Transcription of Podcast Episodes

Episode 1_ How Gender Impacts Patients’ Experience: Pain, Medical Research, and the “Male-Model”

Sydney Feldman: [00:00:00] Fibromyalgia is a disorder that often manifests through symptoms such as constant fatigue, changes in sleep, pattern mood swings, lack of clarity and memory and muscle pain around the body. The fibromyalgia is very common disease. There’s still a lack of understanding regarding the pain syndrome. Research to date takes form as clinical trials. However, very little information is commonplace in a doctor’s office when patients actually come in with complaints of pain in emergencies. Patients diagnosed with fibromyalgia are often prescribed opioids and other pain medications. The long term treatments and cures are still lacking, with more than three million reported cases per year. Why is it that so little is known about the disease? According to U.S. government statistics, about 90 percent of fibromyalgia cases are diagnosed in female patients. Fibromyalgia is just one example of a health issue that disproportionately affects females. Other examples include heart disease, strokes, anxiety, depression and more. This gender imbalance led me to wonder Are patients treated differently based on gender? Today’s episode will focus on some of the ways that females have continued to be treated differently when seeking medical care, when entering a hospital or medical institution with a complaint of pain or when experiencing a medical emergency. I’m pleased to be joined by Dr. Stacy Rosen, vice president of the Katz Institute for Women’s Health at North Shore L.i.j Health System. Dr. Rosen is a practicing cardiologist and echocardiography and is board certified in internal medicine, cardiology and echocardiography. Dr. Rosen has received numerous awards, such as the Anne Gottlieb Award for Excellence in Teaching from North Shore L.i.j, and she was voted as one of Long Island’s top 50 most influential women twice. Dr. Rosen devotes her career to increasing awareness of women’s health issues, in particular heart disease. Thank you so much for speaking with me today, Dr. Rosen. How did you become involved with the Katz Institute for Women’s Health and what originally drew you to the field of medicine?

Dr. Stacey Rosen: [00:02:11] So I am a practicing cardiologist for over 30 years. I am the daughter of two educators actually, who traveled from a nice Long Island suburb into one of the most underserved areas in New York City. When I was a kid. And so fairness and equity and. Priorities became it’s how I was raised that, you know, for us, it was, you know, everyone is entitled to a quality education, and I saw how important that was to my parents. There were no physicians in our family. I thought that you would never be bored in medicine because I saw doctors, even as a high schooler who, you know, some. You know, took care of our family, but some taught medical students and some did research and you know, in the days of smoking cessation and healthy foods, there were physicians in papers who are doing advocacy work. So I thought that it would be a career in which I would never be bored and it would be, you know, an opportunity to give back. I just felt that that’s the kind of home that I grew up in, and I was attracted to cardiology from the get go. It seemed very concrete and important. It’s the number one disease, you know, causes of death and disability in the U.S. It went women and men. It seemed to be an area in the late 80s and 90s where there was an enormous amount of advancement and research. So it struck me as sort of a field where it could be a primary care doctor and take care of patients over their lifetime and my lifetime. But also there was amazing research and technology and computer based advancement, so it seemed like the perfect feel to me when I entered it 12 percent of the U.S. practicing cardiologists were female. Now, thirty one years later, we’re up to a whopping 15 percent. So, you know, it’s still a field that does not have enough women in it. And when you get to health equity and disparities, that’s not an unimportant problem for us in women’s sport. I was taught that it wasn’t a disease of women, and then all of a sudden all I started seeing were women and they presented differently. Maybe their symptoms were the classic elephant sitting on my chest. But women would sort of minimize their symptoms. What were often attributed to psychosomatic issues or stress or dear dear in your head? And I found that unfair and inequitable, and he data started to show that it was in fact, bad medicine.So that that is how my whole career in cardiology has been focused on improving the health outcomes for women with advocacy and clinical practice and research and education for each other, you know, actually both even professionally. So the Katz Institute was focused around how do we reorganize and realign health care delivery to mitigate the disparities that we’ve seen? Basically, because health has been a male model for health, you know, historically, we assume men and women were the same except for the parts covered by a bikini, and we figured it was easier to study men. Women got menstrual periods that bucked up our research, so let’s just study the guys. And except for those parts, assume women are the same. But the truth is, when we do that, we do a disservice to women and we actually do a disservice to men also making the assumption that everything’s gender neutral, except those parts. And the truth is, we came to learn that every cell in your body has a has a sex that’s that’s your chromosomal makeup that you’re born with. And so why should my heart arteries still not be different than my husband or brothers? So I know that is a very long winded answer, but that that’s how I got here. It started thinking that I would never be bored as a doctor, and I would probably otherwise have been a history major at some Ivy League school and never gone to medical school. And I love, love, love what I do. And then the women’s health is about fairness and equity and mitigation from mistakes that the health care world made for decades by assuming that male model was OK.

Sydney Feldman: [00:06:56] And since your time working in the medical field, being a doctor, seeing patients firsthand, have you seen a sort of shift in non gender specific research and putting everyone under one large umbrella and instead kind of looking at people individually?

