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06.22.2020

Episode 75: Conversations about Race in Medicine

by Aledade

Dr. Kisha Davis is a family physician and a Regional Medical Director at Aledade. She joins Josh and Joe to discuss her experience as a Black doctor, confronting implicit bias in medicine, and responding to this moment. To hear more from Dr. Davis, check out her podcast called “The Sisters Will See You Now,” which she co-hosts with her sister who is also a family physician.

In the second part of the episode, we speak to Dr. Emily Maxson, Aledade’s Chief Medical Officer, about how relying solely on data can perpetuate racial disparities in care and what Aledade is doing to address algorithmic bias.

Episode Transcript

Kisha Davis  00:00

The only way that things change or get better is to confront what we see in front of us and live in that uncomfortableness of it in order to push and move it forward. And I think all of us have a piece to play in that.

 

Josh Israel  00:14

This is The ACO Show. The death of another African-American man at the hands of the police has a lot of us thinking about the structures and systems that privilege some groups and disadvantage others, and the medical field is not immune from this. For this show, we have two guests. We start with Dr. Kisha Davis. Dr. Davis is a family physician, and an Aledade Medical Director, and she joined the show for a discussion about some of what has brought us to this current moment; her own experience as an African-American healthcare provider, and mother and citizen; and how the discomfort of the current moment might help us at least start down a better path. Dr. Davis' sister is also a family physician, and together they host their own podcast about the world of primary care called "The Sisters Will See You Now," available on iTunes, Spotify, and everywhere else you get your podcasts from.

 

Joe Shonkwiler  01:03

Welcome to The ACO Show. My name is Joe Shonkwiler, and I lead adoption and training at Aledade.

 

Josh Israel  01:09

I'm Josh Israel. I'm a medical director at Aledade, and today we are joined by Kisha Davis. Kisha is a family physician, and Aledade's medical director of three of our accountable care organizations, West Virginia, Appalachia and Maryland. Kisha, thanks for coming on the show.

 

Kisha Davis  01:25

Thanks for having me.

 

Josh Israel  01:27

We are talking in the midst of obviously a whole lot going on in the world. Most recently, the death of George Floyd has moved so many of us, gotten the world's attention. And there's a lot going on. So Kisha  I just wanted to start by asking, how are you doing? How's everything for you?

 

01:47

Yeah, thanks. As was mentioned, I'm a family physician, an African-American female physician, and, you know, I was really struck by everything that's going on right now with George Floyd and Breonna Taylor and Ahmaud Arbery, and you know so many others even just recently that we've learned about, and you know initially when I heard about George Floyd it was, "Oh no, there's another one, you know, another black man killed by police. That's awful." And same thing with Breonna Taylor, how awful, you know, another Black woman who wasn't doing anything, sleeping in her bed, who was killed by police. And then because we've heard it so many times before, just kind of go back to what I was doing, go back to making my sourdough bread, and go back to doing my work and, you know, helping with homeschooling my kids and cleaning up the yard and then it you know, it hits me again, I heard about a friend's clinic in Minneapolis that was looted, and, you know, another friend who's having trouble sleeping because it's, you know, affecting her so much. And then I look at my husband and my three sons all, you know, three little black boys. And my oldest has started posting some things on his Instagram page. And it was kind of a slap in the face that I needed to say I can't ignore this anymore. I can't just go back to business as usual, I can't just walk around like, "Oh, this is just gonna keep happening. And I don't have a role to play." I do have a role to play, we all have a role to play in making sure that these things stop. You know, I've gone to a couple of the protests. And I think as I think about it more and reflect on it more, what keeps coming up is that these are not isolated incidents. And it's not just a series of one-offs. And I think that's how people outside of the Black community might have been looking at this, as a series of one-offs, and they aren't a series of one-offs. They're a series of episodes that highlight systematic racism within this country and systematic injustices that have been perpetuated for centuries. And, you know, we sit in it, as Black positions we, you know, we didn't get to where we are without at least one time being the only Black person in the room. And I think all of us have had some collective experience of being the other, the minority, a time when less was expected of you or more was expected of you because of the color of your skin, and people have assumed things about you and your intelligence and your ability because of what you look like and not because of what you have demonstrated. You know, I have a lot of degrees undergrad, medical degree, MPH. I've served on a lot of boards and committees, Regional Medical Director with Aledade but when I walk into the grocery store, people don't see that, and it makes me cautious about what I wear and what I do and where I go. How I talk to my children. And I think that all of that sits with me and other Black folks every single day. And I think it is something that is there and underlying all the time, and all of these events just bring it up and boil to the surface. And I think we are all, you know, manifesting that and living with that and you are seeing that erupt on your TV screens.

