October 20, 2023
Join us this week on Talking Pediatrics as Adriene Thornton, health equity manager, and Dr. Christa-Marie Singleton discuss the various ways clinicians can engage and positively impact health disparities inside and outside of the clinical setting. Dr. Singleton is the senior medical advisor in the CDC’s Office of the Associate Director for Policy and Strategy, Office of Health System Collaboration.
Transcript
Dr. Angela 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. 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. Angela Kade Goepferd. On today’s episode, guest host Adriene Thornton, health equity manager discusses the various ways clinicians can engage and positively impact health disparities both inside and outside of the clinical setting with Dr. Christa-Marie Singleton. Dr. Singleton is the senior medical advisor in the CDC’s Office of the Associate Director for Policy and Strategy Office of Health System Collaboration.
Adriene Thornton: And welcome everyone to the Talking Pediatrics podcast. We are doing our equity and action segment. And this is Adriene Thornton, the manager of Health Equity at Children’s Minnesota, and I am very delighted to welcome a dignitary to our show today, Dr. Christa-Marie Singleton, who is the Chief Medical Officer from CDC’s Office of Health Equity. She is also a trained pediatric ER physician and her specialty is preventative medicine. So a well-rounded physician who understands what we deal with in our pediatric world, but also understands what we’re dealing with in our pediatric world as it relates to health equity.
So welcome, Dr. Singleton. I am so glad to have you with us today.
Dr. Christa-Marie Singleton: Thank you. It’s an honor.
Adriene Thornton: So let’s start with you telling us and the audience a little bit more about your current position and how you utilize that position to bring equity to the CDC.
Dr. Christa-Marie Singleton: Well, I think it’s important to understand the journey because people hear the name and the brand, the Centers for Disease Control and Prevention, and it’s an organization that is 12,000 people strong and it is an organization that has a very diverse portfolio. We tend to be known for our work in infectious diseases and our work in more recently emergency preparedness related to infectious diseases. And at the same time, we also have a large portfolio of work on various disease and health behaviors. But where I have come into the CDC almost 17 years ago is within our state and local portfolio.
And why I say that it’s important is that way back, I guess in the ’70s, there was a senator or a member of Congress, Tip O’Neill who talked about all politics being local. Well, I would offer that all diseases and all behaviors are local. And so I’ve had the privilege to serve as a local health department leader. And so when I was recruited to CDC and I brought that lens, and that’s where I have worked to bring access and attention to people’s best lives and best health. So coming to things from a state and local portfolio, state and local preparedness and making sure that each state, each community had access to the best resources to help its communities achieve their best health.
And in that portfolio, early on, probably the first, I would say, eight, 10 years of my career path was in the emergency preparedness sector. And pediatric patients were often second or third tier thought process because children were perceived as not as costly, not as much attention to them, but one, what we offered during an emergency is that people will sometimes make behavior changes and decisions about their healthcare because of their children. So when the pandemic of 2010 happened, H1N1, which a lot of people forgot about, I was actively involved in creating guidelines and thought processes around how do you include the needs of children in that space.
And past is often prologue fast-forward now to 2020 when we had the COVID-19 pandemic and that one was more of a reach and where were the communities that were affected? Our pediatric, our young people because it affected them not only at home but in their schools. And so having that lens of keeping the whole family together and thinking through that, that’s where one piece of someone who is trained in pediatrics can help be a contributor because you’re seeing it from both the parent and the child or the caregiver and the child perspective.
So there’s that lens of it and then COVID-19 just blew a big hole in a lot of people’s thinking about if people don’t have access to jobs and they don’t have access to employment, half the country gets their health insurance from their employer. So if they can’t get access to healthcare, then it makes it challenging to care for their families. And if a child in particular has health needs, that parent is likely going to be less likely to be able to go to work. And so that health and productivity piece related to the children, when you’re speaking up on behalf of those groups, that’s where I’ve used my role both as a pediatrician, as a health policy lead, as a health policy advocate to bring that perspective.
And then again, another thing that COVID blew a hole into was the effects of children of color, Black and Brown children, Native American children, children who don’t speak English as their first language, their needs, them getting more sick, their needs brought to this perspective so that people even know that these existed. But then what are we doing to provide services for those communities?
Adriene Thornton: I read an article from the American Medical Association and it was directly talking about how physicians can address health equities of the past, but also acknowledge their part in the health equities that continue to exist. And essentially what the article said was, you need empathy to create solidarity and then that solidarity will provide the foundation for physicians to advocate for their patients. And I felt like it was a little light on the recommendations piece. Oftentimes people will ask, “Well, what should I do? Where should I get involved?”
And I’m like, “I don’t know. I just don’t know what to tell you.” And I think it takes a little more than empathy and solidarity. But what are your recommendations to clinicians that have that question of how can they contribute to improving health disparities in a meaningful way?