Dr. Stacey Rosen: [00:07:15] Yeah, no, I think there has. And the tagline for that comes from the National Institutes of Health and the Office of Research on Women’s Health, and they talk a lot about sex as a biological variable, and that’s sort of pivoted. And and that’s not a new a new mantra that that came in the nineteen nineties.The first female who ran the NIH was Bernadine Healy and Dr. Healy. The late Dr. Healy, a cardiologist, also said that we always have to sex as a biological variable. And if you’re going to study something and it goes down to the finances, where to apply for NIH funding, then you would need to demonstrate that you included sex as part of. Your design, you had to include women at the prevalence that the disease exists in the real world. So these are old cardiology studies that were 100 percent men that stop passing the the proposal, the muster to be funded. The FDA started doing the same that that a drug that works on a hundred men is not necessarily going to work on one hundred women. So sex is a biologic very well has become, you know, has been for several decades sort of the mantra of this kind of work. But we still don’t do it particularly well in the heart world where men and women die of heart disease equivalently. In the U.S., we looked about a year and a half ago, and one of our major academic journal looked at 10 years of research across the continuum of heart conditions. And on average, we included about thirty five percent of women. And in some diseases that are really important in women, we were in the 20s, so we’re still not. We know we’re supposed to do it, but we’re still not doing it well. And if we don’t do it well and if we don’t ask the question, how is this different in men and women, similar to the fact that we know we have to ask some questions, how is this different and old and young? How is this different in black and non-black, et cetera? Yeah. And what do you believe currently are some of the leading causes of gender disparity in the medical field? Oh, my goodness. So, you know, I think that we are still compensating for decades of the male model being the default. And I think there is still a hesitancy, unfortunately, too many to believe that it matters. So it’s why, after so many decades of this being the rule at a place like the NIH, you know, the largest funder of research in the states, still seeing that we don’t do well with it with something like heart disease, which is the number one killer. So, so I think it is still sex as a biological variable is not still acknowledged as as a as a given and in fact, the fact that this has to be done. That’s number one. I think number two, there are. Challenges when? Researchers and physicians don’t necessarily look like the patient population they serve, and I think that speaks to your second and third question. Right. So in a field of ours that we still can’t get past 15 percent of our specialty to be filled with women, it is is a problem. And we talk about the older individuals in our field who still were trained in a day that this wasn’t a woman’s disease. You know, it’s in your head and you’re having stress at home. It’s hard to undo what you’ve done for decades. So I think that’s to what what the gender and demographics of the clinicians and scientists looks like. And then to not overdramatize it. It’s hard to be a woman throughout the world. These inequities exist in promotion and salary and, you know, in so many other areas, aside from health care. Yep, and when a patient walks into a medical setting and seeking care, how do you think they’re treated differently based on their gender? Oh, there’s tons of studies on that. You know, not dissimilar to the way that we’ve done in the human resources world. Colorblind interview and write the same resume that goes to a boss with a male’s name at the top and a female’s name at the top. So I think women are in general often perceived to be, you know, the word hysterical comes from right the way women react when their uterus acts. So, so so I think I think it’s I think when women are less likely to be believed honestly. But women are also more likely to not put their needs on top of their to do list. And I think that’s definitely part of the problem. Women go to the emergency room. I know I’m really busy. I have to drop you off soccer and I’m baking for this. And you know, I’ve got a webinar to to to give in an hour. So I think women put themselves last and either don’t feel empowered or entitled to good health care. So, you know, I didn’t want to bother the doctor. I’ll take Tums and have the chest pain at home, sort of thing. So I think it’s sort of it is bidirectional and in both directions, opportunities for us to do better.You know, believe a woman when she comes in, you know, it’s not in her head and do the science better. You know, again, there are 80 percent of migraines. Are women. Why is that? You know, I am a migraine sufferer. That’s not me having a bad day. That’s me unable to see how two half of my eyesight, that’s, you know, and it’s managed and all. But could you imagine if we had a disease that was 80 percent male and we didn’t study it and didn’t have to do it? The boy part, right? I mean, my daughter is a young doctor and I guess three or four years out of med school, and I remember her calling me when she was in med school. And she says, You know, why do they call the way women get chest pain atypical? She said it was like a total naivete, even though I’m her mother. And she says, you know, if more women have heart attacks every year than men, why would that be the atypical form? And I’m like, Yes. And they’re teaching you that. And, you know, twenty nineteen in medical school, not in, you know, in nineteen eighties. I guess sort of as a sub question to that, how do you think they’re treated differently when they approach medical professional with complaints of pain or something that could kind of it’s not seen in a test, but is more something attributed to their head? This is called “Doing Harm”. Yeah, I see. Ok? It’s phenomenal. She is a woman who suffers from a rheumatologic disease, and she talks about the whole history of and, you know, women with rheumatologic diseases. They’re often somewhat subjective complaints, a little swelling. But it’s gone now, doctor. Maybe I had a face rash, really tired. They’re hard diagnoses to make, and women on average see four to six doctors and take three years to get an adequate diagnosis and a disease that’s 80 percent female. So if I think women pain is aligned with that hysterical female. It’s in your head. You don’t have a train. Go get a good night’s sleep, buy a handbag. So when you look at hard to diagnose diseases, you mentioned fibromyalgia is a is a classic one hour deal is, you know, just legendary, was a general internist in Manhattan and before coming to us and. So, you know, people would talk about these chronic fatigue syndrome ladies, like they were crazy and depressed. Is there something there, Stacey? And because it’s women, we don’t study it with the same seriousness of purpose that we would if a man came in. So so I think that overlaying of, you know, hysteria, exaggeration, you know, behavioral health conditions, those women a disservice. I think menopause medicine is service, you know, menstrual periods from young women with endometriosis, you know, suck it up, it’s normal. Yeah, and do you think that’s kind of due to a lack of awareness of like what’s seen as actually like a real problem versus hysteria or if that’s sort of like society and gender norms that kind of push that narrative? I think it’s a combination of all of it. I think some of it is the overlying assumption that this is really a manifestation of a behavioral health issue stress, depression, anxiety, whatever and the fact that these behavioral health conditions are more prevalent in women doesn’t help. That’s a real medical condition as well. I think pain and challenging symptoms that require a lot of conversation, a lot of patience, a lot of time are tougher for physicians. Many of us are trained to do tests or to have short visits. You put into this, I give you a pill for hypertension. It’s a type of clinical practice that is challenging.

