understand and know better and develop the skills, they have greater self-efficacy, and are therefore going to be more likely to utilize a particular skill. In this case, we’re talking about palliative care.

Riba: So all of those things were in my mind as the idea of the paper was brought to me. And I said, “Well, it would be really important for us to understand what the scope of this is across other institutions. So that as we start to think about solutions, then we can have a sense of where our starting point is.” That’s really what the interest was for me.

Eric: Then Lindsay, let’s briefly talk about the paper. What did you try to do in this paper? What was the question? We’ll have a link to the paper in our Show Notes on the GeriPal website. So if you’re interested, you can pull up the paper.

Lindsay: In this paper, like Riba mentioned, we wanted to see what the scope of palliative care training was, particularly at institutions that had the highest rate of black medical student enrollment.

Lindsay: Then also see what that looked like at schools that had the lowest rate of enrollment, to understand if there was some sort of difference between those groups of institutions.

Lindsay: We basically just did basic internet searches. We communicated with representatives at these institutions to evaluate across all phases of medical training, if there was palliative care offered at those institutions.

Alex: Yeah. Can I ask, what did you find?

Lindsay: We found, first of all, we looked at all the HBCUs that have a medical program, and there are four of those in the U.S. None of the HBCUs that had a medical program incorporated palliative-care training in their medical school or residency curricula. They also didn’t have hospice and palliative medicine fellowship programs.

Lindsay: Then among the institutions that had the highest rate of black medical student enrollment, we found that their family medicine and internal medicine residency programs were less likely to offer palliative care training, when compared to institutions that had lower rates of black medical student enrollment.

Eric: Then, again, when you’re looking at top versus bottom medical student enrollment, do we have also an idea … I’m guessing that correlates fairly also well with residency enrollment? Is that right? Or do we know anything about that?

Lindsay: I am not sure, honestly. It’s hard to find data on race and ethnicity within each residency program.

Lindsay: So we basically based it off of what we knew about their medical school. And from there, were able to select the institutions that we looked at.

Eric: Okay. Tessie, did this surprise you?

Tessie: No, unfortunately, it didn’t. I would say I was just trying to think back of, “When did you get excited in medical school?”

Tessie: About a subject, right? When do you know that you’re going to be a surgeon or a pediatrician? It’s those experiences that our black students are not even getting exposed to our field. So how do they even know that we exist?

Eric: I think back to my own training; it was really face time with faculty members who served as role models that got me interested in both geriatrics and palliative care. They’re the ones that motivated me and mentored me to go into this field. If you don’t have those people, you may not even know the field exists.

Tessie: Right. We’re such a young field, to begin with. And we are really nice people, palliative care. Especially palliative care pediatricians are. They don’t get to meet others.

Eric: You should meet some of us palliative care geriatricians, too, at the other end of the spectrum.

Alex: Riba, any thoughts from you about these findings?

Riba: Yeah, I mean, like Tessie, they were not particularly surprising to me. We were aware that within medical schools, within residencies, that there are low percentages of African Americans in those training spaces anyway.

Riba: So when you get into the specialty spaces, and the ability to, as you mentioned, see others who are doing palliative care and teaching palliative care, that we already know that that lack exists.

Riba: We know that medical students, it’s just as you said: When you see someone who you can see yourself becoming, doing a thing, then you take an interest in that thing. In this case, a specialty area, or as we’re talking about, palliative care.

Riba: I would say that it didn’t particularly surprise me.

Eric: Somebody could briefly look over this, and without even thinking, say, “Ohmigosh, yeah, these Historically Black Colleges and Universities, these medical programs in them, they don’t have palliative care. They should do a better job.”

Eric: That feels like not the conclusion we should be taking here. I’m wondering, as we think about this paper, and we think about what can we do as a field … no, maybe we can go individual and as a field, to make change to make it better.

Eric: Yet I’m guessing you’re not going to say, “Oh, these HBCUs should do better and I don’t have to worry about this here at UCSF.”

