Hello, my name is Craig Coopersmith, and it is my distinct honor to introduce Dr. Joy Howell. Dr. Howell is a pediatric intensivist and assistant dean of diversity and student life at New York Presbyterian Hospital Weill Cornell Medical Center. Dr. Howell is an expert in the field of disparities, and we are truly lucky to have her here with us today as a thought expert. Dr. Howell. Thank you, Dr. Coopersmith. Good morning, everyone. It's my distinct pleasure to have the opportunity to address you today on the matter of critical care disparities, the fierce urgency of now. Over the course of the next 30 minutes or so, I'll provide a brief overview of disparities in general, as well as what is known and unknown about their root causes, and then transition to a discussion of disparities in access to critical care, in pre-ICU care, as well as documented disparities in care and outcomes that take place within the ICU. Lastly, I'll articulate some of the actions that we as members of the critical care community can take to mitigate some of those disparities. First, I'll share that I have no relevant disclosures to make. One would hardly believe that a quote from the late Reverend Dr. Martin Luther King made some 55 years ago would still be relevant to American health care today. He said, of all the forms of inequality, injustice in health is the most shocking and inhumane. The World Health Organization Commission on Social Determinants of Health has said that reducing health inequities is an ethical imperative. Social justice is killing people on a grand scale. A health disparity is defined by the Institute of Medicine as any difference in health status, health outcome, health care, or health care utilization that is associated with a gap in the quality of care delivered. These may be caused by societal inequities, as well as patient, provider, and system-level factors that result in differential treatment. If you look at the graphic here, there are often going to be differences in care, but specifically disparities relate to the differences in outcomes that are not attributable to patient preference and differential needs. Healthy People 2020 defines a health disparity as a particular type of health difference that is closely linked with social, economic, and or environmental disadvantage. They go on to say that these disparities adversely affect groups of people who have systematically experienced greater obstacles to health based on their racial or ethnic group, religion, socioeconomic strata, gender, age, mental health, cognitive, sensory, or physical disability, sexual orientation or gender identity, geographic location, or other characteristics historically linked to discrimination or exclusion. Since the federal government began tracking health outcomes stratified by race in the late 1970s, racial and ethnic disparities in health care have been noted. Several years later, when the Malone-Heckler report was completed, it demonstrated distressing disparities as evidenced by excess deaths and over 40 diseases. It was only then that resources began to be coordinated and committed to addressing these disparities. In 1987, the Department of Health and Human Services created the Office of Minority Health to develop new policies and programs to eliminate these disparities, to fund research, improve data collection, and to generate policies toward health equity. In 1999, Congress mandated the National Health Disparities Report and convened the IOM to identify contributors. Patient, system, and process level factors were identified, including implicit bias. Since that time, not only has federal data continued to demonstrate these disparities, but literature and evidence has shown that the IOM has been able to identify literature and evidence from within the health care community itself, continues to document disparities that are extensive, pernicious, and pervasive. Disparities that are well beyond what can be attributed to patient access or patient preferences. Evidence exists in the adult and in the pediatric literature, in the medical and surgical literature, and documents the ugly reality of unequal care. It is this excess burden of morbidity and, worse yet, mortality that provoked the Institute of Medicine to characterize the diversification of the U.S. health care workforce as being in the nation's compelling interests. And a little later, we'll discuss the progress or lack of progress that has been made in the 20 years since these publications were issued. The upshot when we discuss disparities is that they are longstanding. They cut across gender, race and ethnicity, socioeconomic strata, geography. They impact every segment of our society, including the pediatric population. If we were to drill down on just a couple of examples and look, for example, at perinatal maternal mortality, you'll find that we here in the United States win the prize with a higher perinatal mortality compared to other heavily industrialized countries. A neighboring example would be infant mortality. If we review the trends over the past 80 years, you'll see in the colored lines that infant mortality rates for all groups has fallen and have fallen dramatically. But if you look at the gray bars, which reflect the ratio of Black infant deaths to White infant deaths, you'll see that that ratio has only