Articles, Blog

Colorectal Health Forum

January 27, 2020

– Good afternoon. – [Audience] Good afternoon. – Now, you know, if Dr. Reede were here, she would not be pleased
with that call and response, so we’ll try it again. Good afternoon. – [Audience] Good afternoon. – All right, my name is Alden Landry. I am the Assistant Dean for Diversity Inclusion
and Community Partnership and I have the pleasure
of helping to organize these equity and social justice events. These events are something that are near and dear to my heart because it’s often conversations that don’t necessarily fit within our traditional educational dogma. And these are conversations
that our students, our residents, our faculty, our community need to hear and be a part of. So, I just wanna say thank
you all for being here this afternoon and joining
us in this conversation. I wanna say thank you to the
many guests that are here. We have, from Harvard
HMS, the Chan School, Harvard Graduate School of
Education and Harvard University. We have many of the hospitals represented, including Boston Children’s
Hospital, BIBMC, MGH, Dana-Farber, Brigham and Women’s Hospital and then we also have the
Boston Public Health Commission, the Center for Surgery and Public Health. And, so, just thank you to all of our wonderful special guests. I especially wanna recognize our speakers who are here today, Dr. Durado Brooks, Dr. Kim
Rhoads and Dr. Darrell Gray. They are past alums of
our Commonwealth Fund in California Endowment Fellowship and just thank you for your presence here. And also to Dr. Nadine Jackson McCleary, who is gonna be leading us
through this discussion, who comes to us from
Dana-Farber Cancer Institute. This is really a collaborative effort and our cosponsors include the Dana-Farber Harvard Cancer Center, the Commonwealth Fund Fellowship and Minority Health Policy
at Harvard University and the HMS Office for Diversity, Inclusion
and Community Partnership. And I want to just take a pause and just say thank you to
Teresa Carter, Ying Wang, Jackie Wright, Sheila Nutt, Fahri and the rest of the staff at the DICP for helping to pull this together, so if we could give them
a round of applause. (audience applauds) So this is our fourth year of doing these Equity and Social
Justice lecture series and it’s really, as I mentioned earlier, the importance of this is
just about having dialogues. We wanna make sure that we
focus on what’s happening within in our Harvard Community but also make sure that we’re standing beyond the borders of the campus and really include our
community in these discussions. And we welcome our participants from the Greater Boston area. This series really gives context to the historical,
current and future state of health equity and social justice in health and health care and engages and equips participants with tools and the ability to take action. Our ESJs focus on four major areas including the historical context, culture and environment,
health disparities and leadership skills and development. This year’s ESJ lecture series
will tackle specific issues focusing on disadvantaged populations and underserved patients. And our speakers will
address not just defining the disparity anymore, because
I think we’re beyond that. We’re really focusing on the intervention at the community,
hospital and policy levels that will allow us to have
the change that we need. For colorectal health, I’m not gonna dive too
much into the details but you’re gonna hear from
some really dynamic speakers that are gonna talk to us about what’s happening for underserved and marginalized communities when it comes to colorectal
health screening, the diagnoses and misdiagnoses, the impacts of these diseases
on our patient populations and how we can work together on a local, on a state and on a national level to really address the health disparities that we’ve come to see bear out in our current health care system. So our format for this
discussion is gonna be two parts. One is gonna be a quick overview
and introduction by Nadine. She’s gonna give us an overview of where we’re at in
this current discussion and then we’re gonna break down and have our panelists join us and give us their different vantage points from the work that they’re doing. And, so, I think you’re gonna see that this is really a 360 conversation and we wanna get you all involved in this conversation as well and we’re gonna try and save time for as much Q and A as possible. So, with that, I’m gonna
pause with my opening remarks and I’m gonna go ahead and transition to welcoming our keynote speaker. So with that, I wanna bring up
Dr. Nadine Jackson-McCleary. She’s the medical oncologist at the Dana-Farber Cancer Institute and an instructor of medicine
at Harvard Medical School. She obtained her BSN from the
University of Pennsylvania and later obtained her MPH
from Johns Hopkins University Bloomberg School of Public Health and continued on to
receive her medical degree from that institution as well. She completed her Fellowship
in Hematology and Oncology and she joined the
Gastrointestinal Center Faculty at Dana-Farber Cancer Institute in 2009. Dr. McCleary has dedicated her research to the development and the application of validated tools to facilitate
shared decision making and improve cancer care delivery. Her initial research translated
patient report outcomes for older adults diagnosed
with gastrointestinal cancers. Her current efforts entail
large-scale implementation of electronic PRO collection
at the academic institution and among oncology patients
who are often marginalized by access, motivation or stigma for electronic communication. Her work is funded by
the Donaghue Foundation, the National Cancer Institute, Friends of Dana-Farber Institute and the DFCI Medical Oncology Grant. So, with that, I will
bring up Dr. McCleary. (audience applauds) – Good afternoon, everyone. – [Audience] Good afternoon. – So this is exciting
to be able to talk about this topic amongst who I consider friends and folks who are very interested in finding out more about what we can do, not just what we’re going through, but what we can do about this. This is a very personal story for me. So, at the start of my
oncology fellowship, literally the last day of my
residency at Hopkins, in 2006, I got a phone call from my father, who was at that point 56 years old. Not a man who likes to go to the doctor, married to a nurse, so forced him to go. And he had his first colonoscopy at 56 but had been bleeding for one year, unbeknownst to any of us in his family. And his PCP was aware of this but really didn’t push this
need to get a colonoscopy. “It’s okay if you’re not ready.” It wasn’t really pushed,
even with her colleague, who was my mom, and
nurse working with her. And so I think this just goes to show that cancer in certain
populations is on the rise. It’s higher in certain
racial and ethnic groups and, particularly amongst
African Americans, we can see higher rates
of not only incidence but mortality for certain cancer types, even colon cancers,
which are highly curable. This higher rate of incidence is present regardless of stage of diagnosis. So, for patients who here compared rates per 100,000, comparing African Americans to Caucasian peers at early stage, at local stages in the middle and the last panel, C, advanced stages, African-Americans stand a
higher rate of diagnosis at each of those stages. This disparity is multifactorial. Whether you’re concerned about incidence, screening, treatment,
mortality, survivorship or risk reduction incidence, African American’s stand third most common cancer in African American men and women and a 20% higher incident,
despite decreasing incidence of this cancer
subtype overall for all comers. They also have later
referrals for screening and, amongst those who are
referred for screening, there are differences amongst what type of screen is selected, Whether it’s colonoscopy versus
a fecal occult blood test. Treatment, timely referral to Oncology has been shown to be an issue as well. Mortality and survivorship, fewer living at five or
beyond years since diagnosis. And risk reduction, as we’ve
discussed in other forums, genetic and genomic testing is lacking in certain racial and ethnic groups, including African Americans. But there is hope. So one intervention that was
conducted statewide in Delaware looked at early screening and noted that early screening leads to early detection and lower mortality. So I just wanted to take a brief moment and walk through this
experience in Delaware, detailing their interventions
from 2002 to 2010. But they really made a hard push to increase screening in that state. And, noted, that screening increased not only for African
Americans who were at risk by 57% over that eight year period, but by 28% for their
Caucasian peers as well. So, overall, you know
rising tide lifts all boats, each person was benefited
by this intervention. Not only were able to screen
and have earlier detection, we also saw a shift in the stage. So in 2001, there were a greater number of patients diagnosed
with regional disease, disease that often requires chemotherapy and/or radiation therapy for rectal cancer and by 2009, with this
earlier screening effort, we’re catching disease at a earlier stage, so more local and curable
and resectable disease. And, again, by shifting that screening, shifting to earlier detection, we also saw a decrease in mortality for patients in this subset who were monitored in
the state of Delaware. So, this reduction was seen
for Caucasian peers as well but was most notable
for African Americans, who up until that time had not
had similar screening rates. So, I think this is very encouraging. And, as you’ll hear later on, “A Call to Action” really
is one of the titles of the talks to today and I think it’s a call to action for all of us. 60% of colorectal cancer
disparity in many papers has been quoted as, “Can be easily addressed by screening “for all eligible individuals” Not just those of a certain
racial or ethnic group, but everyone would benefit
from more aggressive and targeted screening. And the remaining 40% of
this disparity that we see with colon and rectal cancer diagnosis could be tackled by addressing every phase of the cancer care continuum. So, screening all the way to testing, including genomic testing, and the big data that we’re mining now to develop key algorithms for care. We need to determine why those differences in diagnosis and mortality occur, develop targeted interventions and focus on survivorship
and prevention strategies, so we do not continue to see the same disease affecting generations. So, today we are pleased to be
joined by our three speakers and I just wanted to take a moment to introduce each of them. I’ll actually start with Dr. Gray first and then end with Dr. Brooks, after which he will
come up and speak to us. So, Dr. Gray is an Associate
Professor of Medicine at the Ohio State University
College of Medicine, where he serves as Medical Director of Endoscopy
and Gastroenterology Services and Deputy Director for the
Center for Cancer Health Equity at OSU Comprehensive Cancer Center. He completed the
Commonwealth Fund Fellowship in Minority Health Policy at
Harvard University in 2014, Gastroenterology Fellowship at Washington University in 2013, internal medicine residency at Duke University Medical Center, medical school at Howard
University College of Medicine and Morehouse College. Dr. Gray engineered and leads
the provider and community engagement PACE program for health equity in colorectal cancer prevention, a nationally recognized initiative aimed at improving colorectal
cancer screening rates. He also serves on the National
Colorectal Cancer Roundtable strategic planning advisory group. Dr. Gray has been
recognized for his work with the 80% by 2018, National
Achievement Award by the NCCRT, multiple American College
of Gastroenterology awards and with induction as a
National Minority Quality Forum, 40 Under 40 Leader in Minority Health. Dr. Kim Rhoads is an Associate Professor of
Epidemiology and Biostatistics and director of the Office
of Community Engagement for the University of
California San Francisco Helen Diller Family CCC. Dr. Rhoads has board certification in general and colon and rectal surgery and conducts health services research highlighting the relationship between delivery of
evidence-based cancer care and survival disparities for racial ethnic
minorities in California. Her groundbreaking work has demonstrated the link between cancer care equity and the closure of racial
ethnic survival gaps in a variety of malignancies. Dr. Rhoads longstanding
commitment to community engagement as a path to eliminating disparities has led to her current roles as Director of the Office
of Community Engagement for the Comprehensive
Cancer Center at UCSF. Dr. Rhoads obtained
her MD degree from UCSF jointly with an MS in
Health and Medical Science from University of California Berkeley and holds a Master’s
Degree in Public Health, Health Management and Policy from the Harvard T. Chan
School of Public Health. There she served as a
California Endowment scholar in Minority Health Policy. Dr. Rhoads founded and led the Community Partnership Program at the Stanford Cancer Institute, before taking on the directorship at UCSF. And, finally, Dr. Brooks has worked for the American Cancer Society’s national headquarters since 2000. As the Vice President of
Cancer Control Interventions, he oversees the design, implementation and evaluation of cancer prevention and early detection programs at the national, state and local levels, to increase access to high
quality prevention and screening and to decrease cancer
related disparities. He also serves as Deputy Director of the society’s peer review journal, A Cancer Journal for Clinicians. A graduate of the Ohio State University Wright State University
School of Medicine, Dr. Brooks completed his
internal medicine residency and chief residency at Wright State’s affiliate hospitals in Dayton, Ohio and practiced primary care
at safety net facilities in Dayton and Texas for 15 years. He completed the Commonwealth Fund Harvard University Fellowship in Minority Health Policy in 1999 and holds a master’s degree from the School of Public Health. He subsequently worked in the U.S. Department of
Health and Human Services Dallas regional office before joining ACS. In 2015, Dr. Brooks was honored with the Prevent Cancer
Foundation’s Laurel Award for National Leadership in Cancer
Prevention and Early Detection and with that, I welcome Dr. Brooks. (audience applauds) – Good afternoon.
