BOSTON — When a routine cancer screening came back showing an elevated PSA reading, George Brickhouse knew he should take it seriously. His father had been treated for prostate cancer and his brother had dealt with a scare. But the urologist he went to see started ordering tests without fully explaining why. And when he couldn’t get through to a live person to schedule an MRI, he gave up trying to find out whether he had cancer. “I wasn’t comfortable with being pushed through,” he said.
Then Brickhouse met Quoc-Dien Trinh. It was during a Zoom meeting for Black men, part of an outreach program run by Mass General Brigham where Trinh and other physicians walked through the process of screening and treating prostate cancer — and took time to listen to Brickhouse’s concerns. A basketball coach who also runs a youth advocacy nonprofit, Brickhouse felt encouraged, he said, and open to coming in for an appointment.
When Brickhouse did come in, he was pleased to find his care would be overseen by Trinh, a urologic oncologist considered one of the nation’s best young urologists. Brickhouse calls Trinh “the man.” Should he need surgery, Trinh will be there too. Though Trinh’s schedule gets booked months in advance, he has blocked off dedicated time for patients like Brickhouse who come in through his hospital’s outreach program.
It’s an effort to battle a classic aspect of white privilege, in which those in the know, those with connections, and those with pricey private health insurance often get in to see the best and most sought-after doctors. It’s also a palpable sign of change at Mass General Brigham, the large, Boston-based hospital network that has faced criticism for not being welcoming to patients from the city’s disadvantaged neighborhoods. The system is undertaking a sweeping campaign to confront and address the systemic racism that has led here, as it has across the nation, to poorer health outcomes and higher death rates for patients of color.
While many health systems and hospitals are just starting to address medical racism with real action, the work at Mass General Brigham seems to be in overdrive — though it’s too early to say how impactful and enduring the changes will be. Called United Against Racism, the $40 million initiative has launched more than a dozen programs in different clinics and hospitals to provide antiracist care, and has yet more programs in development.
Clinicians are looking hard at disparities among their patients — from why Black women are less likely to receive knee replacements to why Black men are more likely to be accosted by hospital security and why non-English speakers miss so many follow-up appointments — and testing sometimes surprisingly simple ways to end them.
Creating large-scale change hasn’t been easy. Neo-Nazi protestors rallied outside one hospital and institutional inertia and ranks of skeptical doctors have slowed the work that is now drawing national attention.
“It was messy. It was sausage-making,” Karen Fiumara, a vice president for patient safety at Brigham and Women’s Hospital, said of its nascent efforts to understand and confront health disparities in 2017. Once those early efforts started to show results, “we said, ‘Why haven’t we been doing this forever?’”
Now Fiumara is among hospital leaders who have fully embraced health equity work. “I am so proud of what we are doing,” she said, “And oh, my God, there is so much more to do.”
The work being done here is considered so promising, it’s being hailed as a national model by the American Medical Association, which has enlisted Fiumara and other leaders to share what they’ve learned with other institutions. The AMA has even hired one of the Brigham physicians who worked on health equity issues, Karthik Sivashanker, as a vice president in its Center for Health Equity.
Because many of the programs are still getting underway, numbers showing improved patient outcomes in many areas are probably a year or more away. But some progress is already apparent. A program aiming to reduce uncontrolled hypertension in Black and Hispanic patients, by boosting screening for social needs and offering support from community health workers, has narrowed a 6.7% gap between Black and white patients to 5.5% and a 3.3% gap between Hispanic and white patients to 2.4% in five months, said Allison Bryant, a maternal-fetal medicine specialist and senior medical director for health equity at Mass General Brigham.
“This is just in the first five months, and we hope to see these changes sustained. We have more to do, but it’s great to see proof of concept,” she said.
The system has also cut to below 5% the number of patients who don’t have race and language data in their records and increased the enrollment of Black and Hispanic patients into the system’s health portal by more than 20%, she said.
Getting to this point wasn’t easy.
Tom Sequist, now the chief medical officer for Mass General Brigham, had been working on issues of health equity for two decades. Previously, as chief quality and safety officer for the system, he had for years been trying to convince hospital leaders and his physician colleagues to address the stark disparities in diabetes outcomes between patients from racially mixed neighborhoods like Dorchester and those in well-heeled, predominantly white suburbs like Newton. But it was hard going, even at Harvard teaching hospitals in liberal and progressive Boston.
A Boston Globe Spotlight team analysis of the city’s hospitals in 2017 found that Black patients were far less likely to receive care at the city’s elite hospitals even if they live nearby, and far more likely to feel they were mistreated at those hospitals because of their race. “Certain patterns of segregation remain stubbornly entrenched, threatening to undermine the region’s mission of equitable care for everyone,” the report found.