Riba: You’re right, there are those who will read the paper and say exactly that. But it’s not that simple of an issue. And it starts with what we discussed in terms of the exposure.

Riba: You remember that faculty members are the ones who teach based upon their areas of specialty, and their area of specialty can be based upon the exposures that they had.

Riba: If you’re having within a faculty people who may or may not have had exposure, we also want to think about that in the HBCU medical schools traditionally, were centered around primary care, increasing primary-care positions, workforce.

Riba: As we expand into more specialty areas, then we’re seeing more those areas that we see, like cardiology and things of that nature.

Riba: But because just as Tessie was mentioning, that palliative care being a relatively young field, then there’s some lack of awareness of it as a field.

Riba: And thinking too that there are some physicians who, in their personal lives, have had experiences with family members or loved ones who have engaged with palliative care, perhaps in instances when it was much later than they should have been introduced to it. So then their perception may not have been as positive about palliative care, so they have not taken on an interest.

Riba: There are so many layers, both from the individual patient level, then also at the institutional level, that I think is too broad of an issue; too grand of an issue to say that it’s just that “They need to get it together.”

Riba: Now, what we can do is certainly, like some of the partnerships we’re doing here with the University of Pittsburgh. Certainly in spending funding priorities as it relates to building out capacity at HBCU medical schools and other medical schools that have large populations of black medical students, in terms of building out curriculum in spaces.

Alex: Could we hear more about the partnership with the University of Pittsburgh and what that looks like?

Riba: Sure. Yes, we’ve been working with the University of Pittsburgh with Dr. Bob Arnold. Lindsay has been a part of this work, Dr. October has been a part of this work.

Riba: With it, we’ve been able to have exposure to lectures; actually, Dr. Arnold just left us on Wednesday, where he came and did a train-the-trainer session where he worked with faculty members on delivering feedback.

Riba: He’s done another train-the-trainer session with us in terms of teaching communication skills to residents. So we have a series of quarterly talks around various palliative care topics: having a family meeting and things of that nature.

Riba: There’s also an arm of it that deals with mentorship. For those residents who’ve expressed an interest in hospice or palliative medicine, that’s providing them with mentorship. And the scholarship around this work that we’re doing that certainly residents, faculty members and medical students are able to be a part of that.

Riba: Also connecting with resources including the palliative care organization that we’ve been able to get some training through. It’s a multifaceted approach to provide exposure and education both at the faculty level and the training level, that we have been engaged in. Lindsay may want to chime in a little more to get some other layers to that.

Lindsay: Yes, well, I think that you nicely summarized it. I guess the goal of the project itself is to build the infrastructure for the schools that we partner with to have a curriculum at the end that they can incorporate into their medical school and residency program, to make that available for their students.

Riba: And the events have been really well-received from our residents. There are weekly topics that are sent, just very brief bits of information that are sent on everything from opiates to dealing with delirium. I mean, there are various topics given in very short bites that our residents are able to benefit from. Residents and faculty, quite frankly.

Eric: That sounds like a really amazing opportunity, especially for schools that may not have as much access. If they have a high proportion of black students; that’s what I’m hearing from this paper.

Eric: I wonder what your thoughts are on the other schools that may have less enrollment of black, under-represented minorities. What should we be doing?

Tessie: Can I add to that … I’ll step in here just to say that that’s part of the paper, too. Is that our programs at HBCUs don’t seem to have a lot of palliative-care access or opportunity for people to get exposed to it.

Tessie: But a lot of the folks who go on to graduate from medical school and residency and so on still aren’t choosing palliative care. Our black residents are still not choosing palliative care. The issue for me is a bigger issue of pipeline issues, of having more black people actually be able to enter medical school.

Tessie: We know a lot of that is the effects of systemic racism. That it starts from not having to access to STEM activities. It starts even earlier than that in terms of neighborhood. The neighborhood affected your ability to go to a high-functioning school, all the grades and stuff that you need to advance in medical school. Even the bias we know that exists in the national testing.

Tessie: At every step of the way, black students exit the pipeline and don’t finish, don’t get to medical school. Then even once they get to medical school, they’re still not choosing palliative care.