increased. The disparities have gotten worse over the same 80-year period. Minority populations are often experiencing an undue burden of disease and, worse yet, an undue burden of premature death. The COVID pandemic that we are still wrestling with is a very present example. African Americans, for example, have higher age-adjusted death rates for eight of the 13 leading causes of death, leading to tangible differences in life expectancy. Education and socioeconomic strata are not necessarily protective, and critical care medicine, unfortunately, is not immune. As we seek to understand why these disparities have been so stubborn and the contributors that are most easily modifiable, so many questions can come to mind. These include, do women, minorities, and persons from gender identity minority groups present differently from men with certain diseases? Do healthcare providers assess the severity of illness differently based on gender, race, and ethnicity, socioeconomic strata? Can these differences affect intensive care unit admission rates? Does gender, race, and ethnicity play a role when patients and their families make decisions about the aggressiveness of treatment? Do physicians offer the same interventions in the same way, regardless of patient gender, race, insurance status, or are physicians subtly biased in their care? What, if any, differences in patient care can be associated with the gender, race, and ethnicity, gender identity of the provider? What is it about racially and gender concordant care that is favorably impacting outcomes, and how can we go about amplifying those factors to improve outcomes and mitigate the disparate process of care that yield inequitable outcomes? We know that there are many factors that contribute to healthcare disparities, including genetics, access to care, quality of care, and community features, as well as environmental conditions. The social, economic, and environmental conditions where people live, learn, work, and play are known as the social determinants of health, and they affect a wide range of health, functional, and quality of life outcomes. The World Health Organization and the CDC have determined that more important than genes and ancestry, than health behaviors, than access to care and quality of healthcare, social and societal factors have a larger impact on population health. And when we ask ourselves what are the root causes of the social determinants of health, we find structural and systemic racism. The CDC defines racism as the structures, policies, practices, and norms that assign value and determine opportunities based on the way people look or the color of their skin, resulting conditions that unfairly advantage some and disadvantage others, placing people of color at greater risk for poor outcomes. Racism, both interpersonal and structural, negatively affects the mental and physical health of millions of people, preventing them from attaining their highest level of health, and consequently affecting the health of the entire nation. It has been demonstrated that there are differences in practically every stage of disease, from risk factors for disease development to incidence to disease presentation, pre-hospital care, pre-ICU care, and then also differences within the ICU and in post-ICU care. Cumulatively, these result in disturbing differences in outcome, most notably mortality. For example, there are differences in pre-hospital and pre-ICU care based on gender. Audrey Bluer, in 2018, found that rates of bystander CPR were different for men versus women, translating into a 29% higher likelihood of survival to discharge for men. This is compounded by the fact that women experiencing MIs are less likely to receive invasive diagnostic and therapeutic procedures and, net, experience higher mortality after their first MI. If we look at race and access to critical care, Pines and colleagues found in 2009 that African Americans had longer boarding times in the emergency department compared to other ethnic and racial groups. Soto and colleagues in 2013 documented that African Americans are more likely to have delayed ICU admission and are less likely to be admitted to a cardiac intensive care unit after controlling for hospital and insurance plans. In general, non-whites are less likely to be admitted to the ICU compared to whites with the same diagnoses. Getting to the heart of matter, let's take a look at HIV and HIV-positive people. Let's take a look at care within the ICU. Time would not allow for an extensive review of all of the documented disease-specific differences, but if we were to drill down on the three ICU admission diagnoses that continue to carry a high mortality rate, we again find disturbing disparities. In 2020, a publication by Hilton and colleagues, it was documented that ARDS still carries a mortality rate of approximately 50 percent. Similarly, sepsis carries a mortality rate that ranges between 45 and 60 percent, and if we were to look at in and out of hospital cardiac arrest, we find mortality rates of approximately 75 and 88 percent, respectively. If we drill down on sepsis for a moment, part of the genesis of the surviving sepsis campaign was to heighten recognition of sepsis to promote earlier intervention and source control because it's known that delays in resuscitation and source control were