– Good afternoon. – It is a real pleasure to be here. I want to thank the organizers for allowing me to be part of this really important conversation. I was asked to talk
about colorectal cancer from the national perspective and, given the introduction,
my bio you just heard, my focus with the American Cancer Society is really around prevention
and early detection. So, my focus of my remarks is
also going to be very heavily on colorectal cancer screening
and why that’s important. This year, in the U.S.,
nearly 150,000 people are gonna hear the words,
“You have colorectal cancer.” Just like Dr. McCleary’s
dad heard those words. 50,000 people or a
little more are gonna die from colorectal cancer
this year in the U.S. And from my earliest days with ACS, I’ve been driven by the
knowledge and understanding that half or more of those
cases could be prevented. Half or more of those
deaths don’t have to occur. Not because we discover something new, find some new magic bullet. Just using what we have at our hands, we can make those kinds of changes. That’s because colorectal cancer is one of the very few cancers where the screening tests that
we use to find cancer early can also help to prevent the disease. If we screen people effectively, we find and remove adenomatous polyps and keep people from ever getting cancer. So there are tremendous
missed opportunities every day occurring across this country. Now, we have made a lot of progress, and the reality is estimated that about half a million
cases of colorectal cancer haven’t occurred over the last 30 years because of our screening
efforts to a large degree. We’ve also seen very dramatic falls in colorectal cancer mortality. Just during the first
decade of the 21st century, from 2000 to 2011, there was a 27% drop in colorectal cancer deaths in the U.S. So, clearly we’re doing some things right but, as is often the case
in our healthcare system, not everybody is experiencing
that same level of benefit. So we have continuing gaps,
very significant gaps, in colorectal cancer. We have much higher incidence rates and death rates in certain populations, in particular, African Americans and American Indian and Alaska Natives have much higher rates of being
diagnosed with the disease and higher rates of dying from the disease than other groups in the U.S. We have seen mortality rates
falling in African Americans, just not falling as quickly as they have in the white population. And in American Indians, concerningly, there’s some data indicating their rates are actually worsening. So, clearly work to be done. Again, screening can
help prevent the disease. But, even if we miss that
opportunity for prevention, even if when we finally get around to doing that colonoscopy,
we find cancer is there, can still make a huge difference because cancers of the colon or the rectum that are found in the earliest stage, before they penetrate the colon wall, 90% five-year survival. Nine out of 10 people who
are told, “You have cancer,” have a chance of living
five years or more. Many of those folks will
then be cancer free. On the other hand, if the
disease has metastasized by the time it’s diagnosed, only 14% of those folks are
gonna be alive five years later. So screening can prevent the disease but also can totally change
the trajectory of the disease if we do screening on time. And, again, we’re doing a really lousy job in meeting instances
with on-time screening. Again, Dr. McCleary’s dad’s example is one that we all need to keep in mind. He was 56 years old. For 20, 25 years, every
organization that publishes colorectal screening guidelines
says start at age 50. Yet he’s 56 and symptomatic
before he ever got screened. And, unfortunately, that’s far too common. Although screening rates
have improved in the U.S., the last data that we have
from the CDC indicates that for individuals
between age 50 and 54, less than half of those
folks are screened, and those are people for whom screening has been widely recommended
by every organization for more than 20 years. So we’ve got work to do. Now, again, for at
least the last 20 years, there’s been consistent messages from essentially every
major medical organization that for average-risk individuals, you should start screening at age 50. In May of 2018, the ACS
broke with that consensus and our guidelines since that time have recommended that
all average-risk people, regardless of gender,
regardless of race or ethnicity, everybody should start
screening at age 45. We did not break with that consensus without putting a lot
of thought and effort into considering all the
possible ramifications, but our guidelines are evidence based and ultimately we went
where the evidence took us. And one of the main pieces
of evidence was this. This is data that’s been produced by a lot of different folks, but the epidemiologist
that I have the honor to work with at ACS actually had done some of the similar work in this area and noticed that, going back
for close to 30 years now, we have been seeing that steady fall in colorectal cancer
in people over age 50, but in the group between 20 and 49, a 51% rise since 1994. More and more young people being diagnosed with colorectal cancer. So this got us looking
more closely at this data and, every way we sliced it and diced it, it was incredibly concerning. In 1990, 6% of cases of
colorectal cancer in the U.S. were diagnosed in people
under the age of 50. By 2015 that had essentially doubled, 12%. So more than one out of every 10 cases, about one out of every nine cases, is now occurring in somebody
under the age of 50. And, for reasons that aren’t clear, African Americans, Native
Americans more likely to be diagnosed with early stage disease. There also is a tendency for people with early stage disease to be diagnosed with more advanced disease because colorectal cancer, frankly, it’s certainly not on the patient’s mind and often times it’s not even on the minds of the clinicians who are caring for them. And I’ll admit to a blind
spot when I was in practice. If I saw a 30-year-old who
came in with rectal bleeding, I would have probably treated him the same way that Dr.
McCleary’s dad was dealt with. “Ah, probably nothing to worry about.” But that is no longer the case. Any symptoms in anyone, regardless of age, need to be taken very seriously. Now, we had a lot of pushback, I will say, when we published our guidelines and recommended screening
beginning at age 45. And there are some reasonable
and legitimate concerns. But, again, for us, the
evidence strongly suggests that 45 is the right age, and the right age for
everyone to start screening. And we do feel that we
have a chance to change some of that data that you
all were just looking at. The reality is though, if
you look at our guidelines and those of the U.S.
Preventive Services Task Force, other than the 45 year starting age, our guidelines are almost identical. And a couple of important
things to point out, everyone recommends options. Unfortunately, colorectal
screening in the U.S., in most instances, when you talk about it, people automatically go to colonoscopy. No guidelines say everybody
get a colonoscopy. Even the guidelines of
the GI organizations promote the importance of options because not everyone is
willing to have a colonoscopy, not everyone is able to get a colonoscopy. And there are very effective
screening options available, and many of these options
are potentially low-cost, so even people who have
insurance challenges or other economic difficulties can still find a way to get screened. As a matter of fact,
one of the big pushbacks related to the ACS guideline change was, “Well insurers aren’t going
to cover screening at age 45.” Well, if you’re talking
about a colonoscopy for everybody at 45, then you know, that 1,500, 2,000, $3,000
can be a big challenge. But, if you recognize
there’s a whole pantheon of screening options, a $25 stool test is potentially still affordable. The other thing is, actually insurers are starting to cover screening at 45. Because some insurers have gone back and looked at their own
data and recognized that, hey we’re seeing a lot of
people under the age of 50 with colorectal cancer, and
we’re paying a lot of money. The last estimate I looked at estimated that treating stage four colorectal cancer is a 300,000 plus dollar proposition. So maybe screening actually
makes economic sense for us. So we are seeing insurers
beginning to pick up on this. The other important thing though, if we talk about these options, is the fact that colonoscopy is really the common final pathway
if you’re going to diagnose and treat colorectal cancer effectively. So, if someone has a
non-colonoscopy screening test, a stool test or virtual colonoscopy, if that test is abnormal, they
need to have a colonoscopy. And, unfortunately, in particular with regard to stool tests, there’s a lot of data now demonstrating that anywhere from a
quarter to half of people who have a positive
finding on a stool test still don’t get a colonoscopy
within the next year. And, again, a body of work is now showing that those people are at
significantly higher risk of being diagnosed with colorectal cancer in the future and dying from it. So, non-colonoscopy options are great, but, if they’re abnormal, you gotta do the right kind of follow-up. Now, in spite of the tremendous
benefits of screening, we still aren’t doing a great job for the population at large. The last data from CDC indicated that about one out of three
people who should be screened are not up to date with screening. And, again, at the younger end
of that spectrum, 50 to 54, less than half of those folks are up to date with screening. In addition, African
Americans in some places have equivalent screening rates, other parts of the country, not so much. American Indian and Alaska Natives, who I already said have
some of the highest rates in the country, highest
rates in the world, have much lower rates of being
up to date with screening. It also differs by socioeconomic status, by educational status and
insurance status in particular. The uninsured in the U.S.