Sydney Feldman: [00:17:12] And how do you think that the general population, like students or advocates, can be of help and kind of raising awareness for the need for better women’s health and closing the gender gap and helping patient outcomes, things like that?

Dr. Stacey Rosen: [00:17:28] Well, I think a lot of it is understanding where these disparities and inequities come from, that this isn’t, you know, it’s not somebody being a bad doctor or a bad patient or an under empowered.It’s, you know, we really believe this, that that it was all the same in men and women. And, you know, those pesky hormones didn’t matter and it was easier to study men. So I think acknowledging that that’s where it came from and then how you give it, that is how we advocate and change everything. You do it from the top down and the ground up. So so ground up is each of us should become better patients, better advocates for ourselves and our families figure out the toolkit to be empowered. You not not to not to accept, Oh, here’s an anxiolytic, you know, it’ll just stress, you know, go home. And then I think advocating for more funding for research, more access for women and health care, you know, better opportunities for more diverse people to go into the health care world and not just necessarily in medical school. You know that my health care team is you. I had three calls to a pharmacist today who helped me in an enormous way with three of my office patients this morning. He’s an expert in stuff that I don’t know, and I don’t need to be the top of the pyramid. He made a huge impact with three three of my dozen patients this morning. But you know, so getting into health care and a diverse population doesn’t only mean going to medical school or nursing school. The jobs in health care are really, really broad and all should play a really important role in improving the health of all of us, particularly with. How do you think women’s health has changed throughout the COVID pandemic? Yes. So nothing but a good international pandemic to amplify and demonstrate inequities in life, right? So, you know, women were more likely to not see their doctors during COVID than men, and women were more likely to not fill their prescriptions for chronic medications and men. Women were more likely to manage two or three jobs than men or women left the workforce. For women, scientists and clinicians were unable to do their research and continue their promotion trajectory. So, you know, everything we sort of knew or some things that were lurking under just became exaggerated and more amplified. And of course, when you look at women of color and those are less elevated education status or financial means just, you know, it got, you know, algorithmically worse. Right?

Sydney Feldman: [00:20:36] Yep. Is there anything else that you think is important for young people or students who are interested in hearing more about medical inequities to know about females, gender disparities or the health care world in general? 

Dr. Stacey Rosen: [00:20:36] You know, I think that like everything like other things, that this is the generation that will need to fix it for us. And I think an optimistic strategic approach about how to make this better will be important. And you know, sort of the good news is, is that there’s so much overlap in, you know, things that we’re doing with improving housing and improving health care access and clean air and fresh food. All of these things that impact on inequities also impact on health inequities. So, you know, every area that you may want to commit to is an area that ultimately can improve health outcomes. And it comes down to fairness, I think. Do you have any ideas of how to make, I guess, the medical field more equitable for all people or helping minority groups or people who are not of the same socioeconomic status in a way that would be feasible in the future? Yeah. So I think that, you know, not it begins by not accepting the norm and knowing that improving decades or maybe hundreds of years of badness is not acceptable and that it requires true strategy. We can’t just wish it to happen, right? You can’t just hope that we’ll get more women into the field of cardiology. So there are groups of cardiologists, men and women who are focused on how do we make our field less inaccessible to women? Historically, it was described as macho and mean to women and crazy hours. I was called the GF a girl fellow. I was the only female fellow at Cornell, and it was like a really horrible environment. I don’t know that I would have recommended to anyone. A few years after I finish to do this. So but strategy and commitment and, you know, doing the hard work to change that is what needs to be done. And that’s the same in making sure there’s enough funding for pain syndromes and women to understand fibromyalgia in our joke is if that was 90 percent men, they’d have a cure and a diagnosis and a blood test that could, you know, to do it. So so I think not accepting the status quo being strategic and persistent. You know, people look at me and they say, Oh, you know, you oversee women’s health, is that women doctors? And I’m like, Oh, no, it’s not women doctors. It’s disparities in biology and physiology. And you know, after I’m asked that the fourth time, maybe I’m a little less patient about this is a girl doctors. But but it’s being persistent because changing norms is hard work.

Sydney Feldman: [00:24:00] Do you think institutions are starting to place a bigger priority on closing the gap between genders in medical settings? Do you know of other institutions that have similar missions to the Katz Institute? That sort of hold an emphasis on women’s health in particular? Do you find that there is an increase in emphasis and hope to kind of help close that gap?