 

Joe Shonkwiler  05:32

Kisha, thanks so much for for going through that. It's really powerful for me to hear as a parent, as a physician, as a colleague, as somebody who, you know, values you so greatly as being part of the Aledade universe. And I'd love your you know, your personal thoughts on the responsibility of this moment that we're in now, for all of us. And I, you know, you are very humble in reviewing your degrees and background, you were also part of the White House fellowship program during the Obama administration is that right?

 

Kisha Davis  06:04

Yeah, that's right.

 

Joe Shonkwiler  06:05

So, you know, I, I'd love your, just your personal opinion as somebody who's been part of so many of these groups, like what are the responsibilities as a physician of any race or background, but also somebody who thinks deeply and has worked in the policy space, to start these discussions and start to address this major issue nationally?

 

Kisha Davis  06:29

That's a great question. So, you know, I'll start with as physicians, I think, as physicians, we need to look at our own biases, our own implicit biases and how they, you know, trickle in and affect the health care that we provide our patients. I think, you know, if you ask any doctor, we all assume that we're good doctors, and I think most doctors are good doctors. And so you say, "I am a good doctor and I am doing the right thing for my patients." And then you counter that where you look at the rates of things like maternal mortality, maternal morbidity and mortality, and the disparities that you see in race and ethnicity. And honestly, you can look at just about any health condition: cancer, diabetes, heart disease, and see the disparities in outcome. And you say, "Well, why is that? If all of these doctors are trying to do the right thing, then why is it that people have different health outcomes?" Part of that is, you know, communities, it's not a difference in race. It's a difference of how services are applied to racial, different racial ethnic groups and, you know, the resources that are available in terms of parks and schools and food and education, in communities of color. But it also comes down to our education when you know, there have been studies that looked at medical students, even just first- and second-year medical students in terms of how they would allocate pain medication to Black patients versus white patients, and they would give Black patients with the same level of pain, less pain medication than they would white patients, and you say, "Well, why is that? Where does that come from?" That comes from our own implicit biases. And so how do we identify those, call those out, educate people about them? everybody has these biases, we need to look at them and explore them and address it. And, you know, be honest with ourselves in how we are bringing that into our awareness when we're taking care of patients. When I think about, you know, policy, making sure that patients have equal health outcomes goes beyond what I do in the exam room. So it goes beyond what I can do on my prescription pad. It goes into advocating for safe communities. You know, if I know that somebody's diabetes is going to be better, yes, you know, I can give them a medication but I know it's also going to be better if I can get them walking and losing weight and eating better. And to be able to do that I need them to have a grocery store, I need them to have a safe neighborhood, I need them to be educated on how to read food labels. And I can't do all of that in my office, I need the support of the community around me. And so it's inherent, to start to advocate for those things. And that's been my journey, my path is I have always tried to tie that patient care piece with that policy piece so that I'm, you know, advocating in the best way that I can for my patients beyond just what happens in the in the exam room. And I think when you look at that more broadly, you know, beyond just health care, you know, what is all of our piece? What is our part to play in, in addressing and calling out some of these -isms and past hurts? You know, I was at a talk yesterday, one of the protests and he said, you know, you're not responsible for what you were born into. Right? You can't be responsible for what your ancestors did. You're not responsible if your, you know, great-great-whoever owned slaves, if your great-great-whoever was part of the slave trade, if your great-great-whoever, you know, drove Native Americans westward, that's not your responsibility. But you absolutely are responsible for the biases that you perpetuate. You absolutely are responsible for the ideas and views that your kids grow up with. You absolutely are responsible if people around you are spreading beliefs that you don't agree with, but yet you say silent, and don't confront them and push them on that. And so the only way that things change or get better is to confront what we see in front of us and live in that uncomfortableness of it in order to push and move it forward. And I think all of us have a piece to play in that, it can't just be Black folks who move the country forward. And when you look at all of the great movements in this country, around civil rights, it was never just Black folks who were doing it. When you look at the fight for equality, when you look at who walked across the Pettus Bridge in Selma with Martin Luther King. When you look at the civil disobedience, it was Black folks who were walking together with white folks who stood in that moral conviction that it was important to do so. And those times, like now, white folks also need to stand up and walk with us and call out what is wrong in order for us to move forward.

