Equity Actions:
Equitable Healthcare for All: Addressing Disparities and Driving Change

Dr. Kade Goepferd: This is Talking Pediatrics, a clinical podcast by Children’s Minnesota, home to the Kid Experts, where the complex is our every day. Each episode, we bring you intriguing stories and relevant pediatric health care information as we partner with you in the care of your patients. Our guests, data, ideas and practical tips will surprise, challenge, and perhaps change, how you care for kids.

Welcome to Talking Pediatrics. I’m your host, Dr. Kade Goepferd. Making sure that each child and family has the unique resources and care they need to reach their full health potential is the definition of health equity. On Equity Actions, Children’s SVP of Government and Community Relations and Chief Equity and Inclusion Officer, James Burroughs, interviews guests and tackles subjects that help us work toward equitable and inclusive care for all kids.

James Burroughs: Good afternoon, this is James Burroughs coming to you live from the Equity Inclusion Suite from Talking Pediatrics, the award-winning Talking Pediatrics. I’m glad to be here today with Dr. Joseph L. Wright and I’m honored to be here because he’s the first chief health equity officer and senior vice president of equity initiatives, and he’s going to tell a little about where he works, how he works, and the work that he does is so important to pediatricians and physicians around the country. Dr. Wright also provides strategic guidance to the American Academy of Pediatrics Board of Directors and the CEO of the American Academy of Pediatrics Leadership on all health equity, diversity and inclusion efforts, which is a large job. He works to integrate that clinical public health and social perspectives and approach important health equity issues to address these health disparities that we need to address not only on the medical profession but economic disparities as well as social disparities as well. Dr. Wright, welcome to Talking Pediatrics.

Dr. Joseph L. Wright: Thank you, James. It’s a pleasure to be with you.

James Burroughs: As the first chief health equity officer and senior vice president of equity initiatives, can you share what prepared you or inspired you to take on this massive role?

Dr. Joseph L. Wright: So that role is an executive role at the American Academy of Pediatrics, which is the professional society that represents 67,000 pediatricians across the country. The role was established by the board of directors as part of our equity agenda. Then let me just say a little bit about that because I’ve been a card carrying member of the American Academy of Pediatrics for 37 years, since completing my training in pediatrics and then subsequently pediatric emergency medicine at Children’s National Hospital in Washington, DC. And over the course of that time as a volunteer member of the organization, I have had the privilege of having a front row seat for many of the activities and the initiatives that led up to, in 2020, the establishment of a strategic commitment to health equity. And I mention that because even before the murder of George Floyd, we were already along our organizational journey and published the first professional society to publish policy on health equity and anti-racism. In fact, our policy statement entitled The Impact of Racism on a Child and Adolescent Health, which was published in 2019, a year before the murder of George Floyd is the most highly cited statement of its kind in the literature. I’ve had over a thousand references and citations in the past five years.

So I mentioned all of that because again, front row seat, I’ve been a board of directors member at the AAP and having completed my term on the board, was asked to consider throwing my hat in the ring for this new role as the Chief Health Equity Officer and senior vice president. So that’s how I have arrived at the role. I’ve been in the role for a little more than a year, James. It’s one thing to be a volunteer member of an organization and to participate in governance and other committee work as I’ve done over that time, but to really come on as staff, particularly as executive staff, to really see how the sausage making happens for a membership organization like the American Academy of Pediatrics has been quite a journey in and of itself, but I’m enjoying it and the work is a heavy lift, no question, that folks who are doing this around the country know this, and particularly from the standpoint of trying to be representative for our members. I’m on the learning curve myself.

James Burroughs: Your experience as a practicing pediatrician, also emergency medicine, I’m sure you saw a lot of things related to what we talked about earlier, the health disparities that we want to address in this role. Talk to the audience about some of those disparities. What are they? What do they look like? And also too, what do you see these disparities playing out as, as along the race and gender lines? Are there differences among races? Are there differences amongst gender? Tell us a little about those disparities and how you want to address them as well.

