the planning committee for inviting me to speak about diversity, equity, and inclusion. And just to mention, it's a true honor as a cardiologist to stand on this stage. Someone who works in a cardiac ICU to really present to you. And I just wanted to shout out some of the other cardiac, critical care cardiologists like Steve Hollenberg, and I saw Jake Jenser, I saw your face in the lobby when we were coming up to the conference. And of course I want to thank my co-chair, which is Mike Solomon. And Mike Solomon is a critical care cardiologist at the NIH. And through our tireless effort, we really got a member section at the American College of Cardiology. Also there is Dr. Dipti Ichipuria. She's the immediate past president of the American College of Cardiology. And I have to thank her for helping us become a member section. But importantly, she made health equity a strategic priority at the American College of Cardiology. One of the things that she's done is looked at the quintuple aim. And so really starting with the triple aim, looking at improved patient experience, looking at better outcomes, lower costs. And then putting clinician wellbeing, talking about the quadruple aim. But she talked about if you don't have health equity, then you won't have better health, improved economy. And so as we go through this talk, I think I just want you to see, are we meeting the quintuple aim? Are we meeting all of these markers as we talk about diversity, equity, inclusion? As Dr. Evans mentioned, on the ACC Board of Trustees, we have this health equity task force. The first thing we did is define what health equity really means. We talk about these things all the time, but we had to define what health inequity was. And that was systemic, that was structural. Society factors that are unjust and avoidable, meaning that if you find them, you can change these health inequities. And then they cause the adverse outcomes. And this includes racism, structural racism. And health disparities are those adverse outcomes. And we talked a lot because there's differences in healthcare outcomes. So what's the difference between a health disparity and the health differences in healthcare? And breast cancer is a good example of that. Men and women have different rates of breast cancer. That's a healthcare difference. But disparities when they're underlying unjust factors that are causing that. And then we wanted to be bold and talk about health equity as a human right that everyone could achieve their best attainable health outcome. And so we were happy spreading this around the American College of Cardiology. And then we started seeing signs of critical race theory and does that really belong in the school system? I thought that was a, it's a good debate to have where you talk about critical race theory and racism, et cetera. And then this came out from the editorial board. And they're talking about medical education has gone woke where the AAMC and the AMA are talking about these things and we shouldn't really be talking about these things. And I was really glad to see that the president of the AMA which is Jack Resnick and the president of AAMC said no. We're talking about excess mortality and that's important. This is not virtue signaling. Health disparities are really important. And we thought about the same thing at the American Board of Internal Medicine. If you're going to deliver quality healthcare, you have to think about health equity. You have to understand health disparities. And our committee presented this to the board of directors and the resolution passed and so we're working on making sure health equity is on all assessments from ABIM. And let's just think about it. I think we're at a paradigm shift in medicine. There's a lot of different determinants of health. There's a social determinants, there's a biological determinants, environmental structural determinants. And in medicine we've been taught stay with the biology. That's where we belong. And there's this tension because we're moving beyond that. And I think we have to move beyond that if we're actually gonna affect change. And these are some of the examples. When you look at maternal mortality, look at the difference between black women and white women and Hispanic women and maternal mortality. These are things we can't just turn a blind eye. We have to figure out what's going on and solve these problems. And then where does race belong in medicine? We've talked about GFR, PFTs are adjusted for race. Why is it adjusted for race? We need to discuss is that a good thing or a bad thing? How do we ameliorate and rectify these things? On the other side of the slide you can see pulse oximetry. I mean what's more germane than identifying a patient for respiratory failure in critical care medicine? And you see there's an underestimation when you're using some technology for pulse oximetry between black patients and white patients. And that also leads to delay in treatment for patients who had COVID. This is egregious. We cannot turn a blind eye to these disparities. We have to figure out how to make things better. This is just a quick study just looking at the breadth of health equity. We published on why men get reperfusion time and reach that reperfusion time more often than women. And women with acute STEMI have a higher mortality. Part of that is included with how we assess women for acute cardiovascular events. Again, we can't turn a blind eye on that. We have to understand what's going on and is there implicit bias? This is a classic from 1999 looking at implicit bias where you have these actors who have the same story and you see their referral for cardiac catheterization were different. Men were referred more than women. White people were referred more than black people. And there was intersection of race and gender where black women were referred lower. And again, this is the same story that they presented. And I do this same experiment with the medical students and