Tessie: There’s an issue with majority-serving institutions, too, of really trying to draw black residents into those fields. How do we get them engaged and excited about palliative medicine?

Eric: I usually say “the magic wand.” If we had a magic wand, what would we change? I’m going to move that way up from the end to now. Like, getting very practical.

Eric: Again, this is interview season right now for us in residency programs. Well, in fellowship programs, soon to be residency programs. Let’s start off with fellowship programs.

Eric: As we think about this; I even think to myself, I think a lot of fellowship programs think about a commitment to palliative care. Do they have a longstanding commitment to palliative care? Have they done research projects or QI projects in palliative care? Letter writers? Are they from palliative-care backgrounds?

Eric: Because part of it is we don’t somebody who has no exposure to go into a palliative-care fellowship and they’re like, “Oh, I don’t like this.”

Eric: Again, should we rethink how we’re doing this, based on what we’re seeing here in this paper?

Riba: I think there’s two parts to that. I think that certainly at this point, the point of reviewing applications and considering persons to interview and perhaps to rank for the program, I think so.

Riba: Certainly casting a broader net to one that may include a person that has not had the exposure, but has a compelling essay, where you can follow in their essay. Then you know better as you meet and interview them. But it does require a willingness to look a little more broadly.

Riba: But then just as Tessie was mentioning, part of the solution too starts even before that point of reviewing an application. What is the institution, what are the programs doing to reach out to perhaps high school students for summer programs? Or for college students who have an interest in medicine, and may not know about palliative care as a specialty? And to provide research opportunities or even clinical opportunities for them?

Riba: Those are some of the things that can occur that will help to strengthen the pipeline, really, of persons. So that when you are interviewing or reviewing applications, then there are more who’ve had experiences and exposures that maybe they wouldn’t have had at the institution that they attended. Or, with the magic wand, they will have had that exposure.

Riba: But I think the importance really is to give them some exposure earlier on, and thinking about ways in which you can engage learners at earlier stages in their education.

Tessie: I’ll add that some people may hear what Riba said as expanding your vision of what a budding palliative care looks like, might be seen as lowering your standards. I just want to caution us to say that I think what she’s saying is that we have to determine what our priorities are as a field.

Tessie: If we’re saying that as a field, it is beneficial to our patients to have physicians who look like them because they end up with more cultural sensitivity and receive better care, and are more likely to accept palliative care services; then being black alone is a priority.

Tessie: I’m not saying lower your standards. I’m saying you widen your standards so that you see that as a value add, even if they may not have the same Step 1 score, let’s take for example. That’s not going to impact patient care in the same way as them just coming and being able to share those experiences with their patients.

Eric: Yeah. And honestly, it sounds like we should be raising our standards. This is about raising our standards as a field, and highlighting the importance of diversity.

Eric: I mean, I think back to what you were saying about VitalTalk, and all of our programs that we do around education. If there’s not diversity, we got terrible standards, right? Are we really teaching what we need to teach if it’s a bunch of people that look like me that come up with the curriculum? That’s terrible standards.

Tessie: I’ll tell you that at VitalTalk, we’re actually doing something about it. We’ve been really talking about how can we employ more cultural sensitivity when we don’t have black facilitators?

Tessie: We still need to talk about racism. Our patients are still talking about racism. The majority of black patients out there are going to be served by white physicians, or physicians who don’t look like them.

Tessie: So if you’re asking what can we do now, we can improve the skillset of cultural sensitivity for all physicians so that we lead into racism, talk about it, take an anti-racism approach. But also really think about how racism plays into the healthcare experience of our patients.

Eric: Riba, I got a question for you as an administrator, too: I think a lot of what we’re trying to do here is think about the idea of holistic review. It’s not just about one thing, we look at the entire application. We actually have, again, our geriatrics fellowship, a diversity committee that does holistic reviews in addition to the normal process for all under-represented populations.