Dr. Joseph L. Wright: It’s funny that you should reference my clinical time in the emergency department as an example, because certainly one of the areas of care delivery that we recognize is subject to inequitable care is in fact the emergency department. And that’s because very often, the pace, the intensity, the urgency of the work does require us to take shortcuts in the way that we are processing information, decision-making, relying on guidelines. We learn clinical practice guidelines, for instance, to address specific conditions. However, what leaning into the health equity work has showed us is that those conditions of urgency and using clinical practice guidelines as a way to shortcut decision making is inherently biased in the ways that people process information and make decisions. Let me give you an example. In the way that we manage pain for instance. Children come into the emergency department with long bone fractures, children come into the emergency department with appendicitis. These are common conditions that require pain management and we have been able to demonstrate as a specialty over the course of the past five to seven years, very conclusively, that children of color receive inadequate pain control for these conditions. And again, it’s not that practitioners come to work with a goal to discriminate against children of color. But when you look at the outcomes, they are disparate outcomes. The appropriate management of pain in these conditions is different for children of color and in fact, when that data is paired down, it is consistent. These studies that have been conducted, James, have been using a national data set. So this is not confined to any one institution. This is across the board. Now, what does that imply? That implies that there is implicit bias at work. Implicit bias meaning that the response I get when I tell this story or this reality, they share this reality is that, well, Dr. Wright, it’s unconscious, I’m not aware of it. Well, the next challenge for us in addressing something like as fundamental as adequately managing pain in children, is to attack that implicit bias. Why is it that practitioners implicitly take a different decision making path for one group of children than another? And so colleagues around the country are really challenging that mindset, that implicit bias is immutable, that it’s out of reach by first of all, making folks aware of it. So having done this research to expose it, number one, and then number two to really pare down at an individual practitioner level who’s doing what, and this is where the science is right now, James. We are in fact testing instruments called the inequity report card, for instance, that will trace back to the individual provider where they may have provided inequitable care, perhaps resulting in disparity on the outcome side of things.

We’re also looking to include clinical decision support tools in the electronic health record. So for instance, if a practitioner were to go into the EHR for help with a clinical condition, there would be prompts, there would be support tools. For instance, make sure that regardless of race, ethnicity, that all children receive the appropriate agents to manage pain in the emergency department. That’s just one example, James. And there are many examples where inequities are actually built in to clinical pathways that we are trying to unwind at the AAP, because guess what, the American Academy of Pediatrics produces a lot of the evidence-informed information that generates these clinical pathways that institutions like yours. So we have to fix the source in terms of clinical guidance so one of my biggest initiatives here at the AAP is focused on achieving equity in clinical guidance because how it shows up to patients and to practitioners who are using these clinical pathways and clinical guidance that we publish.

James Burroughs: You mentioned an inequity report card. If an institution wanted to use that or start with that, how would they go about doing that?

Dr. Joseph L. Wright: Right now, James, that idea is more of a research tool. If you look at these studies that I just referenced, James, they are secondary database analysis so the studies do not get down to the brass tacks of who’s doing what. The equity report card takes the next step. So at an institution like yours, for instance, the ability to actually track a practitioner’s decision, making what they do and then bringing it back as part of a quality assurance and quality improvement efforts at the level of, for instance, the emergency department. And CJ, this is standard work. This is not, this is something else. I like to emphasize that health equity is not some Johnny come lately, health equity has been a part of quality care, one of the foundation, the six foundational elements of quality care over 20 years. Now, has it been adequately integrated into high quality care? That’s the sticky wicket. But I just remind particularly folks who are in administrative physicians like yourself that health equity is a part of any institution’s responsibility to provide high quality care as one of the foundational pillars, not something brand new.

