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Caring in the time of COVID
ABOUT THE AUTHOR Farah Karipineni, MD, MPH, is board certi ed in General Surgery and fellowship trained in Endocrine Surgery. She is currently practicing in Fresno as an Assistant Clinical Professor for UCSF. Dr. Karipineni earned her medical degree om University of California, Irvine School of Medicine. Her residency in General Surgery was completed at Albert Einstein Medical Center, and she completed her fellowship in Endocrine Surgery at Johns Hopkins School of Medicine.
Dr. Karipineni has been published in journals including e American Surgeon, the International Journal of Surgery, and the Journal of Surgical Education. As I left the OR on a busy Thursday evening, I had an empty feeling in my gut. As is my usual practice, especially during rocky times like these, I ran through the possible reasons in my head. What was I feeling so dissatisfied about? My cases had been stressful that day but with no complications; the patients were safe, my kids were fine, the day was finally over—why did I still have a lingering sense of emptiness, almost dread?
With the exception of one patient, I hadn’t actually seen or spoken to any of my patients’ family members that day. Of course, this was due to COVID; no family members were able to accompany patients in the preoperative area, nor were they allowed to wait in the waiting room. Gone are the days, at least for now, of walking into the waiting room to meet anxious family and friends to eagerly report on the surgery and postoperative care. That day, two of my patients’ emergency contacts did not answer the phone postoperatively, and one elderly patient had no family contact to call after surgery, just her nursing facility waiting to pick her up when ready. I had no one to update about those three patients after surgery.
In surgery, no one involved in my patients’ care can understand or consider the risks of surgery as carefully as I do. My hands are assuming those risks, and even if the risk of a certain complication might be less than one percent, it occupies my thoughts far more than that as I perform the familiar steps of the case. And once that case is over, even if everything went according to plan—as it almost always does—all the stress of performing those steps perfectly falls away. I move on seamlessly to the next battle, as if I had just been rebuilding furniture, rather than a human being.
But does the stress really fall away, I wonder? I realized during COVID that the best part of my surgery days is not at the end of the case, when I close skin, place the sterile bandage on and leave the OR. The low points might linger—the stubborn tumor, the inflamed tissue, the aberrant anatomy. The
best part of my day—when I get to release the stress of Amid the myriad mounting hardships of raging the case, the ball that did not drop, all that hung in the local fires, climate change, social and political balance—is when I get to call instability, and of course the pandemic, these loved ones and deliver the best news, that the surgery personal reflections comfort me as a physician in at went well and their precious least one small but profound way. family member is doing well. This is by far my favorite part of the day, and it is so much patients and family members in much higher acuity more meaningful in person than over the phone. situations, with far more hanging in the balance during the During COVID, I have had many family members cry pandemic. over the phone when I call them to deliver this good news. Amid the myriad mounting hardships of raging local Sometimes they are expressing relief more than sadness. fires, climate change, social and political instability, and of But often, it is the pain of being apart during a critical course the pandemic, these personal reflections comfort time. During these conversations, sometimes I feel like me as a physician in at least one small but profound way. crying too. I apologize that they are not able to be with their The emptiness of my OR days reassures me that I am in loved ones during this time, promising that I treated the this profession for the right reasons. It also inspires me patient like my own family, hoping that promise is at least to redouble my efforts in these times to connect more the smallest consolation. They graciously thank me, but meaningfully and effectively with patients and their of course we both know it cannot be the same. I can only families, knowing that it means the world not only to their wonder how these conversations must feel for practitioners, wellbeing, but also to my own.
Physician
Diversity
BY SUSAN LOGAN, MD FACS, KAMELL ECKROTH-BERNARD, MD FACS, AND IBIRONKE ADELAJA MD, FACS
At the 2008 Meeting of the National Medical Association, the AMA issued a long overdue apology to Black physicians, pledging to right past wrongs and to work tirelessly to achieve physician diversity that “at a minimum reflects the diversity we see among those who need care.” Twelve years later, amid a new national reckoning with the effects of institutional racism, it is instructive to review the progress our profession has made toward achieving this goal.