associated with higher morbidity and mortality. Work by Meyer and colleagues in 2010 demonstrated that African-Americans are less likely to receive guideline-concordant antibiotic therapy for community-acquired pneumonia. This is relevant because pneumonia is the most common cause of severe sepsis, and severe sepsis is the second-leading cause of death outside of non-cardiac ICUs. Quarrel and colleagues in 2019 demonstrated that although the New York State sepsis guidelines yielded improvement in protocol compliance and were associated with a reduction in mortality, protocol completion rates were higher for white patients than for minority patients. Work by Jones in 2017 identified racial disparities in sepsis outcomes that were at least partially attributable to differences in hospital characteristics and quality. So, if we hearken back to the beginning of the presentation where we were talking about the social determinants of health, hospitals in minority communities tend to be safety-net hospitals, which often lack the resources and the infrastructure to achieve optimal uptake of best practices and management protocols associated with improved outcomes. If we look at peri-arrest care, Ellen Bach in 2009 found that African-American race was associated as an independent risk factor with delayed cardiac arrest interventions, including defibrillation, conferring a higher risk of death for African-Americans after both in as well as out of hospital cardiac arrests. Winchester and colleagues in 2018 documented that African-Americans presenting with critical troponin levels were less likely, statistically less likely, to receive consultation from a cardiologist for cardiac catheterization during the hospitalization in comparison with white patients with similar presentations. And then finally, if we were to look at ARDS, Erickson and colleagues in 2009 found that Black and Hispanic patients with acute lung injury have significantly higher death rates compared with white patients. The increased risk for these investigators seemed to be mediated by increased severity of the illness at the time of presentation for African-Americans, but it was not easily explained why there was this disparity among Hispanics. In this study, these authors found that Blacks and Hispanics had higher risk of mortality after age adjustment, and in fact, even after adjusting for gender, mechanical ventilation strategies, the presence or absence of comorbid conditions, the sources of lung injury and PF ratio, the association between Black race and mortality and Hispanic ethnicity and mortality persisted. However, it was only after adjusting for severity of illness did the association between Black race and mortality no longer remain significant, whereas the increased mortality risk for Hispanic ethnicity remained significant. Kang and colleagues in 2019 demonstrated that Blacks and Hispanics have higher mortality from ARDS compared to Whites. In summary, Blacks are more likely to have a greater severity of illness on presentation, more likely to have pneumonia as an inciting event. So again, if minorities are less likely to receive guideline-concordant care, it's no wonder that we're going to see disparities in outcomes. As I mentioned at the outset, race and ethnicity are not the only source of disparities. Work by Valentin and colleagues found that women with coronary artery disease were more likely to be discharged with a misdiagnosis of MI, and once admitted, were referred for bypass surgery later in their treatment course. Men were more likely than women to undergo invasive procedures, despite the fact that women had higher severity of illness. In addition to differences in how we provide care to patients, there is evidence of cultural differences, particularly around end-of-life care that have been documented. The preferences are influenced by a multiplicity of factors, including earned and unearned mistrust of the healthcare system. And it's curious to note that mortality for communities of color are higher, despite the request for more aggressive care at the end of life. You may ask, well, what about the pediatric population? Although there's mixed evidence for disparities by race and ethnicities and socioeconomic position in PICU admissions and outcomes in the United States, there are some striking trends specific to some disease processes. Notably, there are evidence of disparities in the management and outcomes from out-of-hospital cardiac arrest, asthma, severe trauma, sepsis, and cancer, as well as in familial perceptions of care. Furthermore, there's clear evidence that critical care research is limited by under-enrollment of participants from minority race or ethnic groups. In work done by Lopez and colleagues, they demonstrated there was a relationship between the need for mechanical ventilation and insurance status, specifically privately insured children admitted to the ICU had the lowest rate of use of mechanical ventilation, whereas uninsured children had the highest rates of use of mechanical ventilation, and individuals who were publicly insured, i.e. on Medicaid, fell in the middle. Disparities in research enrollment represent an important and outstanding gap that needs to be remedied. Even when we evaluate our practices around preclinical studies, we find inequities. Classic animal models