Dr. Stacey Rosen: [00:24:24] Yes, there is. So so when Bernadine Healy was the NIH director, they had a designation for Centers of Excellence codes and they were funded and they were twenty three or twenty four of them around the country. And like other things in government, over time, the funds dried up. But there are still a. Clinical institutions, research institutions and educational institutions that have this as one of their many priorities. You’d be hard pressed to find a place that says it’s kind of silly stuff. The girls the same class, the focus on on on a more diverse world in medical school, in health care, in physician leadership is a huge priority around the country. Everything from the American Academy of Medical Colleges, the WMC, etc. every year about women in medicine that we’re 50 50 med school and people like Jennifer Ramirez and I who are full professors, I think we’re twenty two percent of full professors are women around the country. So, so AMC does it. All of the every important health system around the country knows that if every chairman is an old white man, that that does a disservice to to the excellence of the institution. So, you know, we’re getting there, but some days Sydney, we’re tired. There are some days that, you know, you make two big steps forward, and they just let us slip back a little bit. This is not just a woman’s problem. This is not a woman’s issue, because if we don’t do this well, we impact negatively on everybody, and I think things are perceived as a women’s issue, a woman’s problem. They’re given a different level of credibility and support. In fact, the person who is the most focused on getting women into the field of cardiology is Dr. Robert Harrington, who’s the chairman of medicine at Stanford. And Rob knows that with 50 percent of our med students being female get only 15 50 percent, but only 15 percent of our cardiology oldies being women. That’s a talent gap. That’s not just a gender issue, right at the end of the day, if the and the brightest aren’t picking our fields, we’re going to be in for some very bad times ahead. Then we need to strategically change that now. So that would be my final message. This isn’t a woman’s issue. This is an everyone issue.

Sydney Feldman: [00:27:00] In summary, gender is not the only source of disparity for patients, though it’s clear through the work of Dr. Rosen and many others that finding ways to help narrow the gender gap will be advantageous to all. I’d like to thank Dr. Stacy Rosen for taking the time to speak with me today. It is through work like hers and the Katz Institute. That change can and will be made.

Episode 2_Physician Discrimination: Experiences of Doctors Based on Race

Sydney Feldman: [00:00:03] When Dr. Tamika Cross, a female black physician, was aboard in 2016 Delta Airlines flight from Detroit back to her home in Houston, Texas. She was the victim of a series of shocking comments that lend themselves to larger flaws in our health care system. Cross was trying to offer medical assistance when another passenger on board flight nine four five was suffering from a medical emergency. Cross chronicled her experience in a Facebook post, explaining that when she jumped up to help a flight attendant question Cross’s credibility, stating that they were looking for quote, actual physicians, all cross was still eager to help the patient in need. Her offers were met with fierce opposition. The same flight attendant began began asking Cross for her credentials while she was traveling and other irrelevant questions only delaying the medical help for the passenger need. She responded to the questions, though her valid responses continued to be met with strong suspicion. When another physician aboard the flight who crossed described as a quote, seasoned white male who fit the quote description of a doctor came over to the scene to assist. He was not interrogated in the same way Cross had been. Instead, his credibility was not questioned, and the flight attendant welcomed his help with seemingly open arms. Cross interjected and asked why this physician was not being questioned in the same way she had been moments prior and the responses she received were fabricated, including lies that the physician had already given his credentials to the flight attendant.The flight attendant’s response was indicative of larger issues at hand. Her remarks were evident of racism, sexism, ageism and more. By uploading her story to Facebook, Cross hope to shed some light on the inhumane discrimination she had experienced. The post, gaining over one hundred and fifty one thousand reactions and forty five thousand shares is evidence of a larger systemic issue in the United States health care system. And as Cross described it and experience that many quote young corporate America women of color can relate to. Following the viral post, articles from the New York Times, The Washington Post and other major publications shared across this story, though in recognition of the problem at hand, the comments on her Facebook post echoed similar experiences of discrimination and prove that more than media coverage is necessary. A wider societal change is required. Dr. Cross’s experience on the Delta flight is representative of a larger, systemic issue regarding the treatment of physicians who are discriminated against based on race, sex, age or the state in which they reside. Dr. Roswell provides useful insight into the experiences of doctors, specifically doctors who belong to minority groups and the constantly evolving scope of the medical school admissions process in particular, Dr Roswell’s professional experience provides context for how these physician experiences and medical school admissions interact to shape the narrative of medical institutions. Thank you so much for joining me today, Dr Roswell. What do you see as some of the things that administrators of health systems are doing to try to help decrease acts of discrimination on physicians, specifically due to racism, sexism, ageism in their institutions?

Dr. Robert Roswell: [00:03:28] And I think are you talking about acts of bias and discrimination towards those physicians, towards physicians? Yeah, I think one thing is that a lot of health institutions are coming up with protocols and templates and education about what to do when confronting racism or sexism, homophobia, transphobia, all of the isms. What what is what is the protocol? What do you do? And it’s difficult because if there’s a patient who who’s coming in, who’s crashing, their blood pressure is going down, they’re about to code and they say that they don’t want you because you’re a woman or you’re black. Like, what are the right steps to take? And I think just the information about having a protocol so people understand when things are lifesaving that all that stuff sort of goes out the window that you have to save someone’s life. But it’s somebody who’s more stable and they don’t want the they don’t want to provide her from a certain religion, from a certain gender or race to set up. That’s not acceptable, and you could find medical care someplace else. And to empower the physicians and staff to ensure that they are protected. And those instances, there are many, many. But there are several instances that friends have told me that some that I’ve witnessed and they’re difficult because in medicine, we’re taught to always put the patient first. Even if the patient hates you and it creates, it creates this conflict. It does create this cognitive dissonance that someone hates you and you have to put them first. And how does that work, particularly if you’re somebody from an underrepresented group or if you’re a woman or a gay person and just having those protocols aware and available and that people know exactly what to do and that their support from higher levels of administration, I think, goes a long way. There’s also a lot of programs in terms of awareness of unconscious and implicit bias and how that can affect. You know, care to patients, but I think you’re going to ask this next.

Sydney Feldman: [00:05:38] How does physician discrimination contribute to patient disparities or care that’s provided?