Eric: I also wonder, because then we ask these individuals from under-represented backgrounds to be on these committees. Then in the back of my mind too, is I also think about this minority tax that we’ve put on them.

Eric: How do you think about all of this? And I’d love everybody else’s thoughts too. Again, at other institutions where they’re under-represented since there may not be a lot of faculty members that are coming from those backgrounds.

Riba: Right. Yeah. Two parts: one in terms of the holistic review of the application. Certainly, I mean, of course we know that we’re looking at scores. We’re looking at the numbers.

Riba: But it’s also important to look at what kind of service is the applicant engaged in? What kind of leadership? What are they saying in their personal statement about their motivation for, in this case, whether we’re talking about geriatric care or palliative care specifically?

Riba: Really, taking all of those things; again, going back to what the priorities are, and what kind of palliative-care physician are you wanting to develop? So it’s important, then, to consider what the substrate is.

Riba: Even, let’s just say somebody who hasn’t had the exposure, yet despite the exposure, has sought out further training, because they have an interest in it. And to tease out what is it that motivates them in terms of what they want to see happen differently with the patients they’re taking care of? That just has to be really part of the evaluation of that application.

Riba: Now, it’s on the applicant, of course, to include something in the personal statement so it’s enough for you to get engaged, to have that interest and then to bring them in to talk to them further. So there is that.

Eric: That’s an interesting point. Because I’ve done a fair amount of mentoring individuals from their personal statements. I have to say is that there usually is … I’m not sure if there’s also a differential in what’s happening with the degree of mentorship.

Eric: From small community programs, for example … I’m just going to stereotype this, but it seems after 15 years of doing this, letters of recommendations from small community programs are usually much shorter than the letters of recommendations I get from top-tier institutions.

Alex: And less effusive. Even about their best candidates.

Eric: Yeah. It’s so hard to know … and it can’t just be about the candidate, because it’s a theme.

Riba: Right.

Eric: Right? It’s a structural bias built into the system, and we see a lot of other of these structural biases. Big institutions usually are pushing back against international medical graduates, that are often much more diverse than U.S. medical graduates.

Eric: How should we be thinking about all of that, too? And I’d love to hear from you, about how do you think about it with your own family medicine residents?

Riba: Sure, yeah. I mean, that last one that you mentioned is tough. Because I mean, there are pressures throughout the system to rank more highly, to focus on LC&E graduates. As you mentioned, the bias against foreign national grads, or international medical grads; that’s something that’s throughout the system.

Riba: Then where programs are concerned about if you have a high percentage of international medical grads, then will you be seen therefore as a program that’s not of good quality?

Riba: So it runs both from the standpoint of how the programs may see themselves, then also the way that they think that they may be seen by others.

Riba: Now, for us, we do look very broadly at the full application. We do look at the scores. You have to do that. But we also will look at those letters of recommendation, and to your point, I do notice the difference in letters of recommendation, depending upon where they are.

Riba: Ultimately, it’s really weighing those different parts of the application to see as a whole, who is this person? There may be a person that you can really just see in the application that they just didn’t have the letter writers. But you can see from other aspects of their application; the electives that they chose to do, whether or not they discussed that.

Riba: Again, some of that comes out in the interview about what their thought process was around selecting certain electives. But at the point of reviewing the application, we just try to look at all aspects of it.

Riba: But as I mentioned, the service, looking at the activities that the resident or the medical student who applies to a residency program, that could be the leadership that they’ve had. What kinds of things they were doing, and whether or not it’s consistent with their stated interests.

Riba: It’s not easy; it’s certainly not an easy task. But certainly it’s important to look broadly and holistically at the application.

Eric: Tessie and Lindsay, any thoughts on what we could do as a bigger field perspective? Let’s say from HPM or like from … let’s focus on the physicians. Again, we’re seeing hospices also another one – where we don’t see that diversity.

Alex: Let me chime in briefly here. I teach the … the Geriatric fellows are required to have two hours of cultural competence training every year; I hate that phrase, but that’s a requirement, and I teach it.