In his work on diabetes, Sequist found it difficult to get other physicians on board. Because damage from the disease unfolds slowly, there was no sense of urgency, he said. At the time, there was far less discussion of how racism affects health care. There was some work underway on equity by individual physicians and residents at the Brigham-affiliated Southern Jamaica Plain Health Center, which has long promoted issues of racial and social justice. But many physicians and hospital leaders didn’t believe the issues Sequist was describing were the hospital’s problem to solve. Then Covid hit.
“All of a sudden, people were dying in Dorchester and Chelsea and people immediately got it,” Sequist said. “I told people, ‘It’s the same thing we were looking at in diabetes, it’s just in fast-forward.’”
The Brigham mobilized quickly when the pandemic hit to beef up translator services. It prioritized care of the most vulnerable patients, and created mobile clinics to increase vaccine uptake in the hardest-hit neighborhoods.
“We were on a very slow journey in thinking about equity — until Covid,” Sequist said. “Covid helped us push on the gas pedal.”
The work is being watched closely by Kedar Mate, president and CEO of the Boston-based Institute for Healthcare Improvement, a health care quality group that made equity a centerpiece of its work a decade ago and has for the past six years partnered with a number of organizations around the U.S., including the Brigham, on pilot projects to reduce health disparities. Mate is pleased to see how much progress is possible when a system prioritizes health equity. “If I had to, I would not have rated the Brigham as the most passionately committed to the cause at the start,” he said. “Now they’re leading the nation.”
“We were on a very slow journey in thinking about equity — until Covid. Covid helped us push on the gas pedal.”
Tom Sequist, Mass General Brigham chief medical officer
But others, even some within the hospital system, remain skeptical about how far the program will go to address the deeply entrenched systemic issues, like residential segregation, poverty, and differences in quality of insurance that have led to Boston’s legacy of medical segregation. They wonder if the work underway is more of a Band-Aid than a cure.
Jonathan Jackson, a neuroscientist seeking to make medicine more equitable through the CARE Research Center he runs at Massachusetts General Hospital, called the United Against Racism efforts “fragmented and limited.” He said its lofty goals are not matched by clarity on how to achieve them, transparency on how funds are being spent, or accountability on what is deemed success.
“While UAR may be helpful from a perspective of corporate social responsibility,” he told STAT, if the projects are not larger, consistent, and system-wide, “the initiative can never be truly impactful or effective.”
Bram Wispelwey’s eyes were opened to health disparities long before Covid. It was 2015, after the deaths of Black teenagers Trayvon Martin in Florida and Michael Brown in Missouri. Black Lives Matter protests were growing in size around the nation and Wispelwey was a second-year resident in internal medicine at the Brigham.
As he rounded, Wispelwey noticed something concerning about the hospital’s heart patients. It seemed to him that white patients were more often found on cardiac care floors, where they should have been, but Black and Hispanic patients — who are more likely to die from heart disease — seemed to be on general floors, without the more specific care and closer attention that patients with failing hearts need. (Patients on the general floors also had older and non-private rooms, he noted.)
The discrepancy was something only a resident would notice, said Wispelwey, because residents work in multiple units, not just one like attending physicians. Wispelwey wanted to conduct a formal analysis as a project to complete his master’s degree in public health at Harvard, but was dissuaded. The hospital didn’t seem ready to assess the problem, let alone solve it. “I was told ‘That’s not interesting,’ or ‘Even if you do find something, that’s going to be awkward,’” Wispelwey said in a recent interview with STAT.
He persisted and, working with a large group of physicians that included Michelle Morse, a former Brigham physician and assistant professor at Harvard Medical School who now works as chief medical officer and deputy commissioner for New York City’s Department of Health and Mental Hygiene, found what he suspected: Black and Hispanic patients were less likely than white patients to be admitted to the cardiology service.
When it came time to write up the findings for publication in a medical journal, it was 2018 and discussions about racism were not as widespread in health care settings as they are today. Naming racism as a cause for the disparities they found became a thorny issue among physicians, including some of those authoring the paper. “Even at Brigham, there was definitely pushback and hesitation around naming institutional racism,” said Morse. “We pushed really hard.”
After much discussion, the group agreed. When they published the work in 2019, the authors called the findings an example of structural racism and the unequal distribution of patients to different floors “an intrahospital driver of racial inequities.” The differences, they thought, were due to multiple factors: Black and Hispanic patients were less likely to advocate for better care, were less likely to have regular cardiologists who would push for admission to the cardiac service, and, most uncomfortably for them to report to colleagues, may have been victims of provider bias.