The Association of American Medical Colleges (AAMC) collects and reports data on US medical students and full-time faculty. In 2008, the year of the AMA pledge, the AAMC reported the percentage of matriculants to US medical schools were 6.4% Black and 7.2% Hispanic. In the 2018-19 academic year, matriculants to US medical schools were 7.1% Black and 6.2% Hispanic. Percentages of full time faculty at US medical schools followed a similar trend from 2008 to 2018, with a modest decrease in White faculty (69% to 63.9%), corresponding increase in Asian faculty (13% to 19.2%), and relative stability in Black (3% to 3.6%) and Hispanic (4.2% to 5.5%) faculty. In comparison, on the 2010 US Census, individuals identifying as Hispanic accounted for 18.5% of the population, Black or African American 13.4%, and Asian alone 5.9%. If the goal is to train a physician workforce that at a minimum reflects the diversity of those who need care, we must do better. >>
Why is it important to increase the percentage of Black and Hispanic physicians? The current makeup of the physician workforce is a result of centuries of intentional exclusion of underrepresented minorities (URM), particularly Black people, from medical training and practice. This segregation continued well into the 1960s, barring Black Americans from a path of upward social mobility, economic and political power. Achieving a diverse medical workforce that reflects the US demographic and correcting the severe imbalance of power in the medical infrastructure are issues of equity and justice.
Training more physicians from traditionally excluded groups is a key component of the effort to eliminate health disparities. In the 2018 AAMC survey of US medical school matriculants, 60.5% of Black students and 41.9% of Hispanic students planned to practice in underserved communities, compared to only a quarter of Asian and White students. Eventual location of practice is highly correlated with intent during medical training, and studies confirm that Black and Hispanic physicians are much more likely to practice in shortage areas than non-URM colleagues. A long history of racial malpractice against Black patients has degraded trust in the medical system. Black physicians can help rebuild that trust. Studies show that Black patients on average prefer to receive care from Black physicians, report a more positive experience with and are more receptive to treatment recommendations by Black physicians. In a recent study, 1300 Black men recruited from a local barbershop were asked to choose among four screening tests, then were randomly assigned to a clinic visit with a Black or non-Black doctor. Patients in both groups selected the same number of tests prior to their visit, but Black patients paired with Black doctors were significantly more likely to follow through with the screening measures, even invasive tests. Video of interactions between clinicians and patients demonstrated better communication and longer interviews between Black patients and Black doctors, and their patients were more likely to discuss additional health problems.
What are the barriers to creating a representative physician workforce? White households own 85.5% of all wealth in the US, whereas Black and Hispanic households own 4.2% and 3.1%, respectively. The Black and Hispanic poverty rates of 26.2%
and 19% are more than twice the White poverty rate of 9%. to entry, beginning with the development of programs to Thirty-eight percent of Black children in the US live below support and mentor local URM youth, active recruitment poverty level. However, an AAMC analysis of economic of URM students in college, and re-evaluation of medical diversity of US medical students from 2007 to 2017 showed school acceptance criteria. The cancellation of the MCAT that approximately 75% of all medical students come from the due to COVID 19 has forced many institutions to waive the top two quintiles of household income. This distribution has MCAT for applicants this year and provides a unique natural been consistent over the experiment to determine past three decades. the true value of this Given the higher share White households own 85.5% of all test. In medical school and residency, Black of Black and Hispanic wealth in the US, whereas Black and and Hispanic students children growing up in generational poverty, it Hispanic households own 4.2% and need Black and Hispanic mentors and role models, is not surprising that an 3.1%, respectively. but these are in short education gap between supply. Academic centers White and URM must take a critical look students begins in elementary school and widens as students at faculty recruitment and advancement policies and make begin standardized testing. Teachers often have and convey the necessary and painful changes needed to create a truly lower expectations of Black students, especially Black girls. anti-racist culture. In a recent review of the 4,032 professors In an interview of 20 women physicians of color in Oakland, of surgery in the US, there were 11 Hispanic women, and 15 40% described high school or college guidance counselors Black women. We know this striking imbalance did not occur discouraging them from applying to medical school, and by chance. Now we must get past knowing there is a problem, more than 50% doubted their ability to succeed in medicine and start doing something to correct it. because they could not find a role model with their racial or ethnic identity. In the AAMC study of MCAT scores, an average score was predictive of passing the first year of medical school training but not subsequent years of medical school Tracy Zweig Associates or residency training. Nevertheless, this heavily weighted test A REGISTRY & PLACEMENT FIRM stands between prospective URM students and a career in medicine. As the importance of standardized tests increased, Physicians so increased the costly test preparatory industry, further Nurse Practitioners disadvantaging lower income applicants. Physician Assistants
What can we do now to increase the percentage of Black and Hispanic physicians? When the AMA excluded Black physicians, it did so not by overt national by-laws proscribing Black membership, but rather passively under the rhetoric of respecting States rights and local customs. This allowed hospitals to deny Black physicians admitting privileges and prevented Black physicians from entering specialty training. Our failure over the past 12 years to significantly increase the percentage of Black medical students is also a failure of passivity. Historic exclusion of Black physicians was intentional; inclusion today must be equally intentional. US medical schools must work to remove barriers