are about half as likely to be up to date with screening
as more affluent groups. So, a big part of the work that I do, that we at ACS have focused on, is trying to move people to take advantage of the tremendous opportunity
offered by screening, in particular, trying to address the needs of a lot of those groups that currently aren’t being addressed. So, beyond just developing the guidelines, a lot of our work at ACS is focused on trying to actually get those
guidelines put into practice. For more than 20 years,
we’ve partnered with the Centers for Disease Control
and an organization called The National Colorectal Cancer Roundtable. That’s a consortium of now more than 120 different organizations that have all come together to increase colorectal cancer screening. We launched, in 2014, an
initiative called 80% by 2018, with the goal of getting
the entire nation, from 62% at the beginning of that, to 80% screening across the country and we fell short but we’re still moving, we’re still moving forward. And we did make significant
progress in a number of areas. Number one, we were able to
get over 1,700 organizations to sign onto that initiative. And these are certainly a lot of different healthcare organizations and public health and government, but we
also got private industry. We had employers like AT&T and FedEx who became part of that initiative. And we changed the conversation. Because, prior to that time, we had a goal of 70% screening by 2020 that was established by
the federal government a number of years ago. Nobody talks about 70 by 2020 anymore. Everybody is talking
about how to get the 80%. We had more than 350 organizations that were part of this initiative that actually increased
their screening rate to 80% or better as well. So, it showed what you can do when you bring people together in
that coordinated fashion. In addition to the NCCRT,
the American Cancer Society also supports the epidemiologic research, like the research I just shared with you. And we have world-class epidemiologists who slice and dice all sorts of data around cancer and screening, and help us recognize those trends. We also have an external research group that funds everything
from bench to bedside and we have a very active
advocacy arm as well. So, my time is up, and I would be happy (audience laughs lightly)
to address (chuckles) any questions once we get
to that part of the program. But I yield now to my
colleague, Dr. Rhoads. (audience applauds) – Uh, yeah, number three. – So, I’d like to thank Alden and Teresa for all their work to
put this forum together and for inviting me to
talk about something that I don’t get to talk
much about in my day job, because now I work more
in community engagement and less on the side of
health services research. So, I’m gonna go back to my
health services research hat, because I gained those
skills through the Fellowship and I see the Fellowship continuing to provide opportunities for me to continue to explore and to develop some solutions to the
problems that I described during my fellowship. Okay, so, I wanna start by saying this is sort of my new soapbox and it probably doesn’t need to be said in this forum necessarily but, outside of these walls, this idea that health disparities are a population level problem is not really well crystallized and the problem with that is two-fold. The first is that, if we look at it as an
individual level problem, then we can take a sort of deficit lens and say, well, we can blame the victim. These people lack education or lack access or lack trust in institutions. And, on the provider side,
we can spend countless hours, waste countless hours,
arguing about whether or not a provider is racist or respectful. And, whenever I’ve said these
things in national fora, I always have som
provider come up and say, “Well this is how I try to
interact with minority patients.” and really that’s not the argument that we need to be having. The problem with keeping
it in this kind of frame of an individual level problem is that our solutions then look like they target individuals. So we’re gonna educate the uneducated, so, again, it kind of keeps
us in this deficit frame. And, for providers,
we’re going to train them in cultural competence. And what’s really interesting to me, is that the cultural competence guidebooks never include a chapter
about white people. And so you’re sort of saying by that that white is normal and everything else needs to be learned. It’s effectively an inequitable position that we start from
trying to get to equity. And I’m not sure that that’s possible. So the fact that the disparities
that we see in California for certain racial and ethnic groups, we see across the country in those same racial and ethnic groups, makes me think that there’s actually something bigger going on, it’s not just an individual level problem. And I wanted to pick up
on something, Durado, that you mentioned, which is that you see, particularly at times when there are new interventions for diseases, there’s a sharp decline
for certain populations but the same trajectory, no change in slope, for other populations. And that can’t possibly
be something related to, for example, our genetics,
simply changed in the population. It has something to do with something that is systematically being delivered in a differential way. So, what I’m showing you here are, these are two curves from
an old paper I published that I really loved so much, because this was the first
time that we were able to see, on the left panel, Kaplan-Meier curves showing survival for white population that was actually lower than
African American population, which is in the red line,
and that’s on the left side, and that’s in California’s
largest integrated health system and I’m sure you all know what it is, I don’t think I need to say it, but you probably can figure it out. On the right panel,
we’re looking at patients who were treated outside of that system, and you see the usual spread of what we can characterize as disparities by race ethnicity in terms of
survival from colon cancer. The first time I saw these
two Kaplan-Meier curves was actually sitting in a
cafe with my statistician and we had just gotten
slapped down by JAMA because we had submitted a paper where we wanted to really talk about why people go where they
go to get their care. And effectively what we were showing was segregation in California’s hospitals, without saying that. And they sent it back and they said, well, if you’ve included people who are enrolled in California’s largest integrated healthcare system, we’re not gonna read it. You have to take them out because they don’t have a choice of where they get their care. So, as we were disaggregating the Californians with colon cancer, my statistician just
decided to run these curves, because everything we were doing
was really about disparity, so he was like, “Hey, let me look.” And when he brought these
curves to me, we were shocked. And we were like, if this is real, this is a really big deal. And we have to figure out
why it looks this way. Because these lines on the left side are all sort of piled on top of each other and, having worked in that system, I know that there are a
lot of algorithms for care. There are certain things you can do and there are certain things
you absolutely cannot do. And so we decided to ask the question, is this effect a difference in receipt of National Comprehensive
Cancer Network guideline care. So we looked across the population in this integrated health system, and we did indeed find
that NCCN guideline care was adhered to across race ethnicity and even across the different types of insurance products that
also exist in this system. So, when we went back
to finalize and analyze the rest of the paper,
which I have to say, we had to use really high-level methods. We had to use propensity score matching, where we’re actually able
to match the patients on race, gender, stage of disease, age, comorbidity score and three
socioeconomic factors, except the difference was
where they got their care. And we found that this same
finding held up very strongly. So when we sent it back in we were asked, well what about in the systems outside? What happens when you
account for in your models whether or not the patients
outside this system got evidence based care? And, when we did that, what we found was the disparities gaps closed
in those settings as well. So, just I think a month later
and by random coincidence, we were writing a similar paper on acute myelogenous leukemia
and we found the same thing. And, since then, I’ve
reviewed a number of papers, including on ovarian cancer and other gynecological malignancies, where people look at comparison and receipt of evidence
based care and outcomes and the disparities gaps close. So, I know that there’s
a lot of big emphasis, especially in this room and on this campus and with forward thinkers, about the impact of the
social determinants of health. And, somehow, we get a dichotomy between, well, it’s the social
determinants, not really care. And I just wanna point out two things. One is there’s variation in care across different types
of healthcare settings. And, number two, as we
found in the first paper we tried to write about segregation, the social determinants actually tell you where you can or cannot get care or drive that part of
where people receive care. So even though care
doesn’t get as much credit, the social determinants are
embedded in those numbers. So what I want to sort of
drive home or emphasize is this idea that we need to
look at the social determinants and work to change policy, but we also need to look at the systems, and particularly the systems of care where people have been
segregated into them, and that segregation has not gone away, and start to think about interventions that can happen actually
at the point of care. Because some people are
gonna get, as we just heard, some people are going to be
diagnosed with colorectal cancer even if they screen appropriately. So this is just one slide from a project that I’ve been working
on for the past year, and this is where the
Fellowship comes in again. So, in collaboration with
a former Harkness fellow, people familiar with the Harkness program, it’s sort of the sister program to the Commonwealth Fund Fellowship and most of the folks are from the UK. My collaborator was from Australia, I actually met him at UCSF, he
was locked out of his office. I was a year out of my fellowship and he came and said, “You know, I’m locked out of
my office, can I sit in here?” And, as we started chatting, he told me he was a Harkness fellow. So we started about a
decade long friendship. And he now works in the
Australian, in Victoria, Australia, in the Health and Human Services Agency. And what he does is he builds platforms that poll from their administrative data to report back to
hospitals how they’re doing in terms of certain types of outcomes. Right now he’s working on
hospital acquired conditions. He contacted me because he
wanted to give this platform to the state of California. And so I said, okay, I’ll
get on the call with you. And they couldn’t understand exactly what it was he was trying to do. But what they asked for was, can you give us a business case? Can you give us one
disease where you can show that evidence based
care makes a difference? Because then we can think about how we distribute this
fact to the hospitals. So over the past year, we
spent time building a platform that plugs right into the
California Cancer Registry data. So what that allows us
to do is grab not only the cancer data for
every patient diagnosed with a non-melanomatous
cancer in the state, but we also get the vital statistics data and we also get the
patient discharge abstract. So we can calculate
comorbidity scores and we can actually look at what kinds
of care patients receive. Not only that, the
Cancer Registry gives us the opportunity to look at whether or not patients refused care, because that’s the other
argument that we get when we talk about disparities. “Oh, well yeah, you know
that’s just patient choice.” So we can actually look at that and, in colorectal cancer,
there’s only 2% of patients who refuse, for example, chemotherapy. We still gave the hospitals credit for recommending that
they get chemotherapy. So what we’ve done is build this platform that is going to be
based on California data. So it’s all sort of
contained within the state, which means that we can distribute it back to the hospitals actually for free. And why does that matter? Well, because there’s inequities amongst the resources that hospitals have. So a number of hospitals are
involved in what’s called The Commission on Cancer
quality improvement program. It’s the largest national cancer quality improvement
program in the country. But it actually costs money. There’s an upfront outlay of
several thousands of dollars and then you have to maintain a registry, staff and data, and make sure
that you’re collecting data in a way that is certified by the COC. What that means, is in
California only a third of the hospitals are
involved in the COC program. And the two thirds that are not involved tend to be high Medicaid
hospitals, which is where racial and ethnic
minorities cluster for care. And so, not only are they
not able to track their data, but they’re not able to
actually intervene on it. And so right now what we’ve got is a system that can deliver
back to the hospitals in an anonymized way. Here’s how you’re doing
on NCCN guidelines. Here’s how you’re doing on COC guidelines. And we’re starting with GI cancers and then we’re gonna compare
you to the rest of the state. And you can’t see who
you’re being compared to, you just know it’s all
the other hospitals. At the bottom of each page of each report, the hospitals have an opportunity, and I think this is uniquely not American, we’re not highlighting the low performers, instead we’re highlighting
the positive outliers. And then we’re giving
the positive outliers an opportunity to tell