 

Josh Israel  11:20

One of the things that are uncomfortable about these conversations for me is every time I have that might come away with the feeling of "Oh, no, I another blind spot I didn't know I had even." As you were describing being in the supermarket and how people see you, I was reflecting that I do some work at one of Aledade's federally qualified health centers. It's in a predominantly African-American part of Wilmington, Delaware, and I walk in there and people who I've never met who have clearly never even seen me before will say to me, "Hey, Doc, how's it going? Hi Doc," and I always thought it was kind of funny. I didn't think it was a compliment. I figured it just meant I was sort of dorky and stiff looking. But I looked at them like a doctor. And as you were talking, it never occurred to me like, oh, that means to them, somebody else doesn't look like a doctor. It just doesn't occur to me as I go through my day of just what it means to to look a certain way and be treated a certain way.

 

Kisha Davis  12:16

You know, that brings to mind, I remember one time I was talking with a group of kids at like a career day or something. And, you know, I went in it was a group of predominantly minority class and I, you know, going through my stuff, and I guess I hadn't said that I was a doctor. And so it was kind of through the presentation that I you know, midway through that, they realized it, and they said, "You're a doctor?" and their eyes just got like, so big and it was like, "Oh my gosh, we haven't seen a Black doctor before," and it was just amazing to me. My grandmother is going to be 102 on Thursday, which we are really excited about. And she was a patient at my previous practice and she saw one of the other doctors there who was also a Black female physician, and I was talking to my grandmother one day and I said, "So when did you have your first Black doctor?" And she said, Dr. Williams is my first Black doctor. Now, Dr. Williams didn't become her doctor until she was 98. And that just was like, oh, my goodness, you know, so many people, even African-Americans walk through their entire life without seeing a person of color in that status. And anything that I can do in terms of mentorship and encouraging Black folks who want to go into medicine to do so is really important. I mean, when you look at the numbers, there's more Black men that graduated from medical school in 1978 than in 2018. And that just baffles me.

 

Josh Israel  13:44

I wanted to ask you something about implicit bias. You've mentioned that is obviously a huge issue. But companies do implicit bias training now, more and more, and as a psychiatrist, I'm a little uncomfortable with it. There's not a lot of evidence behind it, I'm not convinced that training, whether it's a few hours or a day, can really get to the root of something as really deeply enmeshed as an unconscious process like that. That you know, some trainings will help. But then I feel like "Okay, we don't know what to do, but maybe it's still at least sends the message that we that we care and are doing something." Do you have thoughts on that? You know, even right now with Muriel Bowser in DC, there's some controversy about whether the painting of the Black Lives mural did anything. But I feel like, well, it shows where we stand. And so that matters. You know, even if that doesn't change the way policing is done, it's a start. So I guess I'm just asking, do you have a personal opinion on these things that may or may not be evidence-based, may or may not lead to change themselves, but at least show that people are trying to do the right thing?

 

Kisha Davis  14:53

Yeah, so I think, you know, with implicit bias, there's levels, right, so there's certainly a very superficial level of training that can be done, which is kind of "Yeah, here it is," know that you have them. And I think a lot of times that that is what's done. And you know, companies can kind of check that HR box. as "Yep. We talked about implicit bias. And now you all should know it and should check your biases and everything's going to be Kumbaya now." And, you know, Josh, I think you're right, that a lot of times that is not moving the needle. I think what makes the difference is when a company is really taking that implicit bias training not as a one-time event, but as a way to influence their culture, and creating a culture of calling out injustices and recognizing our own biases and being vulnerable, to be able to do that. Because it's not easy to say, "Oh, I have this blind spot." It's not easy to say that, especially in front of a group of people. And a lot of times I've seen that training go to the very superficial like, "Oh, yeah, I have a bias against blondes," or "Oh, I've got a biased against you know, people who come from you know, this country" and not really getting at a deeper level. So I think it can be done well, it can be done. It can move the needle, but a lot of times it isn't. It doesn't go deep enough. And I think part of that's the training. I will just comment a little bit on kind of that broader, you know, does the mural matter? Do the protests even matter? And I'm working on a talk on levers of change right now, what are those different levers of change that people have? And, you know, certainly voting is a lever of change that we can use, right? That you know, go to the ballot box, write your legislator, put an article in the, you know, in the newspaper, you think about the lunch counter protests that you saw back in the '50s and '60s. But protest and rallying is also a lever of change. When you see people in the streets again and again and again. And you say yeah, you know, what's the benefit, do I need to go down and you know, make my voice heard? I'm just one person in a sea of hundreds or thousands. But that gets on the news, and, you know, imagine if you were having a protest and nobody showed up. And so I think that there are benefits in calling things out in whatever way you know how. For some, that lever of change is looting and I don't agree with it, I don't think it's right, but I certainly understand that when things have gotten to a boiling point, that's the only lever of change that they feel like they have, you know. That Black Lives Matter mural on the street is a lever of change, and that it helps people to feel validated, and to recognize what they're fighting for. And I think all of those different outlets, whether it be artwork, or protest, or writing or voting or you know, whatever it is, I think make a difference as a personal outlet, but then also as kind of a community exploration or demonstration of where things need to go

