19. Esther Choo and the Equity Quotient
"In the ER, something we learn up front is that we’re seeing people on their worst day. We don’t hold them to the standard of their best day."
-Esther Choo, MD, MPH
Gender and racial bias are pervasive across all aspects of society, the house of medicine notwithstanding. In this episode, Esther Choo MD, MPH, a titan for the cause of gender and racial equity discusses: a rubric for deciding 'yes or no', single payer healthcare, why confining medical practice to the bedside can be an exercise in futility, sexism and racism in medicine, the wage gap, workforce vs. leadership demographics, managing overtly racist patients, and why the culture of medicine is ripe for sexual harassment.
Guest Bio: Esther Choo (@choo_ek)is a professor of emergency medicine at Oregon Health Sciences University and serves as their research fellowship director. She is a nationally recognized expert in gender and racial bias in medicine, lecturing and writing frequently on these topics. She is a funded researcher, has served as president of the Academy of Women in Academic Emergency Medicine, and is a senior advisory board member for FeminEM.org. She is a co-founder of Equity Quotient, a consultancy that works with healthcare organizations, employer groups, and academic centers to create culture of equity, safety, and respect.
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Esther’s first outward advocacy: responding to the Trump administration’s attempts to dismantle the Affordable Care Act [03:44];
It started with reading a New York Times article addressing how changing “Obamacare” would disproportionately affect vulnerable populations (ie. mothers and children). As a health disparities researcher, this really galvanized her.
She realized that part of her job as a clinician was to be more vocal about things that she cares about.
How you decide whether to say “yes” or “no” when you don’t have time to do everything that’s asked of you [06:15];
Esther asks herself: “When I do this, I’m taking time directly away from my kids. Is it worth it?’”
She devotes her time to tasks that are compelling and which she uniquely can do. If others are equally capable (and maybe even would see it as an opportunity), then she hands it off to somebody else.
Why investing in the development of a single-payer health system would provide better care upstream so that we can save on our costly low-value care downstream [11:00];
The current payer system in the US is too complex and is tremendously wasteful.
We put a lot of resources into highly specialized care while neglecting basic health care, preventive care, and making sure that we have health equity.
What Esther will always stand up against: inequity [17:20];
Working in the emergency department gives you clear insight regarding our structural inequities. This is especially true for those who work at safety net hospitals and when covering the night shift
In the ED you see the enormous gaps in wealth and how the system is stacked against people based on who they are, what they look like, and where they came from.
The importance of advocating for systems solutions to problems, and how confining your practice to the hospital is an “exercise in futility” [19:00];
Many times Esther leaves her shift so frustrated by her inability to fix problems for individual patients that she picks up the phone and calls her senator’s office.
The way mental health patients are treated in the ED is a perfect example of this. They wait for hours, even days, in windowless rooms awaiting admission for psychiatric care. It should be a respite for them, but instead it looks like torture.
While in the moment, as the emergency provider on duty, you might feel that there’s nothing you can do about systems problems such as this, the truth is that if you go out and agitate about the inhumane care being provided, policy shifts.
“When we walk into retirement, medicine should feel different for the people we’re handing off to.”
Esther’s pre- and post-game routines before and after night shifts [25:20];
Lessons Esther tries to impart on her trainees in the ED [29:00];
Her specialty areas include tips regarding efficiency and flow.
She also teaches awareness of implicit biases and how they might impact the care of patients in unexpected ways.
Esther tries to get her residents to ‘lean in’ to patients that make them feel uncomfortable.
The importance of meeting patients where they are, whether they’re a heroin addict, borderline personality, or an a-hole [32:50];
The master skill of dealing with difficult patients is self-awareness. Acknowledging how they make you feel inside can help us treat them with grace.
Someone who may come off as an a-hole may actually just be a person who is super, super stressed.
Esther’s podcast, Doctor’s Log, which is a diary of the experience treating patients during the COVID pandemic [34:40];
Early on in the COVID pandemic, the focus was on PPE, ICU beds, ventilators, testing capacity, etc. It was so dynamic.
As time went on, it became much more about these rolling bigger issues like the vast health inequalities. And how our entire health care system is set up for short-term crises, but not for long-term, extended, multi-dimensional crises.
How Esther responds when a patient refuses to be treated by her because of her race [38:18[;
Her first instinct is to care for the patient and make them as comfortable as she can. If they’re critically ill, delirious, or psychotic, they’re not really accountable for the decisions they’re making or the words they’re saying.
At the same time, there's an obligation to trainees and staff to establish norms and to ensure that the working conditions of the entire team are tenable.
She may have to redirect patients, referring to hospital policies that maintain that harassment of a person based on their gender, sexual orientation, race or ethnicity is not permitted on the campus. If they can't abide by that rule, then they can seek care elsewhere (assuming they’re stable and have a clear sensorium).