Dr. Robert Roswell: [00:05:48] Oh, look at that. I think we’re we’re on track. So I think the other part of the equation is sometimes physicians and health care providers bring their own biases and that gets imparted to patients and end up. And I think that’s one of the big reasons around the maternal mortality crisis is how we interpret. Sort of symptoms from women of color versus white women and who we prescribe medications to prescribe pain medications to who you refer for surgeries and advanced procedures. You’ll be. It sounds like you and your class probably already know about this stuff, but biases and discrimination sort of creep in, and we think it’s not completely explicit. We think it really functions at the subconscious level, and many people are not aware of it, that there was somebody they should have referred to a cardiologist or they should have referred to it for a procedure. And when you step back and look at all the data nationally, you see trends. And in every field of medicine, there is a trend that women and minorities do not get prescribed or see the same treatment as their counterparts. And and it leads to how bad health outcomes it leads to increased mortality. So these little slips of the mind, these. You know, supposedly innocuous, unconscious biases, but they actually do impact and they cause a lot of harm to people, including including losing their lives. So it’s something that I think hospital systems are really investing into and making sure that people are aware of their unconscious biases and also measuring outcomes and measuring, let’s say, referral rates for a procedure or referral rates to cardiologists. I’m a cardiologist just to see, is there a discrepancy within the hospital or the practice where you’re not referring to the right amount of people to a specialist or for advanced procedure?

Sydney Feldman: [00:08:01] Yeah. I mean, something that I was reading a bunch about was fibromyalgia and how majority of diagnosed patients are female. However, so little is known about the syndrome still, just because, like a lack of research. And so I think a lot of that also stems from scientific biases, the male model of research and how that’s also starting to change, I think.

Dr. Robert Roswell: [00:08:24] And I can tell you that’s a good example, but another one is in cardiology. You know, a lot of the medications that we use to treat heart disease or if you have a blood clot in one of your heart arteries, a lot of those medications started out being tested on men. And what happened when we put blood thinning medications and we started seeing and seeing the effects in women, they were bleeding too much. So you have a blood clot in your heart artery and you want to make sure you dissolve that by making the blood a little bit thin. And if your if your your sample size is really based on men and then you try and apply that same treatment to women, it just doesn’t work. Even the way we classify chest pain mostly was on studies of white men and how they experienced heart disease. And there’s a lot of debate in the literature. Do women feel or have expressed heart pain in the same way that men do? I think overall, the answer is yes, mostly. But there are some differences and those those those differences I think people need to know about and they’re not really taught. And that means that a woman gets sort of referred to a cardiologist less often. She gets referred to for advanced procedures less often. And then by that, she dies more often from heart disease.

Sydney Feldman: [00:09:54] Do you think if there were more female doctors that that would kind of change the mindset then of you like a referral increase when a female patient goes to a female doctor or someone that identifies with a specific group, goes to a doctor that identifies with that same group?

Dr. Robert Roswell: [00:10:13] Yeah. And that’s how a lot of the problems are figured out is by getting diversity within medicine. And so studying and looking at all these studies and seeing Wow, this medication was studied with a sample size of like 100000 and ninety five percent that were men. This has to stop. And so the National Institutes of Health set forth that you have to have women and minorities in your your studies to get NIH or federal dollars. And then we see that once people are race, gender concordant, all those disparities and biases sort of go away from the outset. You can’t have a physician workforce that is completely reflective of the population and then that they see each other. Imagine if we had the exact demographic right that we have in this country. We have that in physicians. You don’t know if you go to see that doctor, if you’re going to be matched up with that exact right person. And then there are other parts of the person that might not necessarily align. So it’s a tough thing, and I don’t want to say that. We should have one way or the other, we just definitely need more diversity. We should have less biases, but then we also need to educate so that everybody is on the same page.

Sydney Feldman: [00:11:34] What are some of the ways that, health system administrators are supporting physicians that are either of minority groups or female or are less of the “norm” of what’s historically been seen as a physician?

Dr. Robert Roswell: [00:11:52] So there’s a lot of lot of health systems like, well, for example, has a lot of affinity groups. And so there’s a woman in medicine group. There’s sort of what we have is employee resources, resource groups. And so there’s a black African-American where you can get together and sort of figure out if there’s any issues within the health system and then that’s supported by the CEO. And so you have direct support by the leadership of a health system. So a lot of the health systems are having these affinity groups that are that it could, if there’s any problem or issue, have a place to go and a place to resolve issues. And so that’s one way. And then also by doing initiatives with health equity, with bias, discrimination, bullying, all those different things. I think making a priority in their institution for it to be inclusive also helps things out a lot.

Sydney Feldman: [00:12:48] Is there anything that you think the general population, specifically younger generations can do to change the narrative of the medical field moving forward or ways that they can help kind of increase awareness about the need for greater diversity in the medical field, greater diversity in medical school? Anything about that?