of disease utilize primarily male animals. In humans, it's known that hepatic metabolism and renal drug clearance are influenced by muscle mass, and muscle mass differs significantly between males and females. A case in point is that even after calls in the 1970s and the 1990s for attention to gender and sex representation in our drug research, it was only after Zolpidem came to market that the need for a dose reduction was identified. The Committee on Comparative Effectiveness Research has declared racial and ethnic disparities in healthcare delivery to be one of the nation's top research priorities. It's important also to note when we think about how we choreograph and design our research studies that societal risk factors and epigenetic phenomena cannot be appropriately modeled in animal studies. In the face of this compounding evidence of difference in risk, severity of illness on presentation, and most significantly, differences in care, we must commit attention to the resources necessary to reduce, if not eliminate, these disparities. True progress will require a multifaceted approach, including but not limited to research that moves beyond re-demonstrating the problem to focus on interventions that actually reduce disparities. We need to apply QI methodology to systematically measure health equity. By that, I mean tracking outcomes and adverse events stratified by social and demographic factors to, again, identify the interventions that mitigate disparities. We need to engage in training, education, and advocacy around implicit bias and racism in medicine, as well as structural competency. And finally, we need to attend to the diversification of the U.S. health care workforce. Briefly, I'll define structural competency. Structural competency has been defined as the capacity for health professionals to recognize and respond to health and illness as the downstream effects of broad social, political, and economic structures. As I mentioned a moment ago, we need acknowledgment, advocacy, and education around the fact that racism is, in and of itself, a public health threat. And organizations like the American Medical Association have called out racism rather than race as an important risk factor for disease. We need to pay attention to workforce diversity. There are numerous dividends that have been delineated thus far, including the fact that minority physicians are more likely to provide care for the underserved, that increasing diversity often is associated with increased access to care, particularly for socioeconomically disadvantaged populations, as well as racial and ethnic minority. There are studies that document that racial concordance is associated with increased acceptance of physician recommendations for African American men. And there are studies that document gender concordance, as well as racial concordance, being associated with favorable outcomes. One example, or a couple of examples, in fact, I'll share with you here. Greenwood and colleagues in 2018 documented improved survival for patients presenting to the emergency department with acute MI when they were cared for by female physicians compared to those cared for by male physicians. In this study, they found that female patients cared for by male physicians were the least likely to survive. Work by Meyer and colleagues in 2019 demonstrated that female co-team leadership was associated with an increased likelihood of achieving return of spontaneous circulation and an increased rate of survival to discharge. Why do I link diversity to a discussion of healthcare disparities? Well, the fact of the matter is that the demography of our country is changing. And it's estimated that by 2050, more than half of the U.S. population will be individuals from backgrounds that we currently define as minorities. Fifty years' worth of data collected from the government, more current research, including the small amount of research presented here, the ongoing COVID pandemic speak to the reality of unequal care and should remind us of the conclusion that the IOM came to some 20 years ago. You may ask what progress have we made with respect to workforce diversity since these publications were issued. In my opinion, not enough. Depicted here are the race and ethnicity trends in medical school matriculants and graduates over the past 45 years. You'll note if you attend to the red and the blue representing African American and Latinx students that the needle has barely moved. Summarized here are the racial and ethnic representation of different segments of the healthcare workforce, specifically the physician healthcare workforce. I'll call your attention to the fact that we have leaky pipelines. African Americans represent close to 15% of the population, yet they represent only 7% of U.S. medical school matriculants, 5% of the total U.S. healthcare workforce, but only 3.5% of academic faculty. Similarly, among Latinx individuals, you'll find that they represent 18% of the U.S. population, 6% of medical school matriculants, close to 6% of U.S. physicians, but only 3% of academic faculty. Even in pediatrics, a specialty where women represent the clear majority, there is attrition and insufficient representation, particularly in leadership roles. Work by Andrea Maxwell in 2018 demonstrate that although women represent over 50% of