this is 2022. And guess what? There's the same difference following. And so this is, and let's see the mic is getting better. There we go. And so this 1999 talking about implicit bias and I'm gonna talk about a patient who, her name is Shirley Curvedale and she works in the community in Eastern Long Island. She talks about her and her family's experience with COVID. She was affected with COVID. Her husband was affected with COVID. She was dyspneic. She was having syncopal episodes. She couldn't breathe and get off her couch. Every time the EMS came, they said, Ms. Curvedale, we can't take you to the emergency room in the hospital. Your pulse ox is too high. And she feels like she's one of those people who really got neglected because of the differences in pulse oximetry. But what we're about to see is her husband was admitted and he was in the ICU and he couldn't sleep and he's about to go to a step down unit and he's asking for some aids to help him go to sleep. And this is what happened and this is what he was told. So let's hear from Ms. Curvedale. This doctor, when my husband said to him, well, doctor, I think I would make much better progress at home where I have familiar surroundings. And here, the only thing here is the television. I'm a person like you, I'm educated. I have thousands of books in the library that I could consult. I need more stimulation than this and someone around me who's gonna not keep me in the dark and what have you. Well, the doctor went out based on that conversation and indicated that he had dementia and put him on the dementia ward. And we had to actually intervene and talk to a doctor who knew him outside of the hospital and knew very well that he didn't have dementia and to get that diagnosis taken off of his medical record. And when he tells the story now, he says, he believes it was because that doctor did not expect a black man. He did not know my husband, did not know of his background, did not know that he was a former college professor, that he pastored a church or anything else. All he knew is he's a black man who said that he had 3000 books at home. He must be crazy. So, again, we can talk about all of the systemic antecedents and contributing factors, but I think that if we're gonna have a real in-depth conversation, we need to really understand that the systematic entrenched racism also leads to widely accepted behaviors of implicit, sometimes explicit bias that impacts us as black people and brown people that have disparate impacts because of it. So I think these conversations are wonderful. I think that without them, without unpeeling this onion, we'll never get to the bottom of it. And we'll never be able to heal. So that's our patient, Shirley, talking about her husband who got referred for being delirious because he wanted more books. And I think it's important that we realize that implicit bias is ubiquitous and we all have it. And we have training in medical school to recognize the impact of implicit bias. I'll shift gears quickly just to talk about a research project. And as Dr. Evans mentioned, I'm from New York. And when COVID hit, I think it was pretty traumatic. And the one good thing about COVID is if you could think about it that way, it was very unifying. So critical care didn't matter. If you were pulmonary critical care, neurocritical care, if you could work a vent, you were working in some sort of ICU in the pandemic. And so when the pandemic hit, we knew that people were dying inside the hospital, but we really wanted to understand what was happening outside of the hospital. And so this is a map of New York City and we looked at zip codes and we wanted to see what was going on the zip codes, who was dying outside of the hospital. So we went to the emergency services and we said, could you give us who was having non-penetrating trauma and having out of hospital sudden death? And we compared 2020 to 2019 as a historical norm. We looked at the zip codes and this is what we found. We found that it was very sort of disparate and widespread that you had some zip codes where the increase in out of hospital sudden death was 1.6. And then there were others that were like 20 times as much the year before. So we wondered why are some zip codes only having this mild effect with the pandemic and others are having a tremendous effect where there's 20 times as much of people dying out of hospital. And so this goes to the Kaiser Permanente account, the model looking at social determinants of health and knowing that 80% of health outcomes come outside of the clinical encounter, which is why if we want to really affect health outcomes, we have to move out of only the biological determinants. We have to look at socioeconomic factors. And so what we did with the census data, we looked at all of the zip code and we looked at all the census data. We knew exactly the race, ethnicity, we knew who went to high school, college, we knew who had insurance, all of that stuff. We had that and we put it in a multivariable analysis and it turned out it was educational attainment was the number one sort of contributor to those differences and also the population of black people in those zip codes. And I knew I could explain the discrimination and the toxic stress into the black race and educational attainment. And we were pretty excited because we can share this that if you get equity in education, look what you can do, you can prevent these deaths. And so we decided to submit this to journals and as you're submitted to journals, you're expecting rejections, you're expecting to have to revise. And when we submitted to very high impact journals, they said to us, we don't understand what education has to do with any of the health outcomes. And you're talking about black race and discrimination and these outcomes. We're not sure that there's discrimination against black people and who is actually discriminating against them and you have to identify that in order to be published in our