Mayo Clinic experts in dermatology, palliative care, nephrology and oncology discuss health care disparities in their respective fields and how they relate to coronavirus disease 2019 (COVID-19). The panel members discuss health care disparities before COVID-19 as well as what they are seeing in the middle of the pandemic.
Click here to claim credit and view faculty disclosures. Select Register to begin the credit claim process. Welcome to Mayo Clinic Cove in 19 expert insights and strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with a C CMI guidelines. Hello, I'd like to welcome you thio this program from the Kobe 19 expert lecture. Siri's. Today. I've got three excellent Panelists along with myself. They're going to discuss some health disparities Information related to Kobe. 19. Today we will have the pleasure appearing from a hematology oncologist, Dr Gerardo Cologne. We'll speak with someone from neurology, family medicine and palliative care. Dr. Marcia Robinson and we'll also speak with someone in dermatology. Dr. Yemi Sakombi. Today we'll focus on the medical subspecialties perspective of health care disparities with Kobe 19 to start, I want to tell you that I have no financial disclosures and I'll go over our learning objectives. We want to be able to describe health disparities in outcomes from Koven, Nineteens and patients from minority groups. No, we want to discuss. Some of the co morbidity is that have been linked to hospitalizations for Cove in 19 would also like to describe some health care disparities seen in our different subspecialties on. Finally, we'll talk a little bit about how Kobe, 19 has exposed new healthcare disparities in certain medical fields. To start, I'd like to go to give a little bit of background information currently on the screen. You're looking at census data from 2010 to 2019. What they call the vintage year 2019. Um, remember that. And we're looking at people that are self reporting race. Um, uh, we're gonna focus on ah, lot of people that have self reported one race. Um, Also things to know Tate will be that Hispanics maybe from any race. So they are included in all of the race categories. But if we look at the data from the census, we know that there about 330 million Americans 328 some odd million that were reported at that time. That's a 6% increase from the prior census. So, you know, we were due for another census this year in 2020. Um, I think you'll see the importance of an accurate sense discount and then also accurate reporting within the disease process of Kobe. 19. Uh, note here, 13% of the population were reported. African American note that white alone, non Hispanic population of 60%. And let's look at some Kobe 19 case and, uh, outcome data. So if we look at earlier this week looking at cases reported based off of race and ethnicity, knowing that that isn't always reported, um, but from what we do know, you can look and see that this white, non Hispanic group accounts for 40% of these cases. Okay, so 60% of the population 40% of the cases if you look at your black, non Hispanic group, the African American 13% of the population but 30% of cases that are seen and then also, if we just think about our Hispanic population down here at the bottom, we've got 19% of the population, but 30% of cases. Um, if I go a little bit further, let's talk about some of the outcomes. The worst outcomes. Death, also broken down by race and ethnicity. Uh, interesting is that the White alone non Hispanic group, the largest group, affected 60% of our total population. 40% of the cases half of the deaths, 50% or so of deaths. If we look at our African American non Hispanic group again, 13% of the population 19% of the cases but 21% of deaths so definitely despaired outcomes that we see. And again if we couple that to the Hispanic, uh, reporting down below you see 19% of the census data 30% of the cases onda little bit less 16.7 percent of the deaths that we see from Kobe 19 um, very difficult to wrap our heads around. Some of the reasons why these disparities exist. Very complicated. Um, multi layered. We'll try to talk about some of those today as we think about Kobe. 19 cases and hospitalizations and those deaths that we just spoke of. We know that there are factors that put everyone at risk. And those include crowded situations being in close contact with other people, being in small enclosed spaces and also how long people are actually exposed. And so what we have to