James Burroughs: And speaking of that, when we talk about those foundational pillars, let’s talk a little bit about trainees. Let’s talk about med students first. So now health equity is hopefully being more integrated into the standard work as it should have been years ago. I would guess 37 years ago it wasn’t as integrated as it may be that you’re trying to do now. Well, what can we do to infuse it in our medical students, our trainees, folks in residence with also keeping in mind that those who preceded them, who may be the veteran docs, didn’t get this training, weren’t educated about it, and some may not agree with it. How do you infuse those two things to work together?

Dr. Joseph L. Wright: One thing I have learned is that everybody is not wedded to the moral imperative of leveling the playing field for all patients, all children when it comes to equitable care. So I have taken to really trying to understand the drivers that will bring people to the table. And so to your point, the accreditation and regulatory environment for instance, requires a hospital like yours, a health system like yours, as part of their accreditation to have health equity at the highest level. In other words, the Joint Commission, which is the accrediting body for our hospitals in this country, has elevated health equity to a national patient safety goal. That means it’s a never event, a never event to have an inequities that result in disparities and the outcome side of things. That gets the attention of the C-suite. That gets the attention of the folks who may not have been paying as close attention to what folks are doing on the ground and trying to close disparity gaps. When you say you’re going to fail the Joint Commission tests, my friend, if you don’t meet these elements of performance as they are, that’s the terminology that the Joint Commission uses. So that’s one stick if you will, to get people’s attention around the importance of health equity at an institution level. Now to your question about learners, again, leveraging the accreditation environment, the Accrediting Council on Graduate Medical Education, ACGME, does have language that speaks to competencies in quality improvement efforts that residents, all trainees, are supposed to be exposed to. Again, making the point that we just talked about, making sure that exposure and involvement in QI efforts include health equity is an opportunity for trainees to get exposed. And further, in terms of your point about the teachers themselves not being steeped in the work, this is where we really have to empower this next generation of learners. After all, these are the folk who on fire about this. These are the folk who are challenging dogma and challenging status quo. When they see something, whether it be on rounds, whether it be, for instance, in the case of probably the highest profile example, James was a clinical practice guideline on management of urinary tract infection in children that included race as a dichotomizing variable. In other words, based on a child’s race, you do a different thing than you do for another child.

And so that was called out by our early career members. You got to explain to me why this does not potentially produce disparities in little black girls. That was the group that was according to the algorithm, not being afforded the standard of care, which was to get a catheterized urine specimen. So that’s getting deep in the weeds of a particular example. But this clinical practice guideline, James, had been out there for a decade, more than a decade, and it wasn’t until one of our early career members just called the question and said, Hey, I don’t think this is right. And we have since retired that clinical practice guideline, the AAP and are working on a more equitable approach. But I think that we have to support and empower learners, today’s learners, and really get away from the challenging hierarchical way that we teach medicine in this country where you just do what the attending says.

And that’s the way I was taught. That’s the way I was trained. I will tell you my friend, that there are many things that I’m looking back at now and saying, oh my goodness, why didn’t I challenge that? It comes back to the fundamental way we need to empower learners, and I’m really glad that you have a lens into those learners and early career members because they’re going to make the difference. This is generational transformation. I’m not naive enough to expect that the work we’re doing today, James, is going to have an impact tomorrow, next week, next month or even next year. This is generational. And frankly, some of the, I’ll say senior leadership in our profession, need to move on and make room for folks who are willing to challenge dogma and really not accept the status quo that has been part of our profession for so long.

James Burroughs: Makes me reflect upon the systemic change that’s needed for this work as opposed to the episodic incidents we think about sometimes. We hear about discriminatory incident. Don’t get me wrong, those are bad too. They need to be addressed, but it’s not about that incident. It’s about what is the system, the guidelines, the policies, the training, the education, the standard work that led up to that, or the lack of continuous improvement to say, what do we do to identify sources of the problem? What’s the root cause? How do we solve for it? The same quality improvement methods we use for safety condition we should be using for equitable care.

Dr. Joseph L. Wright: Let me provide an example for your listeners that speaks to the fact that equitable care is not just for any one group of people or children. A rising tide floats all boats. Equitable care provides better care for everyone. So the example that I use when I make that statement, James, is that at hospitals like yours and all across the country, we pay close attention to something called central line associated bloodstream infection, CLABSI.