medical school matriculants and approximately 60% of the pediatric workforce in general, we represent only 40% of the pediatric critical care medicine workforce. Although there have been recent gains in the number of women choosing pediatric critical care medicine as a specialty, women represent only 50% of program directors and 30% of pediatric critical care medicine division chiefs. As of 2018, when her work was published, there were no editors-in-chiefs of pediatric critical care journals. So where do we go from here with respect to narrowing the gaps in our knowledge and understanding of critical care disparities? We need studies that account for ancestry rather than the poorly and variably defined social construct of race. We need studies that account for the variable incidence of critical illness as well as factors around access and care preferences around the end of life. We need studies that adjust for severity of illness when looking at outcomes analysis. We need studies that have adequate representation of minorities relative to representation at the local, regional, and national level. We need studies that evaluate pre-hospital and pre-ICU care, including CPR quality. We need studies that look at our practices both within and following the ICU. As I mentioned before, to meaningfully impact and mitigate disparities will require a multifaceted approach. Every system is perfectly designed to generate the outcomes it gets. So if we are to effect meaningful change, we have to commit the energy and resources toward system-level changes. I close with yet another quote from the late Reverend Dr. Martin Luther King, who said, we are forced with the fact that tomorrow is today. We are confronted with the fierce urgency of now. In this unfolding conundrum of life and history, there is such a thing as being too late. This is no time for apathy or complacency. This is a time for vigorous and positive action. I thank you for your time and attention, and I look forward to continuing the conversation with you. That was sobering, educational, and moving and fantastic, Dr. Howell. Thank you. Unfortunately, we don't have an audience, and so what I have is a list of questions that were given to me by the program committee, and I'll start with this. Does the critical care workforce look like the critical care population? Does the critical care workforce look like the critical care population? And does the critical care workforce look like the critical care population? And does the critical care workforce look like the critical care population? The short answer to your question is no. Does it matter? Yes. As I mentioned during my presentation, the demography of our country is changing. Is it practical? Is it achievable that there will be perfect health care for all of us, and is it achievable Is it practical? Is it achievable that there will be perfect racial, ethnic, gender concordance between patients and their providers? I don't think that perfect concordance is feasible. However, we do need to address the historic exclusionary practices that have limited entrance and access to persons of color and persons from minoritized and disadvantaged backgrounds from getting into the health care profession. And we need to do a tremendous amount of work around cultural, what was formerly referred to as cultural competence, but is now referred to as cultural humility. I also think that we need to do a lot of work around educating the more senior members of the U.S. health care workforce and the pediatric, the critical care workforce in the concept of structural competency. Thank you. My next number of questions are going to be how do we, how can we, questions. You alluded to this at the end. So the first question is how can we close the gap on critical care disparities? I think that we need to systematically measure the disparities. It's been said that how can you change a system if you don't measure it? There are organizations, institutions that are deliberately taking Q quality improvement practices and applying them to health equity. A QI practice involves systematically measuring a perceived problem and iteratively applying or refining interventions until the problem is reduced in significance. If we were to measure adverse events, catheter-related bloodstream infections, CAUTIs, any adverse outcome, as well as morbidity and mortality stratified by race, ethnicity, socioeconomic strata, language, and continue to document disparities, then the next and, dare I say, more important step is targeting interventions and iteratively targeting interventions to narrow those gaps. Thanks. And we're going to take this a step further. How can critical care clinicians extend their work to address disparities beyond the walls of their individual ICUs? I love that question, Craig. In my younger days, I very foolishly and naively thought that advocacy was the work of the generalist, was the work of the internist or the pediatrician, not necessarily the role or space of the subspecialist. But there are ample opportunities for us to engage in advocacy at local, regional, and national levels. We need to give visibility to this issue of healthcare disparities. We need to attend to differences in resources. One of the things that I mentioned is that some disparities seem to be associated with where communities of