“I am so proud of what we are doing. And oh, my God, there is so much more to do.”
Karen Fiumara, vice president for patient safety at Brigham and Women’s Hospital
Today, amid a flood of research that names racism outright and directly ties racism to health disparities, the heart failure study seems almost tame. But last year, the two physicians wrote an article saying they planned a pilot program to place digital flags in the software clinicians use to issue treatment instructions, reminding them of inequities in admissions to the cardiac unit and making such care the default for all heart patients unless there is a specific reason it’s not needed or the patient might be better served on a general care floor. The idea was derided by conservative commentators, prompting a backlash among right-wing groups. The two physicians were targeted on social media — and even needed personal security — while protesters gathered outside the hospital claiming the doctors were “anti white.”
Nothing could be further from the truth, said Mate. “There’s this sense that one person’s gain is another person’s loss but all indications suggest the opposite, that when we work on improved care for the most marginalized communities, we build better systems of care for everyone.” The data on whether interventions are working to narrow the cardiac-care disparity look promising but have yet to be formally analyzed, Wispelwey said.
The protests caught the physicians, and the hospital, by surprise. “Our thinking was this was not a particularly radical piece,” said Morse. Indeed, even the American Medical Association, considered a politically conservative group, has an ambitious plan to embed racial justice into medicine to improve health equity. Many other health systems are on a similar path. If anything, Morse said, the outpouring of support the two received from other physicians “became a community-building experience.”
While the protest was highly public and uncomfortable, it wasn’t a major challenge to their work. A bigger challenge, as Morse and Wispelwey learned in 2018 — and as the rest of the Brigham would learn as they tried to implement antiracist policies after 2020 — came not from external forces and critics, but from fellow physicians who resisted calls for change.
“There was that defensiveness in hearing about this, even at a place like Brigham and Women’s and Harvard Medical School — profoundly white institutions but also ones that identify as progressive and antiracist,” said Wispelwey, now a hospitalist and associate physician in the Brigham’s Division of Global Health Equity. “It’s one of those topics where people say, ‘We know this is real, we know it’s all around us, but it’s not us, we’re not the individuals involved in perpetuating these harmful systems.’”
It’s something Mate has seen repeatedly in his many discussions with physicians nationally about health disparities. What helps him overcome such resistance is data, especially data showing physicians the disparities that exist in their own hospitals or practices. But that data can be hard for many to swallow at first.
“We call it ‘the stages of grief around data,’” Mate said. “It starts with denial — ‘the data are wrong.’ Then it’s ‘the data are right, but it’s not a problem here.’ Then they accept reality.”
Mate himself had to confront uncomfortable data from his own internal medicine practice showing racial disparities in pain management and treatment of hypertension. “No one I’ve worked with — hundreds of physicians — has been willing to accept that this is OK once they’ve seen the data,” he said. “They stop questioning and get into the work of improving.”
The problem, he said, is those who don’t, or won’t collect or look at data on patient outcomes by race that could show disparities.
“There’s plenty of health systems that want this to go away,” he said. “They don’t want to see the data. They are afraid of the data.”
In late 2020 and 2021, research began to emerge showing Black patients in psychiatric crises in emergency rooms — including children — were more likely to be physically restrained than white patients. Sequist wondered whether the same was true in his hospital system’s 11 emergency rooms. It was. Instead of brushing the finding under the rug, he published it.
“As an institution, we were really brave to look internally and see where our problems are,” said Dana Im, an emergency medicine physician and director of quality and safety in the department of emergency medicine at Brigham and Women’s.
These findings spurred Farah Dadabhoy, an emergency medicine resident at the time, into action. She and three fellow residents, using $10,000 in seed grants, started a pilot program to train ER staff about their own biases.
The team brings in actors — one is a white woman, the other a Black man, who act as if they’re having a psychiatric emergency. The situations feel very real and allow physicians, nurses, physician assistants, and other ER staff, including security officers, to try to de-escalate the situations and then assess how they responded. “People come to the awareness that their reactions to these actors are different, and there may be bias,” Dadabhoy said.
The debriefings are often difficult and uncomfortable. “It’s hard,” she said. “No one wants to feel that they are racist or have biases.”
Im said she sees a lot of eyes open — literally — during the training. Sometimes there is shock, sometimes there are tears, other times there’s relief. “It’s an opportunity to talk about something that frankly has been on a lot of people’s minds,” said Dadabhoy, now an emergency medicine physician and fellow in clinical informatics at Mass General Brigham.
