19. Esther Choo and the Equity Quotient

• It started with reading a New York Times article addressing how changing “Obamacare” would disproportionately affect vulnerable populations (ie. mothers and children). As a health disparities researcher, this really galvanized her.
• She realized that part of her job as a clinician was to be more vocal about things that she cares about.

• Esther asks herself: “When I do this, I’m taking time directly away from my kids. Is it worth it?’”
• She devotes her time to tasks that are compelling and which she uniquely can do. If others are equally capable (and maybe even would see it as an opportunity), then she hands it off to somebody else.

• The current payer system in the US is too complex and is tremendously wasteful.
• We put a lot of resources into highly specialized care while neglecting basic health care, preventive care, and making sure that we have health equity.

• Working in the emergency department gives you clear insight regarding our structural inequities. This is especially true for those who work at safety net hospitals and when covering the night shift
• In the ED you see the enormous gaps in wealth and how the system is stacked against people based on who they are, what they look like, and where they came from.

• Many times Esther leaves her shift so frustrated by her inability to fix problems for individual patients that she picks up the phone and calls her senator’s office.
• The way mental health patients are treated in the ED is a perfect example of this. They wait for hours, even days, in windowless rooms awaiting admission for psychiatric care. It should be a respite for them, but instead it looks like torture.
• While in the moment, as the emergency provider on duty, you might feel that there’s nothing you can do about systems problems such as this, the truth is that if you go out and agitate about the inhumane care being provided, policy shifts.

“When we walk into retirement, medicine should feel different for the people we’re handing off to.”

• Her specialty areas include tips regarding efficiency and flow.
• She also teaches awareness of implicit biases and how they might impact the care of patients in unexpected ways.
• Esther tries to get her residents to ‘lean in’ to patients that make them feel uncomfortable.

• The master skill of dealing with difficult patients is self-awareness. Acknowledging how they make you feel inside can help us treat them with grace.
• Someone who may come off as an a-hole may actually just be a person who is super, super stressed.

• Early on in the COVID pandemic, the focus was on PPE, ICU beds, ventilators, testing capacity, etc. It was so dynamic.
• As time went on, it became much more about these rolling bigger issues like the vast health inequalities. And how our entire health care system is set up for short-term crises, but not for long-term, extended, multi-dimensional crises.

• Her first instinct is to care for the patient and make them as comfortable as she can. If they’re critically ill, delirious, or psychotic, they’re not really accountable for the decisions they’re making or the words they’re saying.
• At the same time, there’s an obligation to trainees and staff to establish norms and to ensure that the working conditions of the entire team are tenable.
• She may have to redirect patients, referring to hospital policies that maintain that harassment of a person based on their gender, sexual orientation, race or ethnicity is not permitted on the campus. If they can’t abide by that rule, then they can seek care elsewhere (assuming they’re stable and have a clear sensorium).
• Everyone deserves respect, including the workers.

• When speaking to a general audience of people who have not already bought into the need for change, Esther’s talks are extremely data driven.
• She uses data to disrupt narratives and address common misperceptions around things like the wage gap or the opportunity gap.
• Esther accepts that some people will be upset, and if only 1 person gets up and walks out, she knows she’s doing well.

• Our brains are naturally biased.
• Esther takes an implicit bias test every year and, believe it or not, still has a small bias against women in leadership positions.

• Esther believes that the demographics in leadership should closely mirror the percentages in the workforce. More importantly, our workforce and leadership structure should reflect the populations we serve.
• Health outcomes actually improve when there is some racial and gender concordance to our population.

• A 2016 Wall Street Journal article stated that women earn on average 64% of their male counterparts. This study pulled from US Census data which isn’t well adjusted for other confounders.
• Other studies (ie. the Medscape Physician Compensation Report) are better adjusted for potential confounders, such as choice of specialty, hours worked, clinical productivity, and academic productivity. Even when you adjust for confounders, there’s a persistent unexplained wage gap.
• Esther attributes the physician pay gap to bias discrimination based on gender.
• A large study out of New York looked at starting salaries straight out of residency and found a $16,000 wage gap between male and female residents that was not accounted for by things like choice of specialty. This small inequity upfront compounds over time and downstream becomes very big.
• Pay inequity creeps in even in productivity-based compensation systems which many assume to be objective. Females will be given fewer OR hours, a different case mix, or ED shifts which tend to have lower acuity patients. All of these substantially affect income.

When you create opportunity but don’t pay attention, bias will creep in, because that is how our brains are wired.

• We need to have objective allocation of compensation and be systematic about investigating sources of bias.
• Especially right out of residency, salaries should be standardized. And if it’s not a salary system, you should have audits to try to figure out if there are discrepancies and whether they’re agreed upon by the group.
• A group can decide democratically on a pay discrepancy, but it shouldn’t be decided automatically. It should be an explicit conversation.
• Most groups would benefit from a wage analysis every 1-2 years to determine where income inequality may have crept in. And if it is not a planned inequality, then it needs to be addressed.

• When hired to work with a company, Equity Quotient starts by doing an environmental scan, meeting with leadership to understand the perceived needs. Once the goals are articulated, they make a plan.
• They complete a baseline assessment and collect detailed measurements across five domains: safety, sexual harassment, the extent to which people feel valued, opportunity for advancement, and general culture.
• Recommendations are given to the organization about where their problem areas are, what potential corrective actions might be, and whether they need more assessment.

• Reasons why the culture of medicine is ripe for sexual harassment: it has a traditional hierarchical structure, it’s male-driven, physically it’s set up with private rooms 24/7, there are many different people colliding in different circumstances where behaviors can go unnoticed, and there’s a total culture of tolerance.
• In this culture, not only is harassment going to happen, but people aren’t going to report it because we’ve developed a high tolerance for pain and disrespect.

“Every element that you can put into a petri dish that cultivates harassment is present in health care in a way that just doesn’t always come together 100 percent in other industries”.

• We also need to do some structural dismantling.

“How do we make all of our leadership structures a little bit less vertical and a little bit more horizontal without losing too much efficiency in our decision-making?”

• If you’re not emboldened to speak up when you see something that’s bad for the patient, errors will not be caught or prevented.

• “Physicians need to know that it’s within their wheelhouse to change the things that they gripe about.”
• “If their sphere of action is just within the walls of the hospital, then they’re simply passing these problems onto the next generation, adapting around them rather than fixing the fundamental issues,”
• “We have to be responsible for structural change in medicine and for making the practice humane and good for patients in the way that we know that it should be.”