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Clinician Bias and Disparities in the Mental Health Treatment Continuum

  • May 04, 2023

In our third episode Gabriel Escontrias Jr., Managing director for the Division of Diversity and Health Equity, joins panelists Dr. Junji Takeshita, Dr. Carmen Black and Dr. Michele Durham as the discussed various themes from the webinar on the same topic. They touched on the present state of progress toward equity, the mismatch between educational hierarchy and emerging DEIB efforts, how to be an effective advocate in a politically charged environment and so much more.


Gabriel Escontrias Jr.: [00:00:12] Hello and welcome to the American Psychiatric Association's Division of Diversity and Health Equity podcast. Looking Beyond Unplugged, a webinar and podcast lecture series that examines strategies and opportunities to improve the mental health of historically marginalized communities. Join us in this episode on clinician bias and disparities in the mental health treatment continuum. Our panelists Doctors Junji Takeshita, Carmen Black, Michelle Durham continued their discussion from the webinar, touching on topics such as the present state of progress toward equity, how to be an effective advocate in politically charged environments and so much more. We hope you enjoy our podcast.

Gabriel Escontrias Jr.: [00:00:59] Gabriela Escontrias, managing director of the Division of Diversity and Health Equity. American Psychiatric Association.

Dr. Junji Takeshita: [00:01:06] I'm Junji Takeshita. I'm a professor and associate chair of clinical service at Johnny Burns School of Medicine, University of Hawaii.

Dr. Carmen Black: [00:01:15] I'm Dr. Carmen Black. I'm assistant professor of psychiatry and director of social justice and Health Equity Education at Yale Department of Psychiatry.

Dr. Michelle Durham: [00:01:24] So I'm Dr. Michelle Durham. I'm an adult and child psychiatrist. I'm currently the chief behavioral health officer at the Ibsen Foundation in Houston, Texas.

Dr. Junji Takeshita: [00:01:34] Yeah, I thought actually it was very helpful was to your comment, Carmen, about adding this to the education of the trainees, because I've actually started doing that in the last several years where we'll talk about an individual patient and how their their course of treatment was probably affected by their either their socioeconomic status, their ethnicity, race. Those kinds of things. And I think the students understand this. But to formalize it, I like the concept of really formalizing it.

Dr. Carmen Black: [00:02:13] Yeah, it's been a really fun concept and it's been a really great way to get things into the literature as well. The funny thing is, so at Yale Department of Psychiatry, I'm the director for the Social Justice and Health Equity curriculum, which is all a training intensive, four year longitudinal curriculum of all things that the title professes. The problem that we can develop is particularly [inaudible] ourselves to already be the experts in the mission statements that we're saying towards health equity is that faculty development can be very tricky to navigate, particularly if you're working in institutions where someone's identity has been built on being, you know, the rock star of X, Y, Z for the last 30 years. And here we come saying, Well, actually there's this new content area of things that are really important, really critical that might make you uncomfortable, might make you rethink the way you've been doing your clinical practice. But it's really great for those minoritized patients that we've normalized harms to, the the friction that can be created in a trainee intensive labor force where they're receiving the didactic education and inherently like we've worked very hard to diversify the new body of medicine, but the older body of medicine still has all the power because of the hierarchy. So without faculty development and administrative leadership, we can run into some really tricky situations where in some ways the trainees might have more expertise than the faculty, and we don't ever want to set up those scenarios.

Gabriel Escontrias Jr.: [00:04:01] So there was the question we didn't have a chance to make it to, but we definitely would like your thoughts on it. Someone was asking how the concept of ableism plays into clinician bias and the disparities.

Dr. Carmen Black: [00:04:15] Well, when you look at, you know, the American eugenics movement, it wasn't just racialized bias. Actually, Hitler enjoyed the idea of our eugenics movement so much that it laid the foundation of the T4 program when he passed extermination, starting with folks who weren't assigned like ableist bodies who were designed, you know, a disability, diverse folks. And so the plight of the disabled is often alongside the plight of those who are minoritized through gender minoritized, through sexuality, minoritized through racialization. But more importantly, even if you look at the admissions criteria for medical school, it's very ableist. You have to be able to stand for a certain time, lift a certain thing. You have to be able to have a certain amount of dexterity in your hands before you sign a work contract. To do residency, you have to state that you can do X, Y, Z physical performances. So we're still being ongoing exclusionary against folks with disabilities, and that's lacking representation from the knowledges that they would bring to the table. In contrast, we as psychiatrist, if we were to get disabled and God forbid, have our legs chopped off in a car accident, we wouldn't necessarily lose our ability to be a psychiatrist, right? Our disability insurance would say, Aha, well, you still have A, B, C and D, and I hereby say, I'm not going to pay you because you can still work. Well, we don't have that mentality for training new docs, but we have that mentality to avoid, you know, letting an existent existing physician stop practicing. So I think we need to think more about our ableist notions within health care.