The project, now funded at a larger scale by United Against Racism, has trained 124 ER staff in 16 sessions; 50 more training sessions are planned. They appear to be working. Preliminary data collected for more than a year from one of the systems’ hospitals, Faulkner, show there has been a 50% decrease in the use of restraints in both white and Black patients. There was also a narrowing of the racial gap in who gets restrained and far less use of restraints than at hospitals in the system where staff have not yet undergone training.
Hospitals call them “no-shows,” patients who repeatedly miss visits. It’s a term that can come across as blaming. Efrén Flores, a radiologist at Mass. General Hospital, prefers to call them “missed care opportunities.” He’s launched a program that offers enhanced translation services, transportation for patients who need it, and same-day screenings and breast biopsies so people don’t have to return for appointments.
His inspiration was a patient who’d been labeled a “no-show” because she’d missed two MRI appointments. When they together spoke in Spanish — Flores is originally from Puerto Rico — he learned she had missed the appointments because she hadn’t understood the automated reminder calls, which were in English. He wondered how many other patients were falling through the cracks.
So he systematically combed through the list of “no-show” patients. Sure enough, it was full of Black and brown patients, those who spoke English as a second language, and low-income patients with Medicaid coverage — all who were missing important cancer follow-up screenings and other tests. This, he thought, is how disparities start.
It was something Trinh, who co-directs the Dana Farber/Brigham and Women’s Prostate Cancer Center, noticed too. He knew the Brigham had long lists of patients with elevated PSAs who were flagged because they had not seen a urologist or had an MRI. “In the past, this list would be printed, but not much else happened,” he said. Now, he makes sure everyone on the list gets called. Many who are reached, he said, do not understand they are at risk for cancer. His outreach initiative funded by the United Against Racism program has scheduled more than 100 men for appointments; more than a quarter of them had prostate cancer that required treatment and more than half of them were non-English speakers.
“You might think this is not necessarily about race or ethnicity,” Trinh said. “But guess what, a lot of the appointments that are missed are people who don’t speak English or are men of color.”
Flores, who has seen a lack of access to good health care harm his own family members, said it’s been eye-opening to think about health equity for his colleagues in radiology, who usually don’t interact directly with patients. But times are changing; Flores, the associate chair for equity, inclusion, and community health at Mass General Brigham radiology, is now a sought-after speaker in radiology departments across the country.
His program is already chipping away at missed appointments. A pilot project to offer Saturday mammograms at the Lynn Community Health Center has seen missed appointments drop from 30%-50% on weekdays to 24% on Saturdays. On some Saturdays, no appointments are missed. But he wonders if it’s enough. “What keeps me up at night,” Flores said, “is wondering if this is just the tip of the iceberg.”
The work is not only about bringing in patients who may have been missed, it’s also about treating them well once they arrive. For Nadia Huancahuari, an emergency medicine physician and one of the Brigham’s medical directors for quality, safety, and equity, such work is deeply personal.
Huancahuari came to the United States from Peru at 13. As a teenager in San Francisco, she escorted her grandmother to hospital appointments for abdominal pain and cancer and struggled, with her very limited English, to serve as an interpreter with the doctors they saw. Years later, the memory, and the pain, remains fresh. “It’s like having tape over your mouth,” she said.
She’s working to make sure patients and families who come to her hospital for treatment don’t feel the way she did. A 2013 survey showed that 11% of Black Bostonians reported being mistreated by health care workers, while just 2.5% of white Bostonians did. The Globe’s 2017 Spotlight report on medical segregation found many Black residents felt uncomfortable and unwanted at hospitals serving primarily white patients and said they felt better treated at Boston Medical Center, which has historically treated medically underserved populations.
Too often in the past, Huancahuari said, staff assumed that a family member would serve as an interpreter and turned away people who had traveled for appointments because interpreters had not been scheduled or were not available. “We recognize how painful it is to feel so vulnerable or to have to go to a health care system where you don’t feel welcome,” she added.
She thinks physicians can do a better job, by not just focusing on science and disease, but also on the human beings they treat. “It’s also about making eye contact,” she said. “We need to do a better job of validating people’s fears, and also celebrating with patients when their tests are normal.”
Huancahuari said she’s fighting pushback from some physicians who feel health equity work such as outreach to patients in the community isn’t part of their job. “I get this goes beyond medicine and what we were trained to do,” she said, “but it’s something we need to do.”
As a large urban teaching hospital, the Brigham has an army of staff and a wealth of resources available to attack health inequities. The question is whether smaller health systems with less resources can do the same.
The answer, many say, is a resounding yes. A poll Mate’s institute conducted in 2021 showed that 58% of health systems consider health equity a top priority, compared to 25% in 2019. But many say they face challenges, which include having a lack of data related to equity, a lack of staffing and funding, and uncertainty on what exactly to do. The most important thing for health systems to do, Mate said, is to simply start.