everyone on this platform how are you doing what you’re doing. And the reason it’s important
that it’s anonymized, is this kind of concept that I’ve sort of been
thinking about a lot recently, which is, low resource settings are often the most resourceful
settings (chuckles) because they’ve gotta get
things done with less. But what often happens is, when we come from high resource settings, we look at the low
resource setting and say, oh we’re not gonna do that
because, oh it comes from there and they’re patients are like this. And there’s sort of an
arrogance that goes with it. So when you anonymize it,
you take all of that away and you just have the simple question, can we look at this
intervention in absolute terms, can we adapt it and
adopt it to our setting? So where we are right
now with this process is the platform is actually built and we’ve been talking to the Office of Statewide Health
Planning and Development. They’re very, very interested
in disseminating it across the state. So we’re now looking at
the technical aspects of whether or not they have the staff and the technical expertise
to do all the ID management and the privacy and the logins and stuff, and the trouble-shooting with users. So, on the ground, we have
the UC Cancer Consortium, which has five national NCI
Cancer Centers across the state, and we’re all networked into a network, a consortium we’re called. And so we’ve got four out
of the five UC systems who have agreed to use this platform and then at UCSF, what they’ve done, is they’ve actually guaranteed that four of our partnered hospitals, because big academic
institutions are buying up other hospitals or putting
their names on them, so four of the hospitals in our Accountable Care Organization are now going to be effectively
forced to use the platform. And the reason that UCSF
was interested in doing that is because they know that
what that is gonna mean is that those hospitals have
to come together with UCSF and talk together about how patients will not be lost or
fall through the cracks because they’ve had one part of their care in our system and are going outside to have the rest of
their care, for example. So I’m really excited about this because it’s effectively doing what I call making the system eat itself. Because the hospitals are
gonna get better reimbursement for higher adherence
to evidence based care and for better outcomes. I don’t know that they
care about disparities but in doing and pursuing
evidence based care and higher rates of delivery
of evidence based care, they’re going to end up
having a positive impact on disparities whether
they like it or not. (audience laughs) (audience applauds) – So, good evening everyone. I am extremely excited to be
here amongst friends and peers and folks I follow on Twitter. (audience laughs) Let me get my slides up. If it were to take the time to thank everyone involved in this program, it would honestly take five
minutes of my 15 minutes, so I’m not gonna do that, so no one be dinging me for my time. But, literally, I want to thank all of the people involved in planning. What you’ve heard today is that colorectal cancer’s a problem and the burden of disease
is not equally distributed. And so there’s, if we look at geography, there’s certain areas in
the U.S. that are hot spots that have a higher mortality
rate in colorectal cancer. If we look at race ethnicity, we’ve seen some of rates
and the incidence rates and mortality rates, we’ve discussed that. If we look at educational attainment, we’d see almost a dose
dependent relationship, where those who have less education are more likely to die
of colorectal cancer, and so on and so on. And there’s definitely some
gaps in our knowledge base. We still lack data and understanding, particular of sexual
and gender minorities, we don’t have much data on that. We don’t know what disparities lie there but we can count that
there are some disparities when you look at those populations. We also know, and this was
highlighted in the talks as well, that there are certain
groups that are more likely to under-utilize care or to not be recommended care. And Durado and Kim both highlighted that. And I would like to submit to you today that, like Kim said, it’s
a system level problem but I also I believe it’s about the aim. So it’s a system level problem but it’s also an individual level problem. And I want to submit to you
that, regardless of what you’re. Oh, thank you. Regardless of where you practice, what kind of work you’re engaged in, you can’t afford not to
be engaged in this work And that it’s gonna take all
of us to come to a solution. I think about, actually, as I was walking in, I had the pleasure of
meeting the current fellows. And I was talking with one
of the fellows and she said, “You know, it’s so cool
that we had this discussion, “that there’s subspecialists
who are engaged “because often subspecialists
either aren’t at the table “or they don’t wanna be at
the table or just not there.” And that’s true. Oftentimes, particularly those of us in subspecialty medicine, we may not be at the table for
where the decisions are made, policies are being recommended, and so, for me, it’s truly an honor, but also, I hope that through this talk, you also can see yourself in ways in which you can get engaged, regardless of what you
do as a professional or as a aspirational career. So one of the things
that Kim just highlighted were the social determinants of health. And we know that those
are the kind of structures that impact care, impact receipt of care, impact actions,
recommendations, et cetera. And for those of us who
are in clinical medicine, sometimes we like to think
that we influence largely the outcomes of those
whom we see in our clinics or elsewhere in the kind
of healthcare continuum. But the truth of the matter is, the healthcare setting is
only responsible about 10-20, depending on which paper you read, 10-20% of the health that people have. And so it’s largely those things outside the walls of our clinic, outside those walls of our
hospitals, that influence care. And so what I’d like to
submit to you is that, regardless of whether you’re a clinician, scientist, social worker, et cetera. And, forgive me, if I went down the list of everybody’s profession here, that would take another five minutes. But it’s important that we all be mindful of the social determinants of health and how that influences
the care of our patients. Just to give you a little
bit of background on myself and some of the work that
we’re doing at Ohio State, so one of the things that Kim
very eloquently highlighted, is the impact of systems. So creating structures by
which you can help people and even, Dr. McCleary, you highlighted how in your example and given
the Delaware experiment, how they created a system
even at a policy level to help people navigate
beyond individuals, navigate barriers that they might have at the individual and community level to get screened and then, obviously, have their mortality and incidence rate impacted because of that. The other thing that I think we all have to be engaged in is, one of the things that I’ve
been more thoughtful about throughout my experience
here in the fellowship and then even subsequently is, well, what’s my role as a
clinician in influencing housing? What’s my role as a clinician
or physician, scientist, in influencing education? What’s my role as a physician in influencing structural racism? Or implicit bias? And I think to ignore that
is to turn a blind eye to a problem that we can influence. You know, I think about
our former president, President Obama, and one
of his famous quotes was, “Change will not come if we wait “for some other person or some other time. “We are the ones we’ve been waiting for. “We are the change that we seek.” And so you can’t leave it to someone else to determine who’s gonna
be the social worker to determine where this
person gets housing. Why not be proactive in that? A couple of things that
we’re doing at Ohio State that I’m actively involved in is one thing that I will lead
is a healthy community center. So this is actually, we went to the community and we said, “What kind of things do you need?” And this is a disparate community, high-end for mortality, high cancer, high hypertension, high diabetes, and we held these multiple fora and we said basically, what do you need? This is not a research study, this is actually just trying to figure out how we can better help you. So we’re not coming in to just do a research questionnaire and then leave. And they said, We want information about
how to lead healthier lives. How to eat healthier,
food access is a problem, food deserts is a problem. Can you help us here? And so our health system
purchased a building that was an old library
and we’re turning it into a healthy community center where the focus is food access. So that’s an example. And we’ll have teaching kitchen, we’ll have conference rooms, we’ll have a local market where people can get free fresh produce, partnering with the Mid-Ohio Food Bank. We’ll have a local retailer
who’s selling vegan products from there at below market rate. But that’s an example how, you know, I never would of
thought being a student, being a resident, being a
gastroenterology fellow, that a gastroenterologist would be leading an effort to actually have
a healthy community center. That’s not in the job description
for a gastroenterologist. (audience laughs lightly) So I want you to think about that. The other thing is, we have a Center for Cancer Health Equity. and really our charge
is to think about ways that we can not only help
change the trajectory of those who are engaged
in cancer screening, those who are knowledgeable
about cancer prevention, also increasing in clinical trials. And so I don’t have
knowledge about every culture and every population that we have. We’re actually quite diverse. We have the second largest
Somali population to Minnesota, we have a large Bhutanese population, large Nepali population. And so we actually, through our Center For
Cancer Health Equity, have community health workers that help us in those communities. And that’s helping us to change the face of those who are coming
in for clinical trials. And why is that important? Well, you all know that it’s hard for clinical trials to be generalizable if the people who are
enrolled in the trial do not reflect the population. And so we’re having all
these novel breakthroughs. Novel breakthroughs in cancer
therapies and immunotherapy but, if you go to table
one for most of the trials and New England Journal,
et cetera, et cetera, if you look at table
one and you scroll down to black or Hispanic, certainly
they’re a minority in there and, so, changing behaviors
or changing structures to try to influence that is
one of our goals as well. And what does that look like? So, I think about that from different ways and, again, I’m trying to give
you a different perspective so you can see yourself and
what you can do where you are. So, from an educator standpoint, if you’re an educator, one thing that you may be able to do is to influence those, especially if you’re in medical education, who are pursuing careers in cancer care. If we look at the face of oncology, the face of oncology does
not look like this room. And so we need more oncologists, more oncologists from diverse backgrounds. And why does that matter? Well the data demonstrates
that, unfortunately, physician concordance matters in outcomes. The data shows that if
a patient looks like me, that patient’s more likely to receive and act upon my recommendations. The data also shows that
if I am a black male with colorectal cancer
or any kind of cancer and I go into a white physician’s office who is an oncologist, I am more, and this is evidence out of Wayne State from Terrance Albrecht’s group, and I go in… My age can be the same as someone else with stage three colorectal cancer, my background medical
history can be the same, but they’re less likely to
bring up a clinical trial to me. They’re more likely to use fewer words. They’re more likely to try
to dominate the conversation. And so that matters. So, thinking about it from
different perspective matters. And just like Kim
highlighted, this is, as we, and you’ve probably seen
this diagram multiple times, those of you who are in this work, the upstream and kind of
downstream description. So many of us, those of us
who are in clinical medicine, we like to think that
we’re having impacts, but really we’re at the point of care after diagnosis or at
the point of diagnosis, but we’re not necessarily
influencing the upstream factors. And I would like to submit that, if we’re going to influence
the upstream factors, we have to be engaged
outside of what happens when we’re wearing our white coat. And one of the things that
Durado was hitting on, particularly as we think about influencing colorectal cancer development over time, is colorectal prevention
starts far before someone gets recommended to have a colonoscopy or fecal occult blood test or a FIT test, it actually starts in childhood. And so what are we doing in our schools, I talked about educational attainment but what are we doing in our schools to actually shift behavior? What are we doing to try to
shift nutrition in our schools? And, certainly, many of you are thinking, well, how can I do all of this? You don’t necessarily
have to do all of it, but being able to point
someone in direction to do it is influential. One of the things we also
have at the Ohio State is we partner with Columbus City schools and we have what’s called
Health Science Academies, where it’s a pipeline from
elementary to high school that is a typically, or traditionally, underperforming school system. Where no one wanted to
send their kids there. And we started this Health Science Academy in which we put clinicians, so physicians, dentists, allied health professionals in the classroom with teachers
to deliver the curriculum and then monitor those kids over time. And we’re still very early,