Dr. Christa-Marie Singleton: I’m going to nudge back on you on the empathy piece of it, because the reason why I say that is that without understanding where people, the circumstances of their patients’ environment, it becomes challenging to speak with any sort of credible content. That’s where clinicians-
Adriene Thornton: That’s a good point,
Dr. Christa-Marie Singleton: … is so credible because statements may be made by, let’s say, health insurers, more of the people who pay the bills. They will say, well, we don’t need this. We don’t need that. We don’t have any data for it. We don’t have any claims. We don’t have any whatever. But the physician who is the frontline person with these families can speak up and say, I have X, Y, Z numbers of patients in my practice that are experiencing this issue. When they try to get asthma medications for their children, for their family members, they have to travel. They can’t just go to the pharmacy in their neighborhood.
They not only can’t to go to the pharmacy in their neighborhood, now they’ve got to take a bus across town to get the spacer for them to use it because I tell them they need to use the inhaler and the spacer, but that spacer is not held at the clinic. So therefore, that piece of it, you understand you walk with your patients. If you, the physician are walking with your patient, and we all took an oath to do no harm. So you have that data to bring to the people who are the payers to make those changes.
I often get this question now at this stage of my life, how did I go from a microbiology student at the University of Notre Dame to now working in government and public policy? And I tell the story of as a student, medical student, as a young resident, we started seeing teenage kids coming into the emergency departments shortly after their 16th birthdays wrecking their cars or wrecking their parents’ cars more likely. And what we noticed is that these individuals at the time they were driving because the law said you could drive at 16, but we recognized they did not developmentally have the decision-making powers to drive really at that age. So you can physically drive-
Adriene Thornton: Or to drive safely. You can drive. You’re just not able to make critical decisions.
Dr. Christa-Marie Singleton: Correct. So we as pediatricians, as students, as medical professionals collected that information and went to lawmakers and said, this needs to change. And what our recommendation was was to delay the amount of time it takes for a child, teenager to get their licenses. And that’s where the concept of graduated driving licenses came from is because a bunch of clinicians got together and presented that data to lawmakers. And so now I have a 17-year-old and he has a driver’s license, but he can’t drive that car, can only drive that car with one other person until he gets that six months or so behind.
And every state is different. So at that point is that we noticed a disparity, and we brought it to lawmaker’s attention, to policymakers attention because we walked with these patients. So everyone who is a physician, nurse, whatever that your stories collected together can improve health disparities. One of the projects that I’ve had the real privilege and honor to lead at CDC is a project that looked at improving capacity for clinicians who serve minority communities during COVID-19. And it was focused of course on COVID-19 and trying to get vaccination rates up.
But what we recognized is I knew good and well that the physicians who serve these minority communities in particular couldn’t just focus on giving out shots. They needed to tell the story of their patients. They needed to look at what are the barriers and gaps in care. They needed to look at the social needs of their patients. And so this pilot project of 13 physician practices has been used to collect information as to what does it take to get these patients into care?
And shockingly enough probably to some, it’s not just about the COVID shot, it’s also about, well, do they have transportation? Did they have food security issues? Did they have housing issues? The getting a shot is the last thing on their list. Clinicians can bring this information to individual’s attention and particularly to payer’s attention to say, hey, I need a little bit more help here. Because the payment system right now is largely still focused on what we call fee for service. So what you eat is what you kill, what you bill is what you get paid for.
But if you can then say, hey, I can actually see a different set of patients with a different set of help here in a different payment model, then that’s what clinicians can then use that information of their practices to then show I’ve got this gap. If I had X, Y, Z resource, then I can maybe decrease that gap. And that’s how you can improve the health inequities for your patient population and then that just spreads.
Adriene Thornton: I love that you made it a little easy. You kind of hit the easy button for the lawmakers. They didn’t have to mull over the data and figure out what to do. You all took the data and said, hey, here’s what we’re seeing. Here’s what we think will work. And you all were the experts.
Dr. Christa-Marie Singleton: And the key piece now, especially in the political times that we are, is looking at the outcomes of the decision makers that matter to them. So you guys are in Minnesota, and I can’t speak to the climate there, but I will speak to where I am here in Georgia. And that our governor here made it very clear that health and the economy are inextricably linked. So whatever your political perspective as of Governor Kemp here in Georgia, that was a priority for him from the beginning of the pandemic.
And so knowing that then one could offer that you can then use that data to show how keeping people healthier can then help people maintain opportunities to achieve work, go to work, and then continue that productivity into the economy. So clinicians showing that perhaps a barrier to people getting health services. If the barriers are transportation issues like, hey, these people had access to the transit card or they had some other partnership to work on their housing insecurity, they’re not in and out of doing other things, then a goal is getting them back to work or getting them back to whatever this piece of it.
That was a metric that this governor here and the legislative here is focused on is getting people back to work. So it depends on the data and the outcomes one is trying to achieve. That’s one of the things that clinicians can do is not only do you want to improve the health of your patients, absolutely that always comes first. But at the same time, if a measure of reality check is parents, as a kid, getting the parent back in the office, getting the parent back to work, then what do we need to wrap around that family so that there is less time out for sick visits?