Dr. Robert Roswell: [00:13:09] I think advocacy. I think a lot of times, once a younger generation is educated about particular issues, let’s say climate change, for example. I think the biggest proponents are younger generations to advocate for change. And I think the voice is pretty loud. When you go to the the voting booth and you cast your ballot and you go to Congress and you go to your local congressperson or your local representative and you advocate for for changes in health care. I think one thing I would ask the younger generation to look at is how much do we spend on medicine? And I think we’re approaching somewhere around five trillion dollars in terms of our GDP. That was a projection. I don’t know if we’re there yet, somewhere between three to five trillion dollars and. What what are we getting in terms of the health outcomes, we’re seeing great disparities, we’re seeing very high maternal mortality rates. We’re seeing a lot of like just death and morbidity like. People are losing their houses because of health care costs, right? We have a pandemic that is crippling the health care system. And so if you think about that, how do we have a health care system that when a pandemic hits completely tears it apart financially? Like, for me, that doesn’t make any sense. A health care system should be. I don’t want to say, quote unquote thriving, but if we’re in a capitalistic society and there’s a lot of health care need, this is when you need the hospitals and and health care. How does it then fail and not thrive? And this sort of construct, we’ve created it, we’ve created that this health care system is tied to the economy of our country and it just doesn’t work. It’s not working and people are dying because they don’t have insurance. Besides the bias in the discrimination that we talked about, people just don’t have insurance. Health care costs are are skyrocketing. People can’t get the medications they need. And so I think besides having diversity in medicine, we need to bring back the humanism in medicine. And really, I think that the younger generation may be smarter than our generation and we could move and change health care to something that’s more humanistic where where people are not dying because they don’t have health insurance or losing their homes because they went to the hospital. So I think and I put a lot of faith in the younger generation to change this, I think. I see the younger generation is more. Mobile, more thought provoking, more iconoclastic, more. And I wouldn’t say I think marriage is going against the grain and changing things that don’t make sense. And so hopefully if I, our generation wasn’t able to do it. Hopefully, the younger generation can do it through advocacy, education and and really standing up for health equity.

Sydney Feldman: [00:16:26] Thank you for that. It’s very inspiring to, I think, a ton of students and people that could be the future of medicine.

Dr. Robert Roswell: [00:16:32] So absolutely. Absolutely. I encourage you all to all to do it.

Sydney Feldman: [00:16:38] In summary, physician discrimination is apparent in the U.S., and though many health systems are working to provide support from an administrative level to minority physicians, there still so much left to be done. This is now a pivotal time for health systems to have the opportunity to create regulations to protect their physicians and come up with creative solutions to maintain a safe working environment. I want to thank Dr. Oswald for taking the time to speak with me and for all of the inspiring work that he is doing each day. If you’re interested in hearing more from Dr. Roswell and the process of medical school admissions, consider listening to podcast episode three.

Episode 3_Medical Admissions as a Pathway to Narrowing Diversity in the Medical Profession

Sydney Feldman: [00:00:00] How does the makeup of a medical school class impact diversity in the medical profession? Our admission processes barriers to equitable representation in the field of medicine. Furthermore. These are the questions that I seek to answer in conversation with Dr. Robert Roswell. To speak further on the topic is Dr. Robert Roswell. Dr. Robert Roswell is the associate dean for Diversity, Equity and inclusion at the Donald and Barbara Zucker School of Medicine at Hofstra University. He is also an associate professor of cardiology and science education. Dr. Roswell is board certified in internal medicine and cardiovascular disease as both a practicing physician and associate dean of diversity at a medical school. Dr. Roswell provides useful insight into the experiences of doctors, specifically doctors who belong to minority groups and the constantly evolving scope of the medical school admissions process. In particular, Dr. Rockwell’s professional experience provides context for how these physician experiences and medical school admissions interact to shape the narrative of medical institutions. Thank you so much for joining me.

Dr. Robert Roswell: [00:01:13] That is a little bit of a long story, but I’ll try to make it short [in reference to how Dr. Roswell joined the field of medicine]. And so I, going through high school and college, was always interested in science and I did not want to be a Ph.D.. I wanted to do something that was more, I think, interactive and using some more, I would say more more skills communicating, interacting with people and so putting the two together. Medicine came to mind, and I think this probably would get into something that we’ll talk about a little bit later on is that I think people think of medicine as this completely scientific field. That’s only biology. But the difficulty of medicine, what we’re realizing now is that medicine is science. It is biology, biochemistry, pharmacology, but it’s also that combined with the human touch and humanism. And so you also need to be well versed in sociology and cultural humility and a lot of the social sciences. And I think that is something that the profession is now seeing and struggling with. So that’s one of the reasons, if you think back to why I want to be in medicine was because it wasn’t just science, it wasn’t just chemistry, organic chemistry. It was actually putting that together with a humanistic touch to solve the problems of the world. And why and how I became involved in diversity initiatives. I would say as a black man, going throughout high school, going through college, I was usually the only person, the only person of color. Remember my AP calculus class. I was the only black man. And a lot of my science classes in undergrad and throughout medical school, there was always an underrepresentation of black folks and Hispanic folks, and I wanted to change that. And I started taking an active role in doing that by looking at what the issues are, what the structural issues are and how do we strategize to get more diversity in medicine.

Sydney Feldman: [00:03:25] Yeah, so I guess going off of that, how do you see medical school admissions changing over the past decade or since your time either studying in medical school versus now being involved with direct admissions and administrative type of roles?

Dr. Robert Roswell: [00:03:40] Yeah. So, you know, medical school admissions has changed substantially over the years. And and again, it’s the same. This will probably be the same theme throughout this conversation is understanding what attributes and values and qualities people bring to medicine other than their MCAT scores in their GPAs. So a lot of it is looking at something called holistic admissions, and the holistic admissions process is looking at who you are as a person. Not that you have just a great GPA and cut score, but what have you been doing to get that? Have you been volunteering how you’ve been active in the community? What is your particular life path that leads you to medicine? And I think knowing that and taking all of that into consideration is what we’re trying to do to diversify medicine and even interview styles trying to weed out bias in the process in terms of the application process. And it’s yielding dividends, but it’s doing at a slow rate. And I say the issues are very complicated. One is that we need to build a pipeline to get more diversity in medicine. But at the same time, I also feel like we need to figure out what are the structures that are enabling and perpetuating disparities in the educational process.So people have different paths of life, different ways of getting to medicine. But there are people who have that say money to get MCAT tutoring and make sure they get the best score that people who don’t have that money. And then there are people who have gone to schools that don’t support them and don’t have AP calculus or AP physics that don’t prepare them for college. And then there are people who do have great schools that are giving them AP courses in high school and preparing them. And so there’s a lot of disparities within the educational system itself, and that just spills over into the medical school admission process. So one way we’re doing it is by trying to dismantle that and look at the biases with students coming to medical school. But I think that there’s a greater societal role of figuring out why are there so many disparities? Why are there people who if you had just given them a chance, they will get the top scores on the MCAT and have great GPAs and really humanistic people? So that was a long answer to your question, but I think that’s how medical school admissions are changing and looking at ways of bringing biases out of the process.