So this is an avoidable condition. We don’t want folks developing iatrogenic infection in the hospital from having a central line. And so we track this. This is a standard quality metric. So it was discovered that there were disparities in CLABSI rates between white children and Black and Hispanic children. And the puzzling thing about that reality is that the insertion of a central line and the management of a central line is performed as a standard bundle everywhere in the country, everywhere we do this the same way. I have placed dozens, many, many if not hundreds of central lines. And first of all, in pediatric emergency care, you can’t even know who the kid is underneath the drapes that are necessary to perform this sterile procedure. But nevertheless, we couldn’t imagine what was going on that resulted in this disparity. Well, bottom line, our colleagues out at Seattle Children’s, University of Washington, dug into this a multidisciplinary approach.

They brought in everybody who came into contact with that patient and that family, and what they discovered was that through that multidisciplinary lens that the issue was the monitoring of the lines after the patients got back to the floor or out of the ICU. That children of color had their central lines, which is supposed to be monitored with a regularity that is part of the bundle, that was not being done for some kids. So they fixed that, closed the disparity gap and guess what? The rates of CLABSI for all children, all children, because of that QI effort that was driven by addressing a disparity improved for everybody.

So here’s an example where again, trying to get the attention to C-suite, look, if you can tell somebody I can reduce your CLABSI rates, let’s focus on the disparities that are happening with black and brown children, I’m sure they would take that every day of the week. But that’s an example of something that is standard work already. We’re already tracking CLABSI rates. Now here’s the sticky wicket going back to the Joint Commission. The Joint Commission will come through your door and ask your CEO and your C-suite, are you disaggregating your quality metrics by race and ethnicity as part of standard work? And if you’re not, you would never know. You would not know that part of your CLABSI problem is that you have disparities with a certain kind of kids or children. I think really providing opportunities for executives, opportunities for practitioners, opportunities for our learners to just provide equitable care for all kids is really the sell.

James Burroughs: So one of the things you talked about as far as health equity is how it’s equitable care for everyone. A lot of times though, people hear equity and they go right to race or they go right to sometimes gender equity or they go right to, it’s another thing I got to do in my EMR and it’s not part of my standard work. How do you change the culture of folks in your field to say, you know what? This is part of the work we’re doing and how we’re doing it. And I’ll add one caveat to it, not caveat. One example I’m trying to do here is I’ve added two physician positions to my team at a .20. One’s a gynecologist, one’s our general practice pediatrician, and they’re going to help me understand better doctors. Now I have a bias, I’m a lawyer by training. So we always just talk about y’all. Y’all talked about us, law school, medical school, I always fight back and forth, but I realized if I don’t have any docs on my team helping me understand the lens by which you’re looking through this equity work as you provide patient care and family care, I’m missing something. So we added that to the team and I want to see how that can better help docs and clinicians and nurses too, and also medical assistants too, better understand the health equity work. I know it was a long way to get to that question, but how do we better get folks to understand the change in culture around this piece?

Dr. Joseph L. Wright: Nomenclature is important. My title is the Chief Health Equity Officer, and I spend my time focusing on achieving equity in clinical care delivery. That is no shade, no disrespect to the diversity, inclusion, belonging work that is certainly part of our institutional efforts. A lot of that lives, for instance, with my colleagues in human resources and such, and certainly we work together. But I will say that as you bring on folks who are committing their time and scholarship is also something I wanted to mention. Look, this work, what we’re talking about today, this is science. This is in the same way that we began to talk about QA and QI 20 years ago. This requires the same rigor to ferret out in many instances, we don’t know what we don’t know. Until you start to peel back the data, you don’t know that you’re in the red.