Alex: And one of the images I show them is, what happens when you do a Google Images search for “hospice”? And what happens? I pull up the pictures and there’s a little bit of diversity there. But it sure doesn’t reflect the diversity of our society. It sure doesn’t. In our increasingly diverse society, it’s overwhelmingly white. It’s a challenge, and the challenge comes up in everyday patient care.

Alex: I think about my own family, my mother-in-law, who’s Asian-American, said when her husband was dying, “I don’t want strangers in my house; people who don’t look like me, people who don’t understand me.”

Alex: Huge need, not just in palliative care, also in hospice, also in geriatrics, which certainly doesn’t reflect the diversity of our field. So what can we do?

Lindsay: Well, I think thinking of big-picture things, one thing that we did as a part of our project, which was separate from partnering with institutions, was connecting with the Student National Medical Association, SNMA. They have regional talks, chapters throughout the U.S. It’s an organization for under-represented medical students and residents.

Lindsay: So that was a great way to connect with them, provide exposure to hospice and palliative medicine that they might not get at their institution, and doesn’t require to make partnerships and connections with medical schools, which might be a little more difficult.

Lindsay: So I think being intentional about connecting with those organizations and trying to reach the population of students is a great way to start.

Tessie: Yeah. I’ll add that the program that you guys are doing, the partnership, is a perfect example of bringing the skillset to a group of people who may not have had exposure to it. I think that that’s fantastic.

Tessie: I think what Alex brought up about what hospice looks like is that it’s majority-white, is a huge problem.

Tessie: Not only are we having our pipeline problem with providers and clinicians who are under-represented minorities in medicine, we also have a problem with getting black and brown patients interested and engage them in hospice.

Tessie: They’re more likely to dis-enroll from hospice, even if they have been enrolled. They’re more likely to have end-of-life experiences that include an ICU and lots of medications and all of those things.

Tessie: We as a group, as a society, have to do better helping our black and brown patients even understand what palliative care and hospice is, and all the wonderful benefits of it.

Tessie: Part of it is as a group, we have to walk into talking about racism. Because that is at the core of why a lot of our black and brown patients don’t choose hospice and palliative medicine. The idea of withholding a service; “Oh, you’re just doing this as The Man, the system, that always wants to give us less. You don’t want me to go to the ICU. You don’t want me to get those extra cares.” Without really spending a lot of time talking about all the things that we do add. All the support that hospice and palliative medicine can do.

Tessie: It might mean that more than just a two-hour cultural competency … because I also hate that word, Alex … class. Do we need to teach more about how do we engage black and brown people into wanting hospice and palliative-care services?

Eric: Tessie, any good programs or recommendations? People you think are doing a good job with that, as far as their teaching it or implementing it?

Tessie: Well, I would say that CAPC and VitalTalk are both leaning into this space, where they had not really been leaning into it before. And are being more intentional about creating dialogue and talking mats that include talking about racism.

Tessie: Because when I think of the black and brown patients and their experience in hospitalized medicine is very different than what white patients experience. We’re more likely to have security called on us. To have social contracts, and less likely to have our pain managed or even admitted-

Alex: Assessed.

Tessie: … assessed. Or pain medications given. We need to start undoing some of that to get black and brown people to build trust in the system. It comes from, like I said, these organizations like CAPC and VitalTalk are starting to do it.

Tessie: We also need to have more of this training in our medical schools, in our education system. I wonder if Riba has thoughts about what would we’re doing on the education front, just to get people to start thinking about what the black experience is like in hospitalized medicine.

Eric: What do you think, Riba?

Riba: Well, I think we’re not doing enough. I mean, I have somewhat of a different lens in the sense that I’m at an HBCU. I mean, it’s essential to the education.

Riba: So certainly I think we are doing a good job of understanding that part as we’re teaching and we’re understanding the social determinants of health. Understanding the importance of honoring a person’s cultural beliefs.

Riba: And in this context, as we think about families that traditionally will take care of each other, and take great pride in being able to take care of a family member, particularly during a challenging illness.

