In this episode, we are going to discuss the impact of diagnostic errors on health equity. For patients of color, the unequal medical care and quality of the diagnosis received isn’t due to just location, education, or income. It’s also at times due to healthcare professionals’ cognitive biases, along with decades of clinical studies that examined only white, male bodies, and a lack of understanding about the social determinants of biological illnesses.

The causes of poor quality diagnosis for people of color is multifactorial and is not just related to explicit or implicit racial bias, however — lack of trust, missing data, and reduced data at the point-of-care are just a few of the other contributing factors. Although health inequities within communities of color have persisted for hundreds of years, many are just now waking up to the problem.  There is now an elevated sense of awareness of health inequities in our country due to the exacerbated health outcomes triggered by COVID-19 and preexisting disparities that have been magnified under the microscope of the pandemic.

If one studies history, you can easily find preexisting health inequities that took form long before COVID. It is widely accepted that the first kidnapped Africans to reach European colonies in the Americas for the purposes of slavery did so in 1619 – meaning Black health was ignored from or country’s beginning with health disparities persisting through the next 400+ years. The very foundation of the transatlantic slave trade is false medical theories of black inferiority and physical differences between blacks and whites.

To better how the patient safety movement aligns with health equity, healthcare professionals should listen to Dr. Ronald Wyatt.  Dr. Wyatt is one of the most renowned patient safety experts and health equity champions in this country.  He is Vice-President and Patient Safety Officer at MCIC Vermont, a risk-retention group, where he leads multiple patient safety initiatives for several leading academic health systems. He is an internationally known equity, safety and quality improvement/implementation expert. Dr. Wyatt was the first co-chair of the Institute for Healthcare Improvement (IHI) Equity Advisory Group and is faculty for the IHI Pursuing Equity Initiative. After serving as the Medical Director for the US Defense Health Agency/Military Health System Patient Safety Analysis Center, he became the first medical director of The Joint Commission (TJC) Office or Quality and Patient Safety and the first patient safety officer for The Joint Commission. While at TJC, Dr. Wyatt led the team that wrote the Patient Safety Systems Chapter, contributed to Sentinel Event Alerts and created the Quick Safety publication. He served as technical advisor on the RCA2 document that has been widely adopted as a guide to completing a root cause analysis.

Dr. Wyatt is a member of the ACGME Clinical Learning Environment Review committee, as well as faculty on the ACGME Disparity Collaborative. He also serves on several boards including the IHI Certified Professional in Patient Safety, the Society to Prevent Diagnostic Error and the Consumers Advocating for Patient Safety. Currently, he is faculty/advisor/coach on multiple health equity collaboratives including BCBS Massachusetts/IHI, ACGME BCBS Illinois Equity Matters, KC Learning Action Network and the Providence health system equity collaboratives. Dr. Wyatt has written and published many articles, blog pieces and chapters on patient safety, health equity/disparity and process improvement.

Episode Bookmarks:

01:30 Introduction to Dr. Ron Wyatt

04:30 The human cost of diagnostic error (patient deaths due to a diagnostic error are estimated at 40,000-80,000 per year!)

06:00 “To make the right diagnosis in a timely manner is a core quality component.”

06:30 Dr. Wyatt discusses how correct diagnoses are the link between patient safety and healthcare quality.

07:15 The patient safety goal in diagnostic accuracy is “Zero Preventable” harm, injury, and death.

08:00 Prioritizing a culture that values open lines of communication, teamwork, and patient engagement.

08:30 The authority gradient in medicine that makes individuals less likely to speak up or report a diagnostic error.

09:30 Poor leadership is the common denominator of healthcare organizations with high rates a sentinel events.

10:00 Dr. Wyatt discusses his patient safety work with The Joint Commission that identified root causes of sentinel events.

11:30 LEADERSHIP: The leadership behaviors required in hospitals and health systems to support high performance in Patient Safety.

12:30 The need for leaders to hold physicians accountable and apply systems thinking (going after the “unknown unknowns”)

13:30 CULTURE OF SAFETY: The institution of a Reporting Culture to mitigate risks of patient harm.

14:30 Establishing a system of transparency in a culture that creates a “psychologically safe environment.”

15:30 Implementing strong corrective actions is the responsibility of good healthcare leaders.

16:30 CONTINUOUS PROCESS IMPROVEMENT: using tools and methods to create a closed loop system to make the system safer.

17:15 “Leadership, a culture of safety, and continuous process improvement must all be strategically aligned, operationally robust, and tactically impactful.”

18:30 Health inequities have resulted from healthcare professionals’ cognitive biases and other issues of institutional racism leading to poor trust.

19:15 The origins of health disparities beginning with the transatlantic slave trade.

20:30 Defining health inequity – health outcomes that are avoidable, systematic and unjust.

21:30 Contributors to inequities — Institutional racism, stereotype bias, implicit bias, workforce capacity, resource allocation, ineffective DEI strategies

21:45 “The canary in the coalmine for health inequity existed long before COVID.”