 

Joe Shonkwiler  17:57

Kisha, I think there are a lot of different conversations, frankly, happening all over the world. Really, if you look at the news and see all the protests and discussions. Do you think we talked about the mural and some of these gestures, ehat about just the conversations, you know, with colleagues and friends and everyone that, you know, amongst people of one race versus you know, interracial conversations? Do you think that can move the needle?

 

Kisha Davis  18:29

I think the conversations are actually the most important thing. Because it's easy to hide behind a protest or hide behind a mural or even to hide behind a Facebook post. It's harder to do the real work of having a conversation with somebody that disagrees with you. Or maybe it's somebody that you thought agreed with you until you really get to the underlying feelings on how they really feel. And I think when you can have that sort of conversation with somebody that you trust, and you hold that trust between you, then you can really move things forward. And so a lot of it is having those courageous conversations with friends, or maybe people who are not friends with people who think differently. That really makes a difference to help you think differently to help you, you know, to help people move. And I think that that's a lot more long-lasting. At some point, the protests will stop. At some point, we will get back to some sort of business as usual. But it's that conversation piece. And that continuing to push in that way, that's really going to make the difference.

 

Joe Shonkwiler  19:37

Dr. Kisha Davis, Medical Director at Aledade. Thanks for joining us today in this conversation.

 

Kisha Davis  19:42

Joe and Josh, thank you so much for having me. It's a pleasure.

 

Josh Israel  19:47

For the last part of this show, we're joined by Dr. Emily Maxson. Emily is the Chief Medical Officer at Aledade. And we talked about how something as seemingly neutral as the data we use to guide healthcare decisions and resources can contribute to racial disparities, and how Aledade as a company to start to look at what can be done about it.

 

Josh Israel  20:07

Dr. Emily Maxson, thanks for joining the show. We spoke to Dr. Davis about some of the ways that people are trying to take a closer look at systemic racism, some of the ways that people and companies may have blind spots. Aledade is a company that uses a lot of data and technology as the foundation of our work. And sometimes this can seem like a neutral force, but there may be more to it. So I'd love to hear your thoughts on what Aledade is thinking and what we might be doing about that.

 