journal. Well, I thought that was a little bit crazy and I said, it's clear they don't understand this research. And I was talking a lot about structural racism and racism, and my co-author said, stop saying the word racism. Just talk about structural inequities with race, get past that. And we got it published in CERC A&E. And so months later, these high impact journals said, we need manuscripts that are looking at the interaction of social care and medical care. I was like, really? I was like, because I submitted that to you and you rejected. And so I was able to talk to the editor in chief and they said, this slipped through. We are definitely looking for this. And so I'm bringing those to say that it's important not only to diversify your clinical trials, but also to diversify your editorial boards, your reviewers, your associate editors, because if you don't, you will not expand and you will not be talking about health equity. So this is really important. Another person, this is Dr. Michelle Alpert. She's the president of the American Heart Association and she talks a lot about structural inequities and how that leads to hardship and looking at stress. And she gave her presidential address talking about stress and toxic stress. And supposedly, this is good stress when you're giving a keynote, but there's toxic stress that she talks about that really goes towards health disparities. And I put this slide up that was published by Dr. Churchwell to talk about the social determinants of health and to talk about that they just didn't drop out of the sky. They really came by our policies, redlining, segregation, that leads to all this poor access to healthcare. And then they also mentioned toxic stress. And just to talk about it, we have it. We know that with discrimination and negative social determinants of health, you get increased cortisol levels, increased central adiposity, increased sort of risk factors for diabetes. You have increased norepinephrine levels, increased hypertension and CAD. So when you're thinking about all this, when I hear increased hypertension, diabetes, I know that's the social determinants of health and also the stress. And put that together with a pandemic, you actually get a syndemic. And the syndemic is when you have existing health conditions, stress, social disparities, economic disparities, and then a biological pandemic, you get this synergism of mortality and morbidity, which is what is seen here. Dr. Califf was warning us that what we saw with COVID was just the beginning. Our health system can't handle when we have these things. And if we're not careful, this tsunami is gonna come down and crush us. And on the top of the crest of that are health inequities and other things. And again, we're not looking at prevention. So this all comes down. And when it comes down on us, who feels the brunt of it? Who gets burned out? It's the people on the front line. And looking at this, you can see it's critical care that we get burnt out because of all the things that happen. And so just to really look at this, what are the drivers of burnout in critical care medicine? Of course, it's those patient factors where you have difficult cases, futile cases. One part is our team dynamics. When it gets tough, either patients are delivering microaggressions to us, we're delivering microaggressions to each other, and that in a hospitable environment actually contributes to burnout. Now, I was really honored to work with Dr. Pam Douglas in cardiology where we realized that we have a problem in terms of civility and really creating a really inclusive workplace because that's really important. I'll just tell you really quickly what we've done at the medical school. A lot of talk, and there's a lot of talk about, and there's an article in the New York Times that these DEI workshops, do they really work? So what we did at the medical school, we actually used VR. We put on a headset and had people experience racism, sexism, and we saw the impact of doing that from our surveys. Empathy went from 20% on our survey to about 90% on our survey, and we were so excited about that we published it in a journal. And then what happened year after year, our students reported less microaggressions. Everybody felt more inclusive in their culture year after year. So these diversity workshops do work if you approach it the right way with inclusion and not making people, and having people don't feel like they're being shamed. It really works out. Let's talk about the other factor about burnout. It's about healthcare costs, and you see it's coding. You have a difficult day and you're sitting down to have family meetings, and then you get the coder who says, you coded for cardiogenic shock but you didn't code for heart failure as well, and you didn't say it was systolic heart failure. And then this is just, again, driving to burnout. And when you think about this, I don't envy the people who have to talk about productivities and RVUs and how that also contributes to burnout. And when we're thinking about this, I hope that our healthcare system, since we're talking about money so much, that it's profitable and it's working out well. So this here is how we're doing. And again, think about the quintuple aim in terms of cost and how we're doing with physician well-being. Do you see where we are? So we're here, and this is life expectancy and how much we're paying for healthcare. So you see where Western Europe is. You see where Japan and Korea are. And I can tell you, we've gone past the 12,000 per capita sort of mark, and our life expectancy has dropped by two years. So we've gone to the right and we have come down. And all of this is going on. And the cost of health inequities, and this is a Deloitte slide looking at it, the estimate at $320 billion because we don't have people who have access to healthcare. And if we did, this is how much we would save. 80 to $320 billion is what's costing us in health inequities. And when you think about