we’re about five years in, so we don’t have a lot
of outcome data yet, but it’s influencing education pattern, their success with getting into college, and we like to think
more productive citizens. But we also like to think
that we’re impacting their health in doing so
but that’ll be an outcome we find much later down the line. So, as my time winds down, and I really look forward to
the discussion piece of this, I wanna leave you with a story. So I’m a dad. One thing that wasn’t
mentioned in the introduction is that I’m a father of three. I have a four-year-old, a
two-year-old and a six-month-old and story time is a cherished time for us. (audience laughs lightly) Story time’s a cherished time for me, ’cause that also means that
they’re going to bed soon. (audience laughs)
So that’s also a very exciting time for me. But, this is one of my favorite books, it’s not one of their favorite books, but one of my favorite
books to read to them. And it’s called “What Do
You Do With a Problem?” And it tells the story of a young boy who one day recognizes he has a problem. The problem is captured,
is pictured or depicted as a black cloud. And the more he tries to avoid this cloud, the larger the cloud becomes. He tries to hide behind things, he tries to run from it and the larger and
larger the cloud becomes. Until, one day, he decides he’s gonna turn towards the cloud and face that cloud. In the book it says he say discovered something beautiful about it. The cloud, the problem,
contained an opportunity. And I submit that to you. Like I said, Obama said, you know, we can wait for some other
person or some other time, but this problem won’t
go away until we face it. And it presents for all
of us a great opportunity. Whether you’re in clinical medicine, whether you’re a physician,
scientist, a researcher, social worker, patient
advocate, patient themself, you have tremendous
opportunity to make an impact. And the last story, and with the last probably
two minutes that I have left, there’s a book called “Swimmy”. Anybody ever read “Swimmy”? No? “Swimmy” tells the story of a fish. This was a black fish
in a sea of goldfish. And Swimmy was swimming
all across the ocean and, one day, a big tuna came
up and all of his family, so he’s alone and he’s
searching for another family, another family of goldfish. And he was different. He was the black out of the goldfish. And one day he came
across a school of fish and he said, look guys,
there’s this big, scary tuna. There’s this big, scary problem coming in and we cannot beat this thing
unless we come together. You know, one of the things that I see in academic medicine is we’re so siloed. And I’ll speak for myself, ’cause I know that doesn’t
apply to anyone in this room or any health system represented here, (audience laughs) but we are a large health system and we have such a large university or a land-grant institution, one of the largest
land-grant institutions, and there could be someone working exactly on what I’m working on in
the College of Social Work or at the Law School and
I have absolutely no idea. We’re working in such silos. If we are going to impact the trajectory of colorectal cancer amongst young adults, those less than 50 that
Durado was highlighting, those greater than 50, if we’re gonna influence screening rates, if we’re gonna influence our
systems, like Kim talked about, it’s gonna take all of us
working together to do so. And certainly we have all
different roles to play in this but, I encourage you, when
you leave here tonight, think about how you can interact with somebody across campus. Think about investigating with
somebody at your institution is doing outside of your
discipline to attack this problem. But think about what you can
do outside of your white coat, outside of your role, to
influence the trajectory of colorectal cancer in the United States. Thanks. (audience applauds) – That was awesome. So I wanted to, first, I’m sure there are a lot
of questions and comments, and maybe just start off
by asking a key question, which is all of this has to
be resourced in some way. So Dr. Brooks, Dr. Gray,
Dr. Rhoads all spoke about ways to attack this
problem, ways to intervene, that to me requires resources. Whether it’s national level
resources from the ACS, research level resources for Dr. Rhoads, and Dr. Gray, you’re institute
purchasing a building, that’s amazing, but how
did you get to that point of getting the resources and
marshaling those resources towards tackling this problem of inequities in colorectal cancer? – Well, I’ll start. American Cancer Society, as I said, we teamed with Centers
for Disease Control, more than 20 years ago, to establish the National Colorectal Cancer Roundtable. So CDC brought some resources, American Cancer Society
brought some resources, over the years, those resources
have actually dwindled as the organization has grown. One of the things that I’m
actually most impressed about with regard to the 80% in 2018 campaign, not necessarily pleased but impressed, is we had no money going
into this campaign, we had no new allotment of dollars to put forth this national
initiative and yet, through the partnership with
all those 120 organizations, each of them reaching out
to their constituents, through active involvement from
the American Cancer Society, fortunately the American Cancer Society, just prior to beginning that initiative, we actually went through a reorganization and recreated a veritable army of public health professionals working in communities,
working with hospital systems, working with primary care systems, working with federally
qualified health centers, and those folks really,
they drank the Kool-Aid, and they took took that message out there. But it was really very much a hands-on, field level, organization to organization, community to community
initiative and effort. So, certainly, big dollars are helpful but there’s a lot that you can do with a relatively small investment. I think that that’s really
important to keep in mind. – One of the committees, a sub-committee of the community advisory board
that sits within my office is the Faith Communities Committee. And what I always say is, “You can’t work with the Faith Committee “if you don’t have faith.” (Nadine laughs) So the work that I showed
you has been funded through grants that have sort of popped up out of sort of happenstance. I mean the platform was
built on some of those end-of-the-year funds that the California Department of Public Health said, we gotta get rid of some funds. – Mm-hmm, yeah, – We’re gonna close out our books. But actually what I
wanna highlight instead is the first health
services research paper that I did that kind
of led me on this path, which happened while I was a fellow here, and I remember wanting to get the California Cancer Registry data but not having any money and calling the California Cancer Registry and first explaining that
I didn’t have any money. So that was (laughs lightly) the end of the first conversation. (laughing) And then in the second conversation, I remember coming into the office and Jean Raphael was one of my classmates, one of my co-fellows and I said, “I just wanna get this data.” And he was like, “You should
just call them again.” So I picked up the phone and I said, “I don’t know if you remember me.” I introduced myself and the guy said, “Oh yeah, I remember you,
you’re the one with no money.” (laughing) And he said, “But I’ll give you the data.” So that was the beginning of, not only the beginning
of my use of this data but it was actually the beginning of the California Cancer Registry beginning to distribute the data in a linked way with the discharge data and the vital statistics data that they hadn’t done previously. So I feel like there
aren’t always gonna be the right resources at the right time, but I think if you believe in the thing that you’re working on,
you’re gonna open yourself to stumble into the right people or people who have resources or interest who are gonna help you along that path. – And I think too, as I think about our work
around the PACE program, which is kind of a grassroots effort, it started with an idea. And I remember a class that I took here, a leadership class I took
as a part of the fellowship, I’m not sure if it was Alden’s lecture, but they were highlighting the work of a leadership guru, John Kotter, who was talking about pros for leadership and one is being able to
create a sense of urgency. And so, I remember, when I
first started Ohio State, I went with this idea of the PACE program and the idea being that we
wanted to be able to offer free screening to those who
are uninsured or under-insured, and then be able to see it through. If we identified a cancer, to be able to get that
person treated, et cetera, without them having a
financial burden of it. And it seemed unrealistic, but going into it with
my faculty, my peers, nurses, and then
leadership of the hospital with that sense of urgency and a plan, some return on investment, like you were talking about earlier, information, we made it happen. So really it’s an initiative
that was born out of no money, just me cold calling or
approaching my colleagues and saying, “Hey, every Saturday.” Sorry, every Saturday in March, Every Saturday in March, It was Colorectal Cancer Awareness Month. “I wanna have these free screenings. “Will you donate your time?” Meaning we had to waive professional fees, I had to call Pathology,
“Will you donate your time “to run these specimens,
these polyps that we find?” I had to go to Leadership,
“If we find a cancer, “can you get this person treated.” And, literally, all these
were just calls, cold calls. I called Walgreens, “Walgreens, look, this is
what we’re trying to do. “Can you donate prep?” “Yes.” So a lot of it was, you know, certainly there were nos, but I kept calling until
I got a yes from someone. And it was just trying to figure out ways to make it happen without having money. And so certainly that has been a benefit. And I think too, you know you all are in
different stages of your career, but just being good advocates and learning how to be good advocates
for what you believe in. And I think I’ve just been blessed to be in an opportunity,
in a setting in which I had the opportunities to
influence some decisions, and I think it’s been
just a lot of opportunity. Like, for example, Ohio State, one of our strategic plans that came out about a year or two ago was
around healthy communities. And so the focus is healthy community, so I try to pitch myself
or put myself in position to be an influencer in that space and trying to talk to the right people. So you all have that same ability and there’s nothing special about me, besides that I’ve just taken advantage of opportunities that have been present. And so, similar to buying that building, you know they were gonna
buy the building regardless, but I was in a position to influence how that building was used, so… – Spectacular. I want to open it up to questions about the resourcefulness, the creativity, the persistence that you’re hearing here. Yes? – [Audience Member] I just came here, the American Psychological Association and, you don’t know, I
wanna give you a group hug. I will need to do that.
(laughing) But what I want to say is
that my initiative this year was to be a citizen psychologist and all of you are citizen physicians. And I wish you would involve psychologists in some of this work because,
when the idea was created, people say, “Where did it come from?” Well, I’m a woman of faith and I said “It came from a higher authority “and let’s just move with it.” But it’s just been so
fascinating to hear you talk because you are the physician side of what I created and the psychology side that was already existing. And so now there will be
awards at the state’s level and at the division levels
for all these people doing these wonderful things. So I just thank you from
the bottom of my heart for affirmation that people do good things not because of them but because of their
caring for other people. And I’m hoping at some point you will involve a psychologist who can collect data around
the different patterns of people accepted who
may all be demographically appearing the same but there
are different kinds of things that are going on that you could pinpoint how you need to address that. So hats off to all three of you. You’re just wonderful. A group hug to you. (laughing)
– Thank you. – Another question. Yes? – [Audience Member] Okay thanks. So this is going to be probably
a complicated question. But thank you all for your remarks and you know that you all sort of said a little bit opposing yes, but comments. You know, Dr. Rhoads said
it’s really a community and population health issue. And Dr. Gray said we still need to work on the social determinants of health. So I’m gonna paint the picture here. So I don’t know about all of Boston, but in the partner’s hospitals, we have really intense
population health management and all primary care
doctors are incentivized and care about getting to
all of our quality metrics. And, in addition, we have
98% insurance coverage here in Massachusetts and close to 100% for African Americans. But the head of Quality Partners shared the data by race of
our colorectal screening rates and we do have a difference by race between whites and blacks. It’s probably only about
a 10% difference, maybe. I don’t remember exactly. 10 to 15% difference but
there’s still a difference. And I still find, as a PCP here, that when I ask black patients
about getting screened, most of them say yes but some of them have social determinants of
health that make it hard. They can’t take time off
from work in some cases and will get penalized. Or, in some cases, have no transportation and have no way to get home, which you know is a requirement. So there are both sides of it and I guess I wonder
what sort of strategies you can think of that would
make us look more like that integrated system in California, who will remain unnamed.