Riba: Then to say, “Well, I’ve got control of this.” To allow, I think someone mentioned earlier, someone to then come in and … helping people to understand that this is not having someone to take your place, but rather to serve as an aide, as a support. And a complete wraparound set of services that offer that support.

Riba: To answer your question, though, about how we’re doing in the educational space, I think we are not doing it enough. Because what we’re doing is more one-offs to say, “We acknowledge that culture is important. We’re acknowledging more of the check-offs, to say ‘We’ve had this session.'”

Alex: Right.

Riba: Not integrating it throughout the education system. Even down to the patient who isn’t taking their anti-hypertensive medications, and just say, “Oh, this is just a noncompliant patient.” Well, why? I mean, because very few people want not to take care of themselves.

Riba: So there is some kind of barrier, whether it be related to education, resources, a previous experience with the healthcare system that makes one more doubtful. So there needs to be more of an education around developing trust. There needs to be more education around how we work to understand better our patients, their motivations.

Riba: Those are kind of the things we can do better globally across healthcare education. And to date, have not done it so well because we’re compartmentalizing things too much, just as opposed to integrating it throughout the education.

Alex: I wanted to ask: Going back to Lindsay, you started off with this brilliant research idea. I’m so grateful you did this study, working together with a great team.

Alex: What’s next on the research front? How can we push, expose, advance this issue from a research perspective? What other questions need to be asked and answered?

Lindsay: I think that’s a great question. I guess it would be to see what partnering with these institutions looks like, and if it really makes a difference in the black physicians who choose to specialize in hospice and palliative medicine.

Lindsay: I think importantly, too, we know that these primary palliative-care skills are important for anyone who cares for someone with serious illness.

Lindsay: Looking at diversity as an issue in the field of hospice and palliative medicine, but also what are the changes that can be done across the field that can make a difference in these patients’ lives?

Tessie: I was going to add the same thing, Lindsay, is that it’s going to take such a while to build the pipeline of getting black palliative-care clinicians, that most of these patients are still being seen by their primary-care physician if they’re not going to go to palliative-care services. They’re not going to access palliative-care services.

Tessie: So I think our next goal is really to build up the skillset of primary-care providers while we wait to build the pipeline of palliative-care providers.

Alex: There’s so many areas to focus on.

Eric: Riba, from your perspective, what do you want us to focus on as a field, as far as a research perspective? What do you think is like the big next for us?

Riba: Sure. No, yeah, I was thinking the same thing. Even when I was talking about the primary care focus of some of the schools that are teaching high percentages of African American and Latina students and residents is looking at primary care and how … I mean, that was my exact thought, was building out the skillset among primary-care physicians while at the same time increasing the exposure. What can we do around increasing exposure?

Riba: And really beginning to study the approaches and the effectiveness of those approaches, as far as those exposures are. And what the outcomes are related to being able to take an interest in, and specialize in more palliative care. Or at least utilizing the skillset. Even just having the conversations to send the patients in the direction of the providers of hospice and palliative-care services.

Riba: I think I listed about three or four things.

Eric: Perfect.

Riba: But as a focus, yes, certainly starting to build out the skillset among primary-care physicians is a great place to start.

Eric: Well, we certainly have a lot to work on as a field. And I want to thank all three of you for joining us on this podcast. Absolutely loved the paper.

Eric: I think we’ve had a lot of wake up calls over the last couple of years about what we need to do differently in the field. I would say both geriatrics and palliative care and hospice. And medicine, in general.

Alex: Absolutely.

Eric: Again, thank you for joining us. But before we leave, Alex, want to try a little bit more Beyonce? Let’s hear your inner diva come out.

Alex: All right. Here we go.

Alex: (singing)

Eric: Well, thank you Lindsay, Tessie, and Riba for joining us on this podcast. It was an absolute pleasure to have you on.

Riba: Thank you.

Lindsay: Thank you.

Tessie: Thank you.

Eric: And thanks for all the work that you do. Thank you to all of our listeners for supporting the GeriPal Podcast and Archstone Foundation for your continued support. Have a good day, everybody.

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