how we're spending, the fact that we spend the most, but we also spend the least on social care out of all of those countries. And if you look at this slide here, it's the same thing. If you look at the state budgets and see who's spending on social versus other forms of healthcare, it's directly correlated to health outcomes. So it's the way we structure our healthcare. It's the way we structure our economy. This is what matters. And so let's think about ways that we can really integrate social care in healthcare redesign. So this is from the National Academies of Medicine, Science, and Engineering, and they call it the five A's of integrating social care into healthcare. One is awareness, which is what we're doing now. The other ones, adjustments and assistance, I don't necessarily think apply to critical care folks. So adjustment, for example, is a patient can't come to your office, you do a telehealth visit. They need some assistance, you arrange for a ride share. I think alignment and advocacy are good. So if you think about the opioid crisis, alignment is aligning with an institution or a community center that talks about it and talks about training about naloxone. Advocacy is really going to a structural level. And it recently passed in New York that there's co-prescriptions. If you're prescribing opioids, you have to also co-prescribe for naloxone. So some of these are ways that you can really integrate social care into medical care. I was really happy to see this, which is a bipartisan effort, the Congressional Social Determinants of Health Caucus. I know our Congress now is off to a rocky start, so I don't know if this will sort of continue, but this was really putting healthcare dollars into the social determinants of health. And we always talk about this. Okay, we have social care, who's gonna pay for it? And I think this is what the Congressional Caucus is trying to do. And I'm really happy to see that we have Z codes now. So you could actually bill for these social determinants of health. And if you're looking at the Office of Minority Health, they talk about Z59, which is the problems related to housing and economic circumstances, are the top Z codes that are billed. So you should all, when you go back to your institutions and your EMR, look for these Z codes, because there are ways that you can be reimbursed with all these social determinants of health. So now I talked about advocacy, and we talked about a lot of things that are on sort of high levels, but I think this is the stuff that you can take back. And the first one is embedding health equity metrics into quality improvement. So at every meeting that you're at, you need to sort of understand, are we addressing health disparities? What are the health disparities? And you have to research them, because they're not gonna pop out to you. They're not just gonna be that obvious. You have to go to every meeting and understand it and look at everything through a health equity lens. The other thing is sort of bringing a health equity lens to your care delivery. If you're part of a tertiary care or quaternary care facility, how are patients getting to you? Are you really able to service the community? And also, of course, to screen patients for unmet social needs, which is critically important. So just some take home points that I hope that you've gathered from this quick talk is that health equity is not virtue signaling. It's actually saving lives and making sure that people who shouldn't be dying don't die and really looking at excess mortality. I think the other thing that we talked about is making sure that there's diversity in your clinical trials, so that PulseOx fiasco that we're dealing with now does not happen again. And also making sure that your editorial boards and your reviewers are diverse in terms of understanding health equity and diverse in terms of race, ethnicity, and also gender. Really important to build an inclusive culture because that's gonna combat burnout, all those microaggressions that go around in those toxic environments. In cardiology, we know particularly our catheterization lab and our EP lab to make sure that we build those inclusive climates there because it's critically important. And really understanding. Our healthcare system, I think, leaves much to be desired and understanding that health disparities are pretty costly. Last but not least, what we talked about is integrating social care in the redesign of healthcare. And so on our board of trustees health equity task force, one of our members was talking with one of the medical students about what we're doing and what we're trying to accomplish. And she drew this and I just wanted to share it with you that we're all in this boat together, community advocates, allied health professionals, and we're trying to go from the island of health disparities to the island of health equity. And we're all in this boat. And you see us bumping into the rocks of those negative social determinants of health and we're there pulling water out of the boat. And so I hope with this talk that we need your help. You see how much the water is filling up in this boat. And we need everyone to sort of think about their role in taking water out of the boat and actually moving to island of health equity. And so this wouldn't be possible until I had the support from my staff at Northwell and the Center for Equity of Care, Dr. Jen Merez, the critical care cardiology folks at American College of Cardiology, the American Board of Internal Medicine. And so thank you for your attention here. And I hope you have a wonderful conference and everything that you do in every session, and I hope you bring a health equity lens to everything that you're doing in this session and everything that you're gonna do back when you return to your hospitals. Thank you so much. This has been great and a privilege. Thank you.

diversity

equity

inclusion

health disparities

implicit bias

social determinants of health