(laughing) But also, (laughs) maybe those patients
are more like each other than our patients, which
go from the very, very poor and insured to the very wealthy. And it still is harder to get
the very, very poor screened, even when all the things
are there that might make it possible from the
health care side of things. – Yes, that was complicated. I think, and I’ll hit it
from a complicated angle, I think one of the things that our system is trying to work on, because we are not as developed
as a integrative system like the one that shall be unnamed. But we have an accountable
care organization where their metrics. We have separate metrics
for our medical system, and so trying to align
those is one avenue to take that will allow us to identify
those in highest need. I think the other thing too is that our system has
recognized the importance of identifying collecting information on social determinants of health and we are very much
in our infancy in that. But being able to see those people. When I say see, not literally
see them in the clinic, being able to identify
what their problem is. I shouldn’t even say there’s a problem but what their area is to receipt of care or, in this case, colorectal
cancer screening is huge. And then not only being able to identify but then to act upon it. I think you also speak to a larger issue. So you mention as a
primary care physician, people may not be apt to receive your recommendation for screening, additionally there’s still
primary care providers who aren’t recommending it period. And that’s the number one predictor that someone will get screened, is that their primary care
provider recommends it. So I think trying to
set uniform standards, that’s something our
system is trying to do too, because we also have primary care networks like CPC Plus, et cetera,
that they are reimbursed for. And I think that’s huge. So I think trying to tackle
it from different ways. The other problem that’s
much harder to address, I think even taking it
more to an individual level is, you know, if Adeyu,
one of our current fellows, she’s a former gastroenterology fellow, now one of the Commonwealth fellows, if she sees a patient,
she’s gonna have 15 minutes for a return probably
or 30 minutes for a new. And sometimes, at least
the argument is that, that’s not enough time to address these social determinants of health or other things that happen outside the visit for which they’re seeing you. So that’s part of the problem too. So it’s a system level problem, it’s an individual level problem, with some providers not recommending, for whatever the issue
is, if it’s implicit bias, and then it’s an integrated
delivery problem too, if the system does not allow for tracking of appropriate data, sending out, like that system,
they send out FIT cards. They literally mail it out. Currently, I don’t have the capacity to do that in my health system. They don’t mail out, just
automatically when you turn 50, they don’t mail ’em out to people, so it’s dependent upon the
providers to place the order. So there’s opportunity I
think at all phases of this. – Yeah, I wanna echo that. My purpose in advancing this idea that the social
determinants then feed into what kind of care you end up getting is just to make the point
that we spend a lot of time, and I think its appropriately spent because the attention wasn’t there before on the social determinants. But what I also sort of
want to do is not neglect the systems of care who
can take responsibility and where there are
opportunities to lever power, which is effectively around
reimbursement and money. The first paper that I did
while I was in the fellowship, I used to say was about
high Medicaid hospitals. And people would get offended, like I was saying, well
the high Medicaid hospital doctors are somehow worse doctors. And what I was really saying
was, high Medicaid hospital doctors do the best they
can with what they have but their resources may not be enough, specifically for cancer care. And so that really kind
of got me understanding this concept of you
practice as your setting tells you to practice. I mean I was trained
a certain way at UCSF. When I joined the faculty at Stanford, I started doing stuff, I was like, am I supposed to be doing this? I don’t remember learning this. And it’s just because of
the cultures that are there. So what I’m really trying to advance is not to ignore the social determinants but rather to also not ignore the place where we actually can make
a change around equity, where we can sort of move and drive the way care is delivered. And what that really means is
actually changing the culture. And that’s what this
integrated health system, as I said, through my
training, I actually work there and I know that there are
certain things you can do and there are certain things you can’t do. And so what you’re really
balancing in that setting is if you take 100 patients and you provide appropriate
care based on stage and other things, you’re
gonna get a bell-shaped curve. So 97.5% of them are gonna
do pretty good or great and 2.5% are not gonna do that well. And that 2.5%, if that’s
your family member, you want them to get personalized care, not population health. And I think that’s a point of tension that we’re gonna come to. But the reason that they
get the outcome they get, is ’cause they just, okay,
whatever. We’re doing this. and it’s not precision medicine. When you look at systems
that have a lot of variation, you get a lot of variation in outcome. – [Audience Member] Can I just follow up? What I was trying to say, I’ll try to say it little more clearly, is at Partners Healthcare, which is Mass General Hospital,
and the Brigham and Women’s, most people are insured and
we are highly incentivized to do our very best to recommend screening for every single patient and doctors are bonused on doing it. And, again, most people are insured, but still not everyone’s getting screened. So I do think that there is
a window for something else. So, for example, what Dr. Gray said, even if I have a half
hour for a followup visit, I have to spend a lot of time convincing some black
patients to get screened. Some of my colleagues may not
have the same level of trust, nor the same motivation
to spend 10 minutes convincing one person to get screened. So maybe a community intervention, where they see black doctors who care whether they get screened might
make us get that 10% higher. So it seems like there may
still be some personal factors that might make a difference. – Well, I–
– I’m sorry, go ahead. (laughing) – Well, I think one of the challenges, and I don’t know how
Partners handles this, is our tendency to put responsibility on the physician for everything, and I will say, and I’m just gonna say it, Kaiser, Kaiser, that’s what I’m talking about. (laughing) Kaiser of Northern
California, two decades ago, decided colorectal cancer
screening was important and they have systematized
it in a way that is admirable and that we would love to
see replicated everywhere. Because everybody takes that seriously. Everybody knows they
have some responsibility. The person who checks
them in at the front desk. When you go to the eye clinic, you go see the eye doctor at Kaiser, they’ve got signs asking, “Have you had your colorectal screening?” Or they’ll look in your
medical record to see. And, if not, the eye doctor
will make a referral for you. But they also, as Darrell
said, they mail out FIT kits. Well just the whole idea
of using stool testing, ’cause they started off as
flex sig and colonoscopy and that was it and
they just hit a ceiling. So offering options. They have looked at this
and worked and invested and they are probably the
best system in the world at doing this because
they took it seriously and everybody has a role to
play in making it happen. – Can I just, I just wanted to add that the problem that you’re talking about I think is, so you do the system
piece and then you find, okay, where are the fine
tuning that we can do? And my innovation, this is
another of my new lines, my innovation is to
actually insert more people into the care process rather
than inserting more technology. So we were just talking
today about sort of this clinical trials problem and, if you think about it from
an operational perspective, it’s like, well yeah,
I’d like to invite you to a clinical trial but
it’ll take me 30 minutes to describe to you what the trial is before we get to your questions. So what needs to happen,
is there needs to be an extra clinic room that is
empty that is just for that and there’s a person who
sits in that clinic room whose job it is to just do that. So for the 10 minutes that
somebody doesn’t wanna spend convincing somebody to get screened, there’s a room where people get convinced. And I’m not saying that healthcare systems are rushing to insert more people. But I think, if folks are willing to, and this is where you get
to get outside your silo and you get your health economics people to help you actually
run some Marchov models and estimate how much
money would they save if you did whatever it
is that you’re doing. It probably costs less to hire a person who sits in that one clinic
room to make that happen. So I think that’s the fine tuning piece. – [Ensia] Hi, good evening, My name is Ensia Fisher, I
have a pretty long title, so me and my supervisor, Sonja, we are here from the, oh, God, sorry, I’m kind of loud. I work for the Boston Healthcare
for the Homeless program and my title is Cancer Screening Patient
Navigator Care Coordinator and basically I do what
you just suggested. I am that buffer between the
physicians and the people, where I go out into the community, specifically the homeless and
substance addicted community and I rally for them to
get cancer screenings. The three cancer screenings
that I am in charge of trying to sign people up
for are for colonoscopies, mammograms and also pap smears. And the lowest numbers, and me and my supervisor
were just talking, the lowest numbers that
we have for screenings are for colonoscopies and
because I am in the trenches and I mean, literally,
and I hate to use this, at my job we like to say Recovery Mile, but it is known as Methadone Mile, I am literally in the trenches, trying to get people that
are on Methadone Mile signed up for these screenings. So I do really truly have more
of a comment than a question and I’m saying this to say, a lot of the times when
I deal with clients, and the majority of the
clients that I deal with are actually Caucasian and then minorities kind of come afterwards. But one thing I notice when
I deal with minorities, specifically African
Americans, Caribbean Americans and also people who speak Spanish and, I will say this,
people of the Muslim faith, the number one kind of
resistance I get from them is the manner in which
the test is conducted. Because there’s a stigma
around, unfortunately, having a test that is going
to be a sort of a anal probe. That is the number one thing, and I just wanted to
point that out to people, because, especially with
the Muslim faith population, they are totally against it. And the problem is, we
do advocate for people to do FIT tests, but a
lot of them don’t qualify for FIT tests because there
is a pre-existing history, whatever that may be. I’ve had clients that will say to me, “Well I don’t want to do a colonoscopy, “I wanna do a FIT test.” I go and look in their records
and they don’t qualify for it because they had some type of determinant that excluded them from that. And, because of that, they no longer wanna do the colonoscopy. So I stay on top of the clients but I don’t forcefully do it, because, one thing I noticed with the population we work with, when it comes to healthcare, because of the issues that
they have with substance abuse, it takes a backseat to their health. And, most of the times, when they come and seek my assistance, it’s usually when they’re
in some sort of pain that is unbearable. And I’m just saying that to say that I would love if your organization, any of the doctors here, anybody here, because we do love having people come and do speaking engagements and just coming to the center and really seeing what we do there because, as you said, I am that buffer. My only job is to sign people up to get those cancer screenings and that also frees up the MDs. That frees up the RNs and the NPs, you know, because their
job is already tough, so I’m able to, and I’m literally in
the shelters every week. And it takes a while,
especially with colonoscopies. With the population that we serve, I notice that it’s all about trust. And regardless of the skin color, whether it’s black, white, green, they have to see you enough to be able to trust you to open up to you. So I’ve had to learn how to be very savvy because I have people approach me that are highly inebriated. And so giving them information
under those conditions, sometimes it’s just saying, “Hi, my name is Ensia, here’s my card. “And just I’ll follow
up with you another day. “This is what I do” And I leave it at that. So I wanted to just kind of touch on that, because I notice sometimes
the homeless population, even though we talk about minorities, we don’t necessarily include
the homeless population, who is one of the biggest
minorities, within that. And it’s really deserving work here. And I did notice that our, like I said, when we said
the cancer screenings, the one that falls in
comparison to every other one is the colonoscopies and a
lot of it is stigma related. And you would be so surprised at how many African American men tell me, “I’m not going to.” And, you know, the