color, with where patients from low socioeconomic strata receive their care. There are opportunities for us to engage in advocacy around the distribution of critical care resources or to modify our networks that would allow patients who are most vulnerable at the highest risk of adverse outcomes to receive the most sophisticated care. The short answer is advocacy. Thank you. And we're going to move from that to another how can we. How can we teach students in healthcare professions today to understand the true issues of inequity and what tools and resources should we provide them to truly make a difference in their practice and communities? My response to that might be considered a touch radical. I think that we need to get our students out of the classroom and into the community. It's said that adult learners learn from experience more so than in the classroom setting. And if our students at tender phases of their professional development journey were to get out into the community, to experience public transportation, to walk through neighborhoods that represent food deserts, to look at the quality of care that folks can achieve locally and better understand the communities from whence their patients come, I think that they will evolve into more well-rounded providers. By no means would I suggest that a command of the foundational sciences, physiology, pathophysiology, staying on the cutting edge of drug and other therapies that impact the natural history of disease, that's absolutely essential. But I don't know that in this day and age that it's sufficient. We have to understand and build that structural competency. I'm going to take the moderator's discretion before I ask other questions from the program committee to follow up on what you just said. So you live in New York City and I live in Atlanta, and both of us are in very robust, diverse communities. But not every medical school or healthcare profession is in a robust, diverse community. Some of them are significantly more homogenous. How would you discuss getting into the community if the community isn't incredibly diverse? I would again say we've got to get out of the classroom. At least in a very urban area like New York, like Atlanta, there are robust transportation systems. I'll call your attention to work by Monica Vela. She is an educator in Chicago and she's a medical educator and she developed a pre-matriculation course for her medical students that involves them going out into the community over the space of a week or two prior to the start of the curriculum in earnest. I think that it becomes far more challenging if you're in a rural community where the network and the geography from where, from whence your patients come is very broad. But I think to the greatest extent possible, we've got to get our learners out of the ivory towers, so to speak, into the communities, the most distal aspects of the community that's practical from whence the patients come. Let's move from our learners to our administration, perhaps to our C-suites and our ivory towers. How can administrations be influenced to begin to make changes? In these current days, I would say that the American healthcare system has been paying progressively more attention to matters of equity, diversity, and inclusion. Sometimes that attention can feel performative, but if we are serious about equity, then we need to be prepared to refine our systems, our processes, our practices iteratively until they generate equity. I'll use a recent practice by the NIH as an example. Last year, they issued a call for applications for what was referred to as the first grant. And what they were seeking was for institutions to compete for matching funds if they committed to hiring 10 underrepresented faculty members within the span of three years. We've got to work to push the envelope, not to flagrantly celebrate my institution, but our dean went about the mission of advancing gender equity in our institution and over the past few years has hired three female chairs. Those in leadership, those in positions of power, they have the control to set goals and incentivize and resource others to achieve those goals. So, I applaud you for reading my mind on this next question because you brought up the NIH briefly on the first awards. More globally, how is the government assisted in this issue? By funding, by awareness? Let's talk about that. Well, if I were to circle back to the NIH, another practice that they're engaging in is challenging all of the investigators who are competing for funding and receiving ongoing funding for attending to diversity, either in their study population, in membership of the research team. I would say that those are examples, or that is another example of how on a governmental level we can help advance diversity, equity, and inclusion. What do you think are the best disparity metrics that societies, including SCCM, should strive for? So, in terms of disparity or health equity metrics, I think a very fine starting place is stratifying all outcomes that are deemed important, whether they be favorable or unfavorable, by race, ethnicity, socioeconomic strata, language, zip code, those social environmental factors that are known to impact health outcomes. And for societies looking to understand the opportunities to meaningfully affect change, I would