Sydney Feldman: [00:06:20] Yeah. Do you see most institutions starting to prioritize this diversity in medical school admissions? And like, what are some of the routes that they’re doing this through? What are some of the initiatives include?

Dr. Robert Roswell: [00:06:33] Yeah, I think most medical medical schools and their admissions processes are looking at it to interrogate it for bias. So I think bias and inclusion and exclusion is also an active process, especially inclusion. So when you’re looking at a med school admissions process to really interrogate it for bias, you have to actively go and see what each step of the process is. And how could that be biasing people and come up with ways to dismantle or unstructured and get rid of those biases? So, for example, the interview is one part that was a huge bias in medicine. There’s a lot of literature support this that if you’re from New York and I’m from New York and we have an interview together, that’s a commonality. I start asking you about New York and then all of a sudden, I think that that interview went well. If you’re from Oklahoma, I’m not from Oklahoma. We don’t have. We start off on a different sort of footing. And that difference, just even where you’re from, what major, what college you went to. All of those things can start to bias people already. And so one thing is to start taking away some of that information out of an applicant’s packet for interview and make sure that the interview is there to get what you need from the interview if it’s to figure out how this person is a problem solver.You should structure the interview around that instead of what major or college or your hobbies are, and find some commonality, and we know that that influences a rating. So a lot of schools are moving away from traditional formats of interviewing in a way of taking out structural bias and taking out sometimes even GPA schools. You just interview a person as you see them. You don’t know what they got on the end of their school, yet another major or their GPA. Your job is to figure out how they handle stress or how they were kind of what kind of a humanistic person are they? And how do they think and process things? And so a lot of medical school processes are moving in that way. And then the last thing I would say is that there’s been a lot of unconscious bias training with admissions officers and admissions committees to realize that when they actually are going through people’s application, that there are biases that pop up right away, like people’s pictures, their photos, everything like their names. We should all realize that as soon as you see someone, you see their background of a photo, you see the clothes like biases pop up right away and through unconscious bias training programs. We understand that that is the case in how to mitigate that and make sure it’s not affecting any decision about entrance into medical school.

Sydney Feldman: [00:09:24] So do you think it’s fair to say that interviews are now kind of focusing on a person as a person as opposed to a test score or strictly in an academic setting, but more how they would interact with the people around them and really succeed in a medical setting?

Dr. Robert Roswell: [00:09:41] Yeah. So the interview, I think, was always designed to do that. So when you look at who got an interview in medical school, it’s usually looking at your application and looking at your grades. And unfortunately, there’s many people who have the academic criteria. So if you take all those people who have great GPAs and MCAT scores, then the next question is how do they interact with people? And that’s what the that’s what the interview is there for. And I think most places now are just looking at just that, like, how do you interact with people? How do you critically think? Are you a team player? Are you not? You like a genius in the box, meaning you can get in the lab and you can figure out a really complex problem, but you’re not really that you’re not great at collaborating versus are you the person who really thrives with discussing a problem with someone and trying to solve it in a group? And I’m not saying one is bad or or better than the other, but different medical schools are looking for different, I think, capabilities and abilities. And so if they’re looking for a more collaborative community leaning person like that might be the personality type for them. Somebody else might be looking for a person who’s more sort of an M.D., Ph.D. He’s about to create a cure for COVID. Right. And that person may need to think deeply in a genius way in their lab, but might not necessarily need to be the person who’s facing the patient and communicating with them. So everyone has different skills and capabilities. I think medical schools are now looking at those other things to figure out who best will fit the match for better schools.

Sydney Feldman: [00:11:19] Where do you think there remains more opportunity for greater change in admissions cycles?

Dr. Robert Roswell: [00:11:25] I think, you know, that’s a great question. I think it’s really going back to what I had stated before looking at GPA and MCAT. Those are still like thresholds for getting interviews into medical school. And it’s really difficult because we see that again, there are public schools that are barely barely providing education to students and there’s other public and private schools that are providing top notch education. And I think we’re trying to figure out who who those from who did not receive great education can still thrive and do well in medical school because unfortunately, the difficulty of medical school, I don’t think I know this is being recorded. I don’t think it is the the difficulty of medicine itself. I think the difficulty of medical school is the volume of information that you need to be able to process as at one time. And so I always think about it and and correct me if I’m wrong. It’s like taking 15 to 17 credits, a lot of credits per semester. I just want to make sure because I might be dating myself in terms of that, like not knowing what the credits and classes are like, so if I took 15 or 17, that was a lot of credits. I would say a semester of medical school is like to me, probably taking 30 credits of science classes. And so it just you can actually do all those courses individually, but your mental reserve to do all of that at once, it has to be. It’s a lot. And so figuring out who could actually withstand those preclinical years and comprehend all that’s being thrown at you as a medical student is really difficult.And I think the last part, I think in terms of what makes a great physician also. And so is it the person who gets the perfect score on their MCAT or the perfect GPA? Or is it a person, a different person who has sort of like a mid-range score but is like the best humanistic person who’s the best listener who could actually communicate things the best to patient? And I think where we are in medicine right now is trying to figure that out. What is that combination of GPA, MCAT and communication potentials that make a best doctor? And I would say this, and I’ll say this quite strongly that those who think medicine is only about biology and science are are just wrong. And and they may not understand the full picture of delivering great health care. There are physicians who say to be a great physician, you just need to know all of the science, and that’s it. And I think that was the old paradigm, and we shifted past that and to understand to deliver outstanding health care to a lot of different people who have different issues. Again, you need medicine combined with sociology and anthropology and philosophy to actually be a great doctor. So all those who just think it’s just biology and science, I just think that that is really antediluvian thinking and we need to move past that.