Dr. Junji Takeshita: [00:06:01] Or other current think that's gotten much better than when I was applying to medical school to now as as somebody who's interviewed applicants for many years, I think it has changed, maybe not quite the way it should or the speed, but I think there has been some movement there. And if you look at even the issue about gender, that has changed dramatically in my career.

Dr. Michelle Durham: [00:06:31] I think that's a great point. And I don't know how many questions we have left, but like with everything right, like this is another movement for the betterment, right of all of us. And some of these things take time. And I, I used to work for the former surgeon general, David Satcher. And this is like an imprinted memory of a story he told of like being a resident at the time and being a black resident and not being able to admit patients to the hospital. And this is a man that is still living right. And so in the last, you know, now he's in his 70s and 50. So we're talking about 50 years ago that a black resident didn't have admitting privileges. And and I take stock of that because I think sometimes this work gets so challenging and like, why? Why are we not doing better? And then being able to reflect on moments like that with talking to folks. So I appreciate that point because I think that, you know, we've come a long way and there's a long way to go, but also to take stock in the progress and things that that have gone well. Um, you know, that black residents can actually admit to the hospital. I mean, you know, that bar is. I get it. And how far we've come from people like him and others who have sort of paved the way for us to, you know, similar to Doctor Black I was at Boston University, Boston Medical Center. We also had a four year curriculum. Um, that's coming a long way in a psychiatry program in which many times there was only one black psychiatry resident, you know, one Asian, one Indian, and that was it. And no, no one else. And so, you know, reflect on our residency program as well that I was at, that we were able to have this full curriculum without anybody sort of batting an eye at it. Right. Like, this is what we need to do. This is for the betterment of the psychiatrist we're training and also for the patients that we're treating. But one other point I wanted to loop back on, which I think is very relevant, is that these these sort of integrating to psychiatry residency programs, having curriculums that are very focused on many of the topics like the one discussed today, cannot be on just 1 or 2 faculty members and the residents. And that's unfortunately what's most residency programs across the US are dependent on and or don't even have that to tap into. And so the pipeline then for me, I think about that a lot, like how are we getting folks in this pipeline so that it's not 1 or 2 folks that are marginalized that are actually doing the heavy lifting to integrate this important, necessary work into into the curriculum?

Gabriel Escontrias Jr.: [00:09:24] So something I found interesting and I think worth getting your take on each of you in your own capacities. So as you're probably here, and especially in Florida, but also in states like Texas, there is an attack on DIB and how that looks within medical schools, how it looks in higher education in general, how it looks in K-12. So to those individuals hearing these very right wing states trying to push an agenda, a false narrative, especially as they like to couch it around critical race theory, what are you seeing on the ground and what can other states or other institutions do to really safeguard what's necessary to make sure that we reduce clinician bias and therefore also are able to combat the disparities?

Dr. Junji Takeshita: [00:10:12] You know what to think about. But the clinician bias, we're talking about the clinician bias toward the patient. I think he needs to go both ways. I've been reading recently more and more articles about how to deal with the racist patients and deal with that fairly often in in jury psych. As the patient gets older, they're now demented, they're disinhibited. They'll start saying these things that are unbelievably sexist, racist, so forth. And when I tell the trainees this, how do you deal with this? You can't just sort of look the other way and not address it. You have to address it in some way. Even if we ignore it, that has to be a conscious decision. So I think all these issues really go both ways as we're looking at a much more diverse society is how do we all basically get along with each other? As someone said to me a long time ago, you may not like everyone you work with, but you got to work together. You got to figure out how to how to do that. And I think that's the critical part, is how do you provide good patient care throughout all this stuff? And that's where the challenge I think, occurs. And I think for us as practitioners, you know, regardless of our, you know, racial cultural backgrounds, we're all physicians. And as physicians, you have a certain socioeconomic status with the patient. And if you're dealing with a patient of different social class, regardless of gender and other issues, it's different. How do you deal with that and how should how you know, how is that interplay? You know, worked out. I think that's that's I think that's that's the thing is a difficult part because the patients are not going to be the same as us. Think physicians have more more in common with other physicians, whereas physicians with a patient of low SES is going to be quite different.