You do not understand what is absent if you don’t stratify the data. So by bringing folks in who are committed in terms of bringing scholarship, number one and also providing evidence, informed information forward, we have a very thin bibliometric footprint here, James. What I mean is if you go to the literature, you’re not going to find a whole lot of referencing about the things we’re talking about here today. That’s why I pointed out the Seattle Children’s study. They published that as an example of how to tackle a nettlesome quality issue. And so the other flip side of it is clearly your institution is investing in this work. You’re picking up time for these two physicians to be a part of your team. I’m a full-time employee at the executive level of the AAP. We’ve got 67,000 people. We’ve got several thousand people who are volunteer leaders. But guess what? Every day that I come to work, my focus, my focus is on health equity. So that investment of institutions to leadership in the work and thought leadership, James, it’s places like yours that are really going to inform the rest of us, Well, how did you go about bringing that red to green? How did you go about closing that gap? How did you go about structurally building your team so that you could go about doing the work? So I am very clear that nobody shows up to work wanting to discriminate against children. But if we do not invest in unwinding and deconstructing those systemic and structural inequities that are part of our practice every day, guess what those outcomes will be discriminatory outcomes. I’m very clear about the focus of the work. It’s unfortunate of course, that there are terms and titles that have become lightning rods for us. We have to stay the course. And part of staying the course, again, I’ll say it again, is generating the science. That evidence informed approach is so important for us to get out in the literature and make sure that folks are aware from a very objective standpoint. This is not just what James Burroughs or Joseph Wright says, this is what the data bears. These are the solutions.

James Burroughs: As a member, as a lot of our physicians are of your organization, what are some of the priorities you would love for us to either partner on as an institution and or individual members to say, okay, these are going to be priorities for 2025 and beyond. This is how you can get involved.

Dr. Joseph L. Wright: Well, I value James, our local chapters and the efforts that are going on locally. I’m a public health practitioner as part of my makeup as a physician, and I respect that all public health is local. And so when I hear about what’s going on, for instance at Children’s Minnesota, what’s going on with the Minnesota chapter of the American County Pediatrics, I want that information to flow to me, to inform me how we can help others across the country. So in other words, it’s not what national is doing, which is what I hear a lot is we need direction from national, and that’s what I’m here for, to provide direction to our 66 chapters across the country. But what I would really encourage folks to do is to reach out to me. I get as much out of engagement with local entities, children’s hospitals like yours and our local chapters and our members where they live.

Because look, at the end of the day, the real challenge is meeting people where they are. Differential lived experiences are not about what happens at the headquarters of a national membership organization like ours, but what’s going on locally, so I look forward to in my second year on the job here, is to getting out to even more institutions like yours and engaging with folks like yourself, learning more. I’ve had a long history of collegial relationships across the country and leveraging those to further understand what people are doing very specifically on the ground to address the issues in their local community. So that’s what I look forward to. Obviously we produce policy, privileged to be the lead author on our policy around eliminating race-based medicine, and I encourage all of our members to read those policies. Those policies are evidence informed and provide recommendations by which we should all abide to get to the objective of the policy statements. So I commit to continuing to follow the lead of our members, but also to provide bidirectional guidance for them as we continue on the journey. James.

James Burroughs: Well, Dr. White, it’s been my pleasure to talk to you. Thank you and your role, and we thank the American Academy of Pediatrics for having that role as we move forward in this work. Talking Pediatrics is proud to have hosted you, and we look forward to partnering in the future to do more things in the community in a local way as well. So thank you for your time and thank you for your dedicating your hard efforts and work and energy to this important cause.

Dr. Joseph L. Wright: No, thank you for the opportunity. I really appreciate the time to talk with you.

Dr. Kade Goepferd: Thank you for listening to Talking Pediatrics. Come back next time for a new episode with our caregivers and experts in pediatric health. Our showrunner is Cora Nelson. Episodes are produced, engineered and edited by Jake Beaver and Patrick Bixler. Our marketing representatives are Amie Juba and Krithika Devanathan. For information and additional episodes, check us out on your favorite podcast platform or go to childrensmn.org/talkingpediatrics.