Emily Maxson  20:37

Sure, Josh, and thank you for having me. I think that this is a critical time to pose this question, and in many ways, too late of a time to pose this question. But the events of the day, and really of the past 400 years, have not only prompted a lot of personal introspection, but company-wide introspection. And one way as you mentioned is that we use risk algorithms to prioritize patients for interventions. And to prioritize a patient for intervention, you're seeking to give them extra resources, you're seeking to build a bridge to another service that could really help them. And so given that resources are limited, you're always trying to find a way of matching the patients who are maximally benefit from a service with that service. There was actually a really interesting article that describes this and probably more eloquently than I'll be able to, but I'll give it a shot. And this was an October 2019 Science article by Obermeyer et al. And it was examining the ways in which universally available risk algorithms actually build in racial bias. And I've been thinking a lot about this lately, as has the company. So to try and summarize this, risk algorithms that are traditionally used across all kinds of insurers think about predictions and actuarial estimates of actual cost in the future. But we know that Black patients are treated systematically differently in the US healthcare system. For one thing, race and socioeconomic status are deeply correlated, unfortunately, due to ingrained institutional racism that preceded and followed both enslavement and emancipation, and we know that poor patients face barriers to access to care. There's also a healthy mistrust of health care among many Black patients after the horrors of Tuskegee and personally experienced adverse events in health care by many people in the community. And then lastly, I'll mention that, unfortunately, there are disparities in care provided. We know, thanks to a voluminous amount of literature, that due to unconscious and conscious biases in the healthcare system, Black patients are afforded different care than white patients. Actually, preventive service rates are very different, and having a Black physician actually matters: you get better promotion of health and wellness actually, if you're a Black patient if your physician is also Black, and we don't see an equal workforce in healthcare yet. So for all of these reasons, what you get by prioritizing health spend is that we're seeing Black patients access care in a very different way. And if you look at spend alone, what you tend to see is that at a given risk score, a Black patient is systematically sicker as judged by the burden and severity of their chronic diseases than their white counterparts with the same exact risk score. So if you use these risk algorithms, and you end up prioritizing patients differently if you prioritize an initiative based on these omnipresent models of risk. You won't be prioritizing a Black patient until they are already systematically sicker than the white patients you'd be prioritizing at the same time. And so this is a little bit mind-boggling, but the way in which we are addressing this is to try and first examine our data: Are we actually doing this? Are we falling victim to this? And I worry that we are, because we do use these actuarial risk models as a very heavy part of our prioritization for new services. And for core services at Aledade, such as wellness visits and high-priority status for Transitional Care Management and other innovative pilots, care management as well. And one thing that I really appreciated the study for pointing out is that they didn't just point out the problem, they pointed out that it is fixable. So they did an experiment and with a huge data set, they actually combined the health status of the patients with their cost predictions, and they were able to reduce the bias in their algorithm by 84%, getting them 84% closer to equal prioritization of patients.

 

Joe Shonkwiler  24:55

Emily, thanks for walking us through that. That's fascinating, but what does that mean for Aledade? So what are we doing with our own prioritization process?

 

Emily Maxson  25:04

The first thing we need to do is to look under the covers a bit. And so what we've done is we're asking our impact and analytics colleagues and our business intelligence team to really critically examine whether we are perpetuating inadvertently healthcare disparities as a result of the way we prioritize our work and for any reason at all. So, we're going to be examining our critical core services, Annual Wellness Visits, Transitional Care Management, emergency room follow-up calls, accurate risk coding, for example, as well as provision of chronic care management services and critical preventive health measures, such as blood pressure control, diabetes control, availability and adherence to statins for patients with high-risk heart disease. So all of these things we're going to be looking at, and we're going to be using our data in the system for hundreds of thousands of patients to take a look and see what our rates of high-value service and chronic disease control are for our Black patients versus our white patients to evaluate whether we can put resources into mitigating healthcare disparities. We have a team that we're going to be standing up to think creatively about other ways we could be messaging and prioritizing patients if we do find disparities, and to prioritize that work.

 

Josh Israel  26:32

What strikes me about this is Aledade is one company, you know. We are a aggregator of accountable care organizations, you know, not a huge player in the landscape of American industry, and we have this glaring blind spot and probably more. Just to think that probably every company has these, you know, every industry, every institution, it's really, it's striking. You know, if a quick look at ours finds these, just what else is out there that hasn't even been examined — it's unpleasant to think about.

 

Emily Maxson  27:02

That's right. It's unpleasant, and it's a very real reality for our patients. And so we hope that by being public about what we're seeking and what we'll find and our efforts to address these glaring healthcare disparities, we can hopefully set an example and collaborate with others across the country on ways to address healthcare disparities, and hopefully eliminate them in the United States.

 

Joe Shonkwiler  27:25

Emily, we're clearly living through a significant moment in the United States, but also around the world with these discussions. What do you see as the impact long term in how we do this? Is this gonna solve it for us? Like what's, what are you looking ahead at?

 

Emily Maxson  27:41

I think we have an imperative not to consider this as a moment, but a movement, and it's really important to acknowledge that this is just the beginning. We are committed long-term to identifying and addressing healthcare disparities, and we only regret that it took us this long and these tragic moments to come to terms with our responsibility in this. So we certainly are embracing the call to action, and we'll continue to prioritize this work in the years to come.

 

Josh Israel  28:11

Dr. Emily Maxson, appreciate you coming on the show. 

 

Emily Maxson  28:14

Thank you so much.