Dr. Michelle Durham: [00:12:26] Sorry. I mean, Gabriel, I know you were also referencing states I'm in now in Texas. So it's been interesting to come from a state like Massachusetts to Texas in in real time. Where, you know, even at a basic level, like insurance, you know, everyone was insured in Massachusetts. That is not the case here in Texas at a fundamental level. Right. And so I'm still figuring that out myself. But what I do. What I do know, and I think that we all, as psychiatrists, need to be a part of is thinking about that, that the other you know, we always talk about clinical work or research work or administrative work, but many of us forget that fourth piece, in my opinion, which is that advocacy work. And I think it's just so critical for us to be at the table and not to have other folks making decisions on our behalf or on our patient's behalf. And what we see every day and what we're in the work we're doing. Um, and so that's no, I think that's no different. Like if we're going to think about transgender health, for example, or people who are pregnant and need to have an abortion or want to have an abortion, we know that the consequences of not of all of not being able to or not being accepted or something happening is that there may they may end up in the mental health realm at some point, maybe seeing a therapist or a psychiatrist, you know, someone to talk through the difficulties. We know for youth in particular as a child psychiatrist, right, that, you know, transgender or or kids who are just questioning and trying to figure out, you know, things. That their mental health is greatly impacted when they don't have a supportive family and a supportive network. And so I think we need to be there advocating, you know, speaking to our legislators, our state reps and talking to them like and we know that telling them stories and the stories of what we see and what we hear and how people are impacted, I think resonates so much than just the data points because the data gets manipulated, quite frankly, we've seen that on on media. You know, I think Texas is one of the last and mental health care. And the governor several months ago said that that wasn't true. So we so giving stats is not always I don't think, the best way to go, but telling the stories of how people are impacted by a lot of these policies and laws and things that people are saying if we're like sort of. Advocating on folks behalf and getting a seat at the table that unfortunately sometimes they don't get a seat to to express what's really going on, I think is really important in our role as as psychiatrists.

Gabriel Escontrias Jr.: [00:15:18] Thank you, Dr. Durham. And that was definitely a great way, as a reminder for everyone that the member to get involved with your district branch or your state association because really telling the story, especially in a day and age where gaslighting and race lighting is so prevalent. We need to make sure that what's being put out there is factual and there's no better stories than the ones that you that you can tell directly as being on the ground.

Dr. Carmen Black: [00:15:46] Yeah, it's interesting for me because I'm from Georgia, currently existing in Connecticut, and you'll hear no great compliments on Connecticut, cost of living, weather, scenery, much of anything. But as I contemplated a strong desire to go back home to Georgia, the sad part is I had to think of where would my career go? Um, because the things I say are not code switched, you know, especially if I'm looking at a state funded institution. By definition, health equity is going to challenge some people's world view. Literally by definition, what is an institutional, an institution's commitment to health equity? You know, the larger AMA, APA, all of the bodies are saying, oops, we're sorry, we want to do better. But when you're working in these political climates, these sociodemographic climates that are actively excluding our voices from the table, what do you do? So real talk. I even interviewed for a position back home that I didn't get because I was told, quite frankly, we don't need two black physicians in this department. What do you do with that? It's not uncommon, but just real talk. We, you know, advocacy, being involved, but also recognizing that there are active resistances to our existence in medicine. Dr. Takishita mentioned, you know, physicians often don't come from a low SES background. Well, that's also by design, right? The pipelines aren't going to the red line districts helping the folks who've been suffering by design for decades. They're going to the ones who have the formed GPAs, the pre formed MCATs. Right. Which is less convenient when you're looking at representation of lower SES immigration status, racialized minoritized folks. So I'll stop ranting, but all I can say is I'm thankful for the smartphone because that is the minoritized best defense against, you know, national gaslighting and I am thankful for. You know, compared to the Jim Crow era. Now, all the frackle knackle, which is not new, but the frackle knackle, has a conversation that oftentimes didn't exist as it was unfolding real time decades ago.

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