language is very explicit, and they tell me, “I’m not doing it. “No, I wasn’t raised. “I’m not, no this. “I’m not that.” And that’s why I say, sometimes, it’s just more or less though, just kind of building a relationship and just talking to people
and making them understand. And I tell them this all the time, two things, you don’t wanna witness is a person dying from cancer. And I tell ’em it eats
’em from the inside out. And I try to kind of be a little graphic but, like I said, once again, I fine tune what I do to the person that
I’m speaking with at the time. But I’m here and I think
the position that I have is so integral because, like I said, I’m just there to focus on the things that you guys may not be
able to necessarily do within your 30 or 15 minute appointment, where I can follow up with, sometimes I’m following up with patients two months in a row
and, by the third month, I’ve convinced them to get a colonoscopy. So, you know, it is very integral. My background is criminal
justice social work. So it’s very integral
that you do have somebody that can take the time. Because sometimes it’s not
about giving the information, it’s about building that relationship. And one of the biggest things that we do, is we eliminate barriers
to getting the screenings. That’s bus passes, even
getting them a meal, even just giving them
information, letting them know. And I’m actually, and
I’ll end it with this, I do go and do lot of advocacy when I take patients
for these appointments because a lot of our
patients are homeless. And what I noticed a
difference in the disparity in how they’re treated when they go to these healthcare providers, as opposed to how I’m treated
because I have paid insurance. And I do go to appointments with patients because I’ve had patients
come back and say to me, “I’m scheduled for the appointment.” And I’ll say, “Do you
want me to accompany you?” “No, I’m fine, I can get there.” They’ll call me back, “Can you reschedule this
appointment and accompany me “because they are literally,
because they know I’m homeless “or they feel like I’m homeless, “they’re treating me a certain way.” And when I go in there,
things get done right away. So advocacy, advocacy, advocacy, and just being empathetic
and having the knowledge and know how is really critical for getting these cancer screenings and, specifically, with
the colorectal cancer, and I just wanted to say, I think, and I hate to say this, categorically, if you have to break it
down between religion and race, you have to
understand each religion and each race why there are
those social determinants for them not to get these screenings and then try to kind of be that buffer and make them understand
that getting the screening, and, most of the time,
the clients that I have, they’re so scared and they
want to get the screen and they don’t have to go
back for 10 years (chuckles) and that’s the best part. But then, when there’s a follow up, that’s when having good
skills come into play, ’cause sometimes it’s hard
to get clients going back to get the follow ups
if they found something. So I just wanted to say that. And I’m here afterwards if anybody want to exchange cards and information and come and visit the center. Because, I really say this, in this city, what we do in the center that I represent is really integral to healthcare period. Mental and physical health. All right. – Thank you.
(crowd applauds) – [George] Hi, thank you. I’m George Maleen. I’m a fellow in surgical oncology. I train in general surgery at MGH. I’m doing my fellowship at
Dana-Farber/Brigham and MGH. And thank you for this great talk. I’ve been thinking about this issue of fragmentation of cancer care and my particular focus is
liver and pancreatic cancer. And I think one of the
things that really struck me during the three talks was, how do we get to a more
integrated healthcare system? And one of the things that I saw… I went to medical school here, I did my third year rotations at MGH. I’ve been living in this
area now for about 15 years, and there’s a huge discrepancy of the patients that we
treated at Mass General, at the Brigham or Dana-Farber. And those patients are
predominantly white, well-off patients. And so we’re not seeing… And I love Partners and
MGH and Brigham/Dana-Farber but we, and I believe we
provide excellent care, but our system is very limited. We don’t have patients
coming from the homeless or, you know, center work, because they go to BMC. And we don’t have an integrated
healthcare system in Boston. We have a partner system, a BI system, a BMC system and a Tufts
system and they don’t talk. I would see patients
that had a certain cancer which could not come to
MGH from North Shore, which is Partners/MGH affiliated hospital. So, my question is, how do
we create more integrated health care systems that cross boundaries, the boundaries that we have
formed by hospital systems? And I’m interviewing for
jobs and, it’s funny, because I just interviewed
for a Kaiser job. (laughing) And I had no idea of Kaiser. I actually want a academic job. I’ve been raised in academia. I do research, I publish. My mentors are all nationally renowned and I even feared saying
Kaiser in front of them, because, you know, it’s
a private, what is it. But I was just blown by their talk and their healthcare system is literally an entire region of California. And we don’t have that here. So how do we get to that? Because an integrated healthcare system could worry about housing,
can worry about food, can worry about safety. And how can we get in
the next 20, 30 years? Is it Medicare for all? Is it, you know, what is it? Thank you. – Thank you. – So, I’ll take that one. And I just, I’m not a neither, you know, I’ll go more here on Kaiser. I’m not neither confirm
nor deny it’s great. But what I would say about your hesitancy around it not being academic, is that because it is a contained system, they have, I won’t use any expletives but they got a lot of data. And there’s a lot of
opportunities for research and you actually have
to be Kaiser affiliated in order to get access to that data. They guard it very closely. But it is primo data. So, in terms of how can
we create these systems, what I would, I’m not sure. Because what we’re up against
is the issue of market share. That’s why you’ve got Partners and then you’ve got all their affiliates but they don’t work together. It’s actually because they formed Partners in order to negotiate insurance contracts, so they could get good reimbursement rates for all of the hospitals
but it doesn’t mean that they’re all sharing with each other, it was just a negotiating strategy. For cancer care, the Affordable Care Act actually had built within it
a few different strategies for reimbursement for hospitals and one was Accountable
Care Organizations. And the other one was bundle payments, which is turning out to not work so well. But the Accountable Care Organizations were the path forward. Now it’s kind of in question what’s gonna happen with the ACA? And the other part of that is, all that the Accountable Care Organization description said was about size. And so what you would see is a
number of different practices jamming together so that
they have a big size and that they can claim, ’cause you’re supposed
to claim a population that you’re taking care of. So, you’re big enough,
but John Ayenian, I think, wrote a paper a while back where what they found was that there were more differences inside of an Accountable Care Organization
than if you compared one Accountable Care
Organization to the other. And it’s because you smash
together a bunch of practices but didn’t actually put
any administrative thought into, how do we practice
together in a streamlined way? And Kaiser really is the model
right now for how to do that. And what I think healthcare
systems need to look at is that not only is Kaiser doing that, but they’re making money doing
it because it’s efficient. And they’re, to just kind
of put an exclamation point behind that, they’re
community benefits budget is one B with a billion dollars, which means they have that
much revenue over expenditures that they can spend on other things, like big campaigns that
keep people thinking about, how can I be healthy? How can I get outside? Should I eat more blueberries? (laughing) So, you’re right, that’s
the direction we need to go. I would recommend that you, if you’re interested in
kind of moving that agenda, either partner yourself up
with some MBA type people and also some health policy and healthcare administration people, because they’re the ones
who are gonna understand the structures that have to come together. And what you could contribute is actually have a streamline that care. Because that’s the piece
that’s often missing as we work in silos. And then I would just
say that in California, Sutter is our second-largest kind of kind of integrated system
that is trying to move toward a Kaiser model. So, if payment streams and reimbursement do start to focus on
Accountable Care Organizations, you will see places try to get
themselves more integrated. But, short of that,
you’re not gonna see it, because healthcare is a business and so you have to think
about who’s paying for what and, whatever intervention
that you design, hopefully you’re reducing
the cost for someone, and that’s who you go to
to sell your intervention. – Was there a question? Yes? Okay. – [Mia] Good evening, I’m Mia Chandler. I’m one of the Commonwealth
Fund fellows this year and I had a question,
out of curiosity for you. And it was sparked by
our collaborator here in the march for equitable
progress in healthcare mention. She talked about a lot of these
cultural factors as barriers but where my mind went was thinking about some of the technology
that I’ve read about that may still be in it’s nascent form with respect to colorectal screenings. I wanted to know if either
of you had any insight on how that’s progressed and where it is? So, what I’m specifically referring to is having read about pill-size devices, and you may have spoken about that already when I was in class, but pill-size devices that can be fed to the gastroentrologist. And I imagine that could even progress to the robotics of snipping a biopsy. So where are we in that and
who’s funding that research for people who are in that field? – Well, there is actually
what’s called a pill cam that is used and it has
a really, currently, very narrow indication for
colorectal cancer screening. It is, I don’t know that
there’s any research being funded on it, other than by the company
that makes it, actually. It was initially designed
for use in the small bowel because there’s no way to
get an endoscope in there. So, for the small bowel,
it works pretty well. For the colon, not so much, because the colon is
usually a pretty dirty organ and you don’t get a lot
of nice clear pictures. That’s why we do the prep for colonoscopy, so you get those really clear pictures. The pill cam technology is improving, but I don’t know that anyone recommends it as a first, second or even third line colorectal cancer
screening tool right now. There are other technologies, and I think I eluded
to virtual colonoscopy, or CT colonography, which
is a radiograph study which has total replaced barium enema. But that also requires a prep. It doesn’t require insertion of a scope all the way through the colon and it might be something
that might be acceptable to some of your patients
if it were available. And that’s actually, I think, pretty well-proven technology and useful. But, it and any of the other
non-colonoscopy technologies, again, the final issue is, if
something abnormal is found, you’ve gotta undergo the colonoscopy. – And I think too, as you’re
thinking about technologies, I encourage you to, one very big movement is
artificial intelligence or deep learning or machine learning, however you would like to describe it. And certainly one of
the leaders in that area is in the field of
gastroenterology, in that space. So one of the concerns that, I was in a forum where they
were talking about this amongst different leaders
in artificial intelligence and what’s not clear is the disparities that might emerge as a
result of its uptake. So, if we think to, and I’ll take you back
to your sociology lesson of the fundamental cause hypothesis, and you think about, as new technologies or new innovations are coming up, who is most likely to benefit from them? It’s not gonna be the underserved, it’s not gonna be the uninsured,
it’s not gonna be the poor. It’s gonna be people who
have the money to afford it. And so, you know, certainly I expect that. And there’s different uses
for artificial intelligence and deep learning, but those of you who are in that space, where you intersect with… And this is going back to what
I was talking about earlier, think about your intersectionality with other specialties on your campus, if you’re in academic medicine
or your business partners, those who are in computer technology, because they need you in the room too to think thoughtfully about how these technologies
are gonna be uptaked. But look into artificial
intelligence in this space. – Well and actually,
one other new technology that was I was remiss in not mentioning, is there is actually a
blood test that is available for colorectal cancer screening. It doesn’t perform
exceptionally well right now but it’s approved by the FDA for patients who refuse all
other kinds of screening. How they document that, I don’t know. Its uptake again has been very poor but I think that that’s
really just step one, and we are, I really believe,
in the next five years or so, that we’re gonna have a blood test that is potentially an
effective screening tool and that changes things dramatically, but we still come back to, if you have abnormal
findings on that blood test, you gotta go see Darrell.