Sydney Feldman: [00:14:45] Have you seen like a smaller minority group, representation in medical school classes lead to worse health outcomes for minority patients or decreased access for minority patients? Kind of. How does the medical school admissions directly contribute to disparities in the health care field more generally?

Dr. Robert Roswell: [00:15:05] Yeah, I think that also is a very important question in the topic because there are data that support that patient physician or patient provider. Concordance does a lot in terms of adherence and medication, which also saves lives. So the less diversity that you have within the class, the less likely there are to be sort of physicians who look like the people from the community to engender trust, et cetera. I think we could take, for example, COVID and COVID vaccination. It’s clear that when you have somebody from a similar background who’s talking about vaccines and COVID, that that patient is more likely to accept the vaccination, they’re more likely to be adherent to their medications. So if you have and this goes for a lot of demographics, it goes for sexual orientation, race, ethnicity, language, culture, gender, background, all of that. And so if you have someone with whom you can relate, you’re more likely to believe what they’re saying. You’re adherent to whatever they prescribe. You ask the right questions, they ask the right questions. And let’s say, for example, for vaccination, someone gets the vaccine and there’s less likely of spread and mutation of viruses, and it’s better for everyone. So patient physician concordance is critically important, and I think the data particularly about taking medications adherent to medications, adherent to prescriptions and also a treatment plan that really impacts patients morbidity and mortality. But then I always fall back to say, you know, you, not everyone could have a doctor who looks exactly like them. So we need to have more diversity in the physician workforce. But we also need to train other physicians how to take care of different types of physicians so that they could engender the same trust that somebody from that same community of culture would engender.

Sydney Feldman: [00:17:11] And do you think there are like opportunities to maybe bring in older generations that might think they’re too old for medical school to go back now or with COVID inspire people that might not have been so inclined towards, like applying to medical school to now enter that workforce and really encourage other minority groups and other demographics to engage with the field of medicine more generally.

Dr. Robert Roswell: [00:17:38] Yeah. You know, I would say as many people, the diverse group that we can have applying to medical school, the better. I think, as I mentioned to you, medical school is throwing a lot at its students in terms of studying. And so the prep work just needs to be there to make sure that when you get to medical school that you don’t sort of have difficulty because the worst thing you would do is to bring in more people and those people can’t make it through the curriculum because it’s so tough. And so I think if you’re talking about older generations and other people bringing them in, I think just making sure that they are trained and could survive the thirty thirty five credits that we throw at them and one semester. And I think that would be great again. The more the merrier, the more we can diversify the application applicant pool, the more we can, the more diverse we can make our classes, the more diverse our classes are. Patients actually do better. And again, we mentioned, you know, the cultural concordance that the data, they are pretty strong to show that that actually affects lives in adherence to protocols and treatments.

Sydney Feldman: [00:18:50] Is there anything else that you think is important for people to know about diversity in medical school, either in admissions or how that contributes to the professional field of medicine?

Dr. Robert Roswell: [00:19:00] I think one thing I would. I would like for everyone to think about is that diversity is bringing a lot of different mindsets and types of thinking together. And so diversity is a wide and broad term, so it means everything under the Sun from language, differences, culture, religion, race, ethnicity. I think the most glaring problem that we have are racial and ethnic disparities. And so that’s why we’re focused on that. And I think just bringing the most diverse mindsets to the table to solve how health care disparities. It just goes such a far away. And so even if we do have people from different races and ethnicities, also like a diversity of thought is also good. So we love to have people in medical school who have gone out in the business world and have come back bringing their perspective. People who have families, people who have just finished college are going forward, people who have studied abroad, people who are interested in and public health. People interested in global health. And also people who are interested in translational health. So I just wanted to leave with the mindset that diversity and race and ethnicity and and diversity of thought is so important because we have huge problems in this country and we spend so much on health care as part of our GDP. And the disparities that we see are incredible, particularly maternal mortality in this country that we spend so much on health care and the rate of women who died during childbirth. It’s that of Swaziland. A country that does not put as many resources as we do into and health outcomes, and so I think if our country were a corporation, I would probably dissolve it and fire its CEO because our health outcomes are not where they should be. And we have to figure out how to restructure our health care system to get the right people to think about the problems that need to be solved and get a diverse again body of physicians in mind. And but to help solve these really complicated problems.

Sydney Feldman: [00:21:17] Though the state of medical school admissions is constantly evolving, and institutions like the Donald and Barbara Zucker School of Medicine are placing priorities in creating more holistic admission review processes, there still remains work to be done to ensure that medical school demographics and admissions are more equitable. I want to thank Dr Oswald for taking the time to speak with me and providing information on some of the work that he is doing to create a more accessible medical profession.