Could it be is the clinicians speaking up saying, hey, if there is a particular employer in a town, is there a way you all could do an onsite clinic so that family member doesn’t have to leave the job? Or could they bring their kids to that space? Or could we do some sort of joint partnership so that the health gaps, you won’t close them, make some progress, but you’re still meeting those goals? As a multicenter stakeholder, that’s a key piece that clinicians can be doing in this space.
Adriene Thornton: So I want to circle back to the empathy thing. And I appreciate you for pushing back because you made really valid points, and I agree with you by the way. But you can teach empathy, but it’s sometimes a hard thing to really grasp. Do the health institutions, the medical schools, where do they fit in? Can they help with the training piece for clinicians to help them as they’re coming out of medical school have a stronger foundation of how to have that empathy that will get them to the point where they’re able to really move forward with making improvements in health disparities and decreasing that health equity gap?
Dr. Christa-Marie Singleton: Absolutely. And it needs to, in my opinion, start a lot earlier. The first two years of medical school training is very, very focused on the pathophysiology, the anatomy, endocrinology, whatever. And you’re teaching to the test, and I have my own thoughts on that. You’re all teaching for these exams. That being said, sometimes helping them understand whatever you’re trying to teach in the classroom with these books for the test, but putting it in a patient-centered manner, so you see how it actually plays itself out.
Some people can learn and there are just straight memorization people. I’m not one. I needed to have the human context to look at it that way. And so that’s bringing more of that patient-centric component of it in the medical school training early on in your first and second year. So how does it fit with a particular patient and how does that play itself out and demonstrate it in a real person’s life? That’s one piece of it. And then another piece of it is then you’re teaching early on to screen for these social needs.
So let’s say if someone has high blood pressure and the first line drug according to the textbook is that they need to take a statin, well, yes, and. What are the issues with said statin? What might be some of the expected, I wouldn’t say side effects, but things that could happen to the person and then what is the cost of said statin? What are those other social things that need to go around it? That part is often not discussed. Oftentimes, it’s they’ve got high blood pressure. The protocol says they need to be on a statin, put them on a statin. Done.
When you don’t look at the whole picture, how is it going to fit into that person’s life? What is the cost of said medication? What else needs to go with the food that needs to go with it? That’s where you can teach that empathy because what may happen is person needs to be on a statin, person does not take said statin, patient is then deemed as non-compliant. But if then as you say, by the way, Mrs. Jones, Mrs. Smith, here’s where you are in addition to you want to get better, here’s the medication and these other pieces of it, now help me.
Are there things that we can talk about that might be barriers for you taking this medication? How is this going to fit into your lifestyle? And that’s where the empathy piece comes in and can be taught a lot earlier. And I go back to the payment piece of this, again, the cost of this stuff, because a lot of times people don’t think about the health insurance aspects of it or not. And so again, if the patient says, they nod their head and say, okay, fine, doc, I’ll take the medication. And you have no idea what that person’s got to go through to get those coins to pay for it and then they’re just thumbing their nose at you.
Adriene Thornton: I love that we have all these workarounds for the expensive medication in the US. So I actually testified before the legislature here related to capitating copays for chronic illnesses such as asthma and diabetes, because diabetes to copays were up to $700. So I appreciate you bringing that forward because we don’t talk about that enough. So I just want to say this has been wonderful. I just feel like we’ve known each other for a while and we could talk about this all day, but we can’t.
And so as we wrap up, do you have any pearls of wisdom for our clinicians or any one or two things that they could do maybe tomorrow or next week or the next month or throughout the year to help them move forward in their journey to help with health equity?
Dr. Christa-Marie Singleton: I would say walk with your patients. The more you walk with your patients and understand the patient experience comes first, that can give you invaluable information that then you can use to advocate not only for your patients, for yourselves, for your practices. As healthcare is financed in changing payment models, the health equity is often not in those models. And if equity is getting everyone access to their best possible care, by you collecting that information and showing how the payment systems can change, you advocate for yourself, you advocate for your patients, and you can remove these outcomes to a better space.
Without a focus on equity, you, the providers are being penalized. But again, the patients matter first, and that’s what they’re harm first. And so the more we can be that expert, you, the physician are the expert on your patients, and you can bring that information to the table. Not just well I had three people who had COVID, but I have three people that have COVID and these other things and here are elements that we would recommend that can help get everyone to their best health, a productive community, health competitive community, and a more prosperous community.
Adriene Thornton: Wonderful. That’s perfect. The patient matters first. That is our word of the day. Thank you so much, Dr. Christa-Marie Singleton. This has been a joy and a delight. Thank you so much for this. And thank you you to all of our listeners for listening today and have a great day.
Dr. Christa-Marie Singleton: Thank you.
Dr. Angela Kade Goepferd: Thank you for joining us for Talking Pediatrics. Come back each week for a new episode with our caregivers and experts in pediatric health. Our executive producer and showrunner is Ilze Vogel. Episodes are engineered, produced, and edited by Jake Beaver. Amie Juba is our marketing representative. For more information and additional episodes, visit us at childrensmn.org/talkingpediatrics, and to rate and review our show, please go to childrensmn.org/survey.