22:30 Dr. Wyatt provides a comprehensive explanation of the history behind  slavery and how the resultant devaluing of black lives led to health inequity.

23:45 Social drivers of health as the manifestation of racism.

24:45 Food insecurity explains why Mondays are the most attended school day of the week.

25:30 Mortality rates of minority populations during COVID-19 pandemic should not have been a shock to anyone studying public health data.

25:45 Implicit and explicit bias and “trust decay” due to lack of empathy by the health system.

26:20 Dr. Wyatt describes why current DEI efforts are insufficient.

27:15 The cultural revolution for civil rights and social justice following the murders of George Floyd, Breonna Taylor, Ahmaud Arbery, and others.

29:00 Dr. Wyatt discusses how over-policing is a public health issue and shares a personal story of how he was discriminated by police as a young man.

30:00 Slave patrols that led to a persistence of racism in law enforcement that carries on to the modern day.

30:20 Dr. Wyatt discusses “The New Jim Crow”, i.e. mass incarceration of African American males in the U.S.

32:00 “Weathering” in adulthood due to past childhood experiences of racism and over-policing that are carried over to the healthcare system.

32:30 Dr. Wyatt shares the story of police beating a patient inside of a hospital and how an African American physician was arrested for obstruction of justice.

33:15 The answer is not defunding the police, instead it is integrating them in the communities they serve.

34:30 The longstanding history of distrust with the healthcare system in African American communities (e.g. gruesome experiments on slaves, Tuskegee syphilis study)

35:40 “The historic erosion of trust in the healthcare system.”

36:30 The Philadelphia Negro – statistical differences in health between races is “a peculiar indifference” (1899)

37:00 Trust can be created by authentic displays of respect and compassion in the healthcare setting.

37:30 Dr. Wyatt describes how his son experienced distrust of the healthcare system based on a bad experience with a pediatrician.

39:00 The need for more African American physicians will increase trust in the healthcare system.

40:30 “Race is an independent risk factor for death, and the data bears that out.” – Dr. Don Berwick

41:00 Dr. Wyatt discusses the need for health equity transformation in our country at the training level.

41:30 Racist myths in the medical profession that have persisted since the 1800’s (e.g. race-based decisions in CHF, renal failure, transplant referrals, etc.)

43:30 Creating tele-equity to positively impact patient care and diagnostic accuracy.

44:15 14 million homes in urban settings and 4 million homes in rural communities lack broadband access (and 75% of them are people of color).

45:00 Dr. Wyatt describes his collaboration with the American Telemedicine Associationto create a framework for implementing telehealth to improve health equity.

47:20 Building structural competencies into the deployment of telemedicine (“closing the power gap”)

48:15 Aligning health literacy with digital literacy.

48:30 Payment reform of telemedicine services to make it more affordable.

49:30 Growing concerns that AI and machine learning algorithms reinforce existing biases.

51:00 Referencing the NEJM article “Hidden in Plain Sight – Reconsidering the Use of Race Correction in Clinical Algorithms”

51:45 Abolishing biased algorithms through community partnerships and the avoidance of “over the horizon” decisions in clinical treatment.

53:00 Understand the culture of a community before applying data to make algorithmic decisions in diagnosis (creating a social risk picture)

55:00 Starting with the ACO REACH program, CMS plans to be embed health equity into all payment models, with more focus on improving health outcomes in underserved populations.

56:00 Dr. Wyatt explains the 4 Domains of Value-Based Purchasing, i.e. clinical outcomes, community engagement, patient safety, efficiency and cost reduction.

56:30 Stratifying HCAHPS data by race, ethnicity, and language for health equity performance management.

58:00 CMS requirements for health equity strategic planning and leadership.

60:00 Allocating population health resources to highest need (not most wanted) once high-risk populations have been identified.

61:00 Developing an anti-racism action plan to reduce health disparities starting with The Joint Commission standards.

62:20 Dr. Wyatt provides a framework for developing a value-based care strategy for Health Equity.

64:00 Diagnostic error account for 17% of preventable errors in hospitalized patients.

64:45 The dearth of research in diagnostic error prevention despite the abundance of overwhelming data showing the severity.

66:00 Leaders confronting biases in diagnoses to overcome health inequities. (Those who won’t need to find another job!)

67:45 “With regard to health equity, a rising tide does not lift all boats.  We must put systems in place that adjust depending on those most in need.”

69:30 Be prepared not to get paid for poor outcomes in underserved populations.  Payment mandates for health equity are forthcoming.

70:00 Wisdom from the Dalai Lama on Compassionate Equality — having compassion for all sentient beings.

71:30 “The root of the word courage is Latin word for heart.  We must commit to “heart work.” Healthcare quality begins and ends love.”

73:00 Dr. Wyatt is optimistic for the future because of conversations like this podcast!

74:00 If you love people, you can change the world.