call attention to the American Medical Association's recent publication on strategic planning toward social justice and anti-racism. It's a very comprehensive tool that, truthfully, I am still in the process of making my way through, but the AMA, the American Public Health Association, and other organizations are trying to lead the way in terms of promoting social justice in the American healthcare system. Thank you. To sort of change gears here, minority caregivers have been subject to overt racism and microaggressions from patients. In some types of businesses, customers can be refused for being racist or sexist. However, in healthcare, we're expected to care for the patient irrespective of patient behavior. How should hospitals address the situation when a patient is being discriminatory? Well, I think that we have to be measured in our responses. Certainly, if we place primacy on the well-being of the patient, if a patient is critically ill, if a patient lacks capacity, we need to do what is necessary to keep the patient safe. However, there is a precedent. Several hospitals across the country have put in place policies that, if it is not medically inappropriate, that would seek to limit disrespectful, biased, discriminatory behavior on the part of patients. Unless harm would come to them, if a patient is not willing to comply, to invite them to seek care elsewhere. But again, that wouldn't apply to a patient who is critically ill or unstable or who lacks the capacity at the time that the problematic behavior is being demonstrated. Can you discuss the challenge of inclusiveness? Someone always feels left out. How can inclusiveness truly be implemented and fostered? So, there's a lot of work that is being done in the social sciences, as well as in healthcare, around implicit bias and around microaggressions that are a major manifestation of the implicit biases that we all hold. The problem with microaggressions and implicit bias in general is they make people feel unwelcome. And if we are to create learning and working and care environments that are truly inclusive, we have to set a standard of a culture of respect, set inclusiveness where everyone can find belonging as a goal, and we have to hold one another accountable if there are individuals or actors who are violating institutional norms and values. We have a few minutes left in time for a few more questions. Many treatment decisions are based upon disease severity scoring systems. And some of them, like SOFA, may overestimate mortality in some races. How should we use data on disparities to inform our treatment decisions? Thank you for that question, Craig. I don't know that time would allow for a rigorous discussion or distinction between race-based and race-conscious medicine. There are a few examples that I can cite. Probably the most prominent one is how we go about calculating glomerular filtration rate. And prior to the past year or so, those calculations factored in race would, in the case of EGFR, would assign a lower number to African Americans. And the concern was that that practice would delay referral to transplant and necessary interventions. The concept of race-conscious medicine calls for us not to ignore the social and environmental factors that contribute to adverse health outcomes, but to factor them in. We also have to be mindful of the fact that race is a social construct, not a biologic construct. The Human Genome Project demonstrated that there is greater variability within individual races than between races. And it is racism rather than race that is the risk factor for adverse outcomes. And so, the way we go about addressing that reality is to be mindful of the social factors rather than the color of the skin. So, instead of focusing on an individual being Latinx, we should focus on whether or not the individual speaks English. Focus on factors like poverty rather than race that we know is an artificial social construct. So, you touched on this in your talk, but do you feel that progress has been made over the last 10 to 20 years? Do you think there's been regression or somewhere in between? I think we are making progress. It feels sometimes frustratingly slow. I do think that there's an opportunity for us to pick up the pace. When you look at the amount of time that disparities have been documented, when you look at how persistent some of these disparities have been, I cited perinatal maternal mortality and infant mortality. I can't help but believe that we can do better than this. But I think it's a matter of disparities being a prominent enough issue to concentrate the resources. And I also think that we need to move beyond re-documenting or re-demonstrating that there are differences and focus on the interventions that actually narrow the observed gaps. So, while we could do this all day and all night, and I wish we had the opportunity to do so, we're going to have to leave it there. So, I will thank Dr. Howell for an extraordinary session and just say this is pretty much the definition of a thought leader. Thank you so much, Dr. Howell. This was truly remarkable. Thank you for the opportunity.

critical care disparities

health disparities

societal inequities

implicit bias

pediatric population

access to critical care

gender disparities

race disparities

diversifying healthcare workforce