Everyone deserves respect, including the workers.
Sexism in medicine and how to get everyone (not just women) on board as advocates for equality and reversing disparity [43:55];
When speaking to a general audience of people who have not already bought into the need for change, Esther’s talks are extremely data driven.
She uses data to disrupt narratives and address common misperceptions around things like the wage gap or the opportunity gap.
Esther accepts that some people will be upset, and if only 1 person gets up and walks out, she knows she’s doing well.
How implicit bias is a side effect of being human [48:30];
Our brains are naturally biased.
Esther takes an implicit bias test every year and, believe it or not, still has a small bias against women in leadership positions.
The discrepancy of the demographics in the workforce vs. in leadership positions [58:00];
Esther believes that the demographics in leadership should closely mirror the percentages in the workforce. More importantly, our workforce and leadership structure should reflect the populations we serve.
Health outcomes actually improve when there is some racial and gender concordance to our population.
Explaining the gender wage gap in medicine [1:03:00];
A 2016 Wall Street Journal article stated that women earn on average 64% of their male counterparts. This study pulled from US Census data which isn’t well adjusted for other confounders.
Other studies (ie. the Medscape Physician Compensation Report) are better adjusted for potential confounders, such as choice of specialty, hours worked, clinical productivity, and academic productivity. Even when you adjust for confounders, there's a persistent unexplained wage gap.
Esther attributes the physician pay gap to bias discrimination based on gender.
A large study out of New York looked at starting salaries straight out of residency and found a $16,000 wage gap between male and female residents that was not accounted for by things like choice of specialty. This small inequity upfront compounds over time and downstream becomes very big.
Pay inequity creeps in even in productivity-based compensation systems which many assume to be objective. Females will be given fewer OR hours, a different case mix, or ED shifts which tend to have lower acuity patients. All of these substantially affect income.
When you create opportunity but don't pay attention, bias will creep in, because that is how our brains are wired.
Strategizing solutions to gender pay inequity [01:10:00];
We need to have objective allocation of compensation and be systematic about investigating sources of bias.
Especially right out of residency, salaries should be standardized. And if it's not a salary system, you should have audits to try to figure out if there are discrepancies and whether they're agreed upon by the group.
A group can decide democratically on a pay discrepancy, but it shouldn't be decided automatically. It should be an explicit conversation.
Most groups would benefit from a wage analysis every 1-2 years to determine where income inequality may have crept in. And if it is not a planned inequality, then it needs to be addressed.
Esther’s company, Equity Quotient, whose mission is to “work with standout health care organizations, employer groups and academic centers to create a culture of equity, safety, and respect” [01:11:34];
When hired to work with a company, Equity Quotient starts by doing an environmental scan, meeting with leadership to understand the perceived needs. Once the goals are articulated, they make a plan.
They complete a baseline assessment and collect detailed measurements across five domains: safety, sexual harassment, the extent to which people feel valued, opportunity for advancement, and general culture.
Recommendations are given to the organization about where their problem areas are, what potential corrective actions might be, and whether they need more assessment.
The NEJM article, Time’s Up for Medicine? Only Time Will Tell, and why medicine is ill-prepared to make meaningful steps toward ending harassment [01:17:00];
Reasons why the culture of medicine is ripe for sexual harassment: it has a traditional hierarchical structure, it’s male-driven, physically it’s set up with private rooms 24/7, there are many different people colliding in different circumstances where behaviors can go unnoticed, and there’s a total culture of tolerance.
In this culture, not only is harassment going to happen, but people aren’t going to report it because we’ve developed a high tolerance for pain and disrespect.
“Every element that you can put into a petri dish that cultivates harassment is present in health care in a way that just doesn't always come together 100 percent in other industries”.
Why change won’t happen if we don’t improve the diversity representation from the ground floor up to the highest leadership [01:19:45];
We also need to do some structural dismantling.
“How do we make all of our leadership structures a little bit less vertical and a little bit more horizontal without losing too much efficiency in our decision-making?”
The reason Twitter became Esther’s social media medium and how Chelsea Clinton’s comment on her tweet took her to the next level [01:22:56];
Why patients of surgical attendings who are abusive to staff have worse outcomes [01:27:00]; and
If you’re not emboldened to speak up when you see something that’s bad for the patient, errors will not be caught or prevented.
Esther’s call to action, [01:30:42];
“Physicians need to know that it’s within their wheelhouse to change the things that they gripe about.”
“If their sphere of action is just within the walls of the hospital, then they're simply passing these problems onto the next generation, adapting around them rather than fixing the fundamental issues,”
“We have to be responsible for structural change in medicine and for making the practice humane and good for patients in the way that we know that it should be.”