“Just get that first project going, that matters so much,” said Mate, who has worked with dozens of health systems, large and small, to encourage health equity work. He has found that once systems start this work, they don’t want to stop. “That’s the story of this whole thing. Once you learn these kinds of problems are not ossified and they can make change pretty darn quickly, they want to change everything because it feels so good.”
That’s what happened at WellSpan Health, a mid-sized health system of eight hospitals that serves an area in south central Pennsylvania and northern Maryland and sits between Philadelphia and Pittsburgh. The group had been part of IHI’s Pursuing Equity program; about six years ago, the board of directors decided that equity should be one of their strategic priorities and developed a set of precise goals.
That led to an effort to build databases to look at health outcomes and break them down by race, ethnicity, and language. “We wanted to make sure we were providing excellent care to every member of our community,” said Mike Seim, an emergency medicine physician who serves as senior vice president and chief quality officer for WellSpan.
When the team looked at maternal morbidity data, he said, they found their Black patients had three times higher rates of preeclampsia than their white population. They addressed the problem by giving out free home blood pressure monitors and aspirin to patients. They were able to cut the rate of preeclampsia in Black patients from about 20 events in 1,000 patients to 8. Health of pregnant white patients also improved: Events were reduced from 7 per 1,000 patients to 3. “It’s really common in health equity work, you see everyone getting better,” Seim said.
Because the databases were already in place when the pandemic slammed the hospital system, Seim and others could quickly see that Covid-19 cases were some 30% higher in Black and Hispanic populations. The system doled out half a million dollars in grants to community groups to help with Covid mitigation and provided housing and food for those living in multigenerational homes.
Aiming to reduce disparities in breast cancer screening, the system employed a mobile mammography bus in areas with lower screening rates, started calling people in their native languages to make screening appointments, and more aggressively scheduled screenings when people came in for other visits and an interpreter was present. The screening rate for Black and Hispanic people, which had never risen above 70%, climbed dramatically in just five months earlier this year: The rate is now 74%, close to the total screening rate of 75%. The efforts worked so well, Seim said, the system met its five-year goal for screening Black and Hispanic patients in a single year.
Seim has two simple pieces of advice for other health care organizations. You have to start with an engaged board of directors and leaders who really support the work, and, you just have to start. “It seems like a very daunting task, but the reality is you just have to jump in and pick a topic,” he said.
Data is key, including for persuading leaders and other physicians to get on board. “Be prepared for denial. Be prepared for fear. Be prepared for folks saying this doesn’t happen here,” advised Mate, who regularly speaks with leaders of health systems. “Come prepared with data.”
And be prepared for awkward, uneasy conversations about race, a topic that has rarely been openly and frankly addressed in many health care settings.
“Be uncomfortable and don’t be afraid of being uncomfortable,” said Sequist. “If nurses, physicians, and hospital staff are not uncomfortable, it’s probably not working because this topic is uncomfortable.”
He also recommends not to make this work the responsibility of diversity, equity, and inclusion officers who often have small teams. It should be the responsibility of a CEO, COO, or chief medical officer who has the staff and power to drive change, he said. “I worry when hospital systems create separate equity initiatives,” said Sequist, at Mass General Brigham. “These teams are small and can’t always drive change.”
Another route for smaller systems is to tie work on health equity to patient safety, a function that’s already firmly established in all health systems. Fiumara, the Brigham patient safety leader who took on health equity work, sees strong parallels between equity and patient safety work. “Twenty years ago, when there was a bad (safety) outcome, the knee-jerk reaction was, ‘But I’m not a bad doctor,’” she said. “As we discuss health care disparities in a more open way, we find the knee-jerk reaction is, ‘But I’m not a racist.’”
Focusing on structural issues, she said, can make such conversations easier. There’s guarded optimism at Mass General Brigham that some of the same approaches that improved patient safety decades ago will also curb health disparities.
Morse, however, is a little more skeptical. Brigham and Women’s Hospital happens to have a Black president and CEO, but most health care institutions have white leaders, who may remain resistant to change when it involves issues of race, she said. “This is a different kind of change. There is profound defensiveness, and certainly a lot of resistance and emotion,” she said.
She notes that more than 20 years ago, the publication of the groundbreaking report on medical errors by the Institute of Medicine, called “To Err is Human,” led many organizations to radically change how they delivered care, from patient handoffs to medication dispensing, to how they communicated with families. Around the same time, another major report on health disparities, “Unequal Treatment,” was released by the same group. The level of funding and interest, she noted, was minimal.