– You still need the scope. – So, the colonoscopy, I think,
for the foreseeable future, is gonna be kind of our bottleneck with regard to really
providing the full range of that critical care for folks. – I got a question. My name is William, by the way. I since moved from being a pre-med to a first year medical student on the bottom of the totem pole. (audience applauds) – That can be–
(audience laughs) – That’s what it is. I have one question, I’m
sure like my peers back here probably have the same thing. A lot of the conversations
that are being had are pretty high level. And, just as starting
first year medical students and seeing what we’re learning in class, particularly like the neuro-technologies. Do you have any insights into how we can think about these things and how we can integrate what
we learn in the classroom to actually thinking about
it more on a systems level, and how to integrate that in the future, when we’re actually
physicians and practicing. What are the things we
should be thinking about now and doing to make sure
these problems are solved? Thank you. – Great point. Thank you for that question. I am, in full transparency, I’m not familiar with the curriculum here, so I may say some things
that you are already doing. But, if not, I would
encourage you or your peers to champion development of curriculum that highlights such things. So, one of the things that we
heard from our students at OSU is, hey, we want more
exposure to understanding health disparities, how to address them, what health equity means, how we can be more
engaged as a student body? And so, one of my peers
came to me and said, “Hey, do you think you
could lead such a course?” So I’m in the process of developing that for this spring course. So your voice matters. I say that because your voice matters and change happens because of that. You’ve heard Kim also mention
research that she does. As a medical student, I encourage you to get
engaged in research, even if you have no
inkling of being involved in research as a career aspiration. And because it helps to
you to think critically about situations, about
circumstances that you may not have thought about before, whether it be what we’re talking
about, social determinants, or even at the basic science lab. And so getting engaged
in research with people who here I know are doing
fantastic work in this space, who can help you to be an
influencer on these issues. – So I would echo the idea that
you have the power right now and it’s because you’re paying tuition. (laughing)
Once you’re being paid, “Ah, you want that? Too bad.” For myself, I took a health policy course, it was actually required as part of my medical school curriculum. But I held out for that
program, I was on the wait list, because I wanted to take health policy. Why I knew that, I don’t know. But I guess what I would say, and I don’t know how
tight the curriculum is, especially in the first year, I mean there’s probably
no time for anything, but try to take a look
around, and, in particular, I don’t know how you’re
affiliated with Dr. Reid’s office, but be looking for those
opportunities to get outside of just this sort of medical
school curriculum. Because where the action is, for example, one of the things that I ended up doing, is I went and worked for a
community-based organization that was focused on African
American women’s health. And so then I ended up
meeting all these other people who were doing things outside of medicine. So I feel like everything that you said, I would be over there trying to find out how can I get involved, even if it’s just a couple
of hours or an hour a week, because that’s where you’re
gonna start meeting people, who are gonna lead you to other people, who are gonna lead you to some
questions that will be unique because they’re based on
that sort of ripple effect of meeting people outside
of this narrow focus and scope of what is
the first couple years of medical school. – Yeah, actually I was
gonna make the same point about trying to look out in the community and see where there are organizations that you may have a personal interest where you would want to invest some time in interacting with folks outside of the medical environment,
I think is very helpful. Within the medical environment, again, I don’t know how much focus is placed on this here at Harvard. When I went to medical school, we had an epidemiology class
that was one hour a week for, I don’t know, six weeks or something, and so you just learned as much as you needed to and then moved on. It wasn’t actually until I, and I practiced medicine for 15 years, then when I came back
and did my fellowship, and took a real epidemiology class, I recognized how much I
did not know (chuckles) and how much good information there is. And, also, learning how to
really read a medical article, a journal article, because it’s easy just to king of gloss over
and look at the abstract and look at the results
and the conclusion. You need to turn to table one,
like Darrell talked about, and does this even apply to the population that I serve or I want to serve? So, those are a couple of things that come immediately to mind for me. – One of the things I would add about getting out into the community now, and this is something that I experienced in working with the Bay Area
Black Women’s Health Project, is that they accepted me as a layperson. And, once you cross that
threshold of you’re a doctor and now you’re attached
to some institution, that level of acceptance and opening doors and telling you the secrets and showing you where they
think the problems are kind of shuts down. The interaction changes. And I feel like that was a real benefit to the rest of my career and
sort of how I think about how care is delivered
and how I think about how I as an individual, I
myself, interact in that setting, was very influenced by the experience working in the community
and seeing how the community was perceiving the institution. – I think that was a perfect
question to end our forum, really looking towards the future. I know there are many other–
– We can’t squeeze one more question in?
=Questions, so we’re going to maybe ask your question if we can. Okay.
– Short question, short answer – [Mark] Okay, I think this will be relatively short. First of all, again, thank you, panel. My name is Mark Kennedy. I’m with the Boston
Public Health Commission. This question is for
Dr. Brooks specifically and I certainly would
welcome any other comments. When you started your comments, you talked about the issue of age. You talked about diagnosis in a population younger than age 50, which is why, of course,
ACS lowered the age to 45. You mentioned, when you were saying that, that there were some concerns from other, whether they were guidelines institutions or individuals with
prominence, whatever have you. I’d like to know what some of
those concerns are or were? And then the other question
I’d like to ask is this, if I am younger than the
guideline age for a colonoscopy, and I take a stool test
that has a positive result, if there’s blood found in my
stool, and I have insurance, can I get a colonoscopy as a follow up? – I’ll answer the second question first. And the answer in most
cases is gonna be yes because, even though
many insurers may limit screening colonoscopy to
people over the age of 50, diagnostic colonoscopy’s
a whole different deal. So you may end up with
a co-pay or deductible which you wouldn’t for a screening test, but the bulk of the cost
for that colonoscopy should be paid for if you have
a positive stool test finding because it’s now not screening any more, it’s a diagnostic study. With regard to the pushback we got regarding changing the guidelines, there are some valid concerns. I mean the numbers overall
are still relatively small of people who are diagnosed
before the age of 50, so you’re talking about
doing a lot of screening and potentially a lot of colonoscopies to find a smaller number of cancers. We ran the numbers and,
from our perspective, it made sense anyway. There also was concern about whether we are shifting resources and one of the big issues of concern, and Darrell alluded to it earlier, is that are we suddenly gonna
have all the 45-year-old, care leading, bicycle riding, white women coming to get colonoscopies when their risk is still very, very low and meanwhile, for minorities, there’s not gonna be any shift for those people who are at higher risk. So are we gonna be potentially even diverting some resources. ‘Cause there are some
places where colonoscopies are a relatively limited resource. Are we gonna make it harder for people who really need to get screened? Overall, across the U.S.,
there is excess capacity for colonoscopy, quite frankly. – But it’s not distributed.
– No, it’s poorly distributed. But, the other thing is, our guidelines don’t say, “Everybody
go get a colonoscopy.” You say, “Get screened.” So it comes back to that
stool test question. But there are concerns just about the resource cost for the nation. Are we spending too much additional money without bang for that buck. So, again, a lot of
reasonable questions raised but questions for which we
felt we had looked at the data and we believe that moving to
45 is the right thing to do. – And he didn’t say it but
he’s largely talking about the gastroenterologist community. (laughing) I was there at a meeting
when he bravely stood up in one of our largest annual meetings and made those comments. So I applaud him for doing that. Yeah. – Yeah, that was fun. (laughing) But no, but I will say though, it’s primarily the academic
gastroenterologists actually. The rank and file, found
that when I go up and speak in communities across the country, the rank and file gastroenterologists for the most part are very supportive because they’re seeing these people at not just 45 but 42
years old, 38 years old, I get stories all over. And they would, I think,
rather do a lot more extra colonoscopies to
find that one extra cancer. – And all I’m gonna say about
that is follow the money. (laughing) – And with that, Dr.
Landry, thank you so much. – So, if we can just give our panelists and moderator one more round of applause. (audience applauds) We have these wonderful
gifts for all of you. Thank you for your time. And I want to say thank
you to the audience for engaging us in such
a thoughtful discussion around a variety of topics. I really think it shows sort of the depth and breadth of the experience
of you all in the audience and also how we all can work together to address some of these issues. And I think, as we talked about
stepping out of our silos, I think there’s opportunities
for us to partner, whether it’s in research or advocacy, policy change or education, this is the space that
these conversations start. So let’s continue to
have these discussions. With that, I just wanna highlight a few other Equity and
Social Justice events we have coming up. On October 10th, we have a dinner for Muslim students, trainees and faculty. On October 17th, we have our
LGBTQ and Allies reception. October 23rd, we have a discussion
around imposter syndrome. October 28th, we have a discussion around celebrating the 50 years of diversity and
inclusion at HMS and HSDM. We have a conversation around diversity in graduate medical
education on November 4th. And then we have another
Equity and Social Justice lecture series on veteran’s health. All of this information is available on the back of your
pamphlets that you received. Again, thank you for your time. Thank you again to the
panelists and to our moderator. Thank you to the DICP
staff for supporting this. We have coffee and light
snacks in the back of the room for a time for congregation
and fellowship. And with that, we will end this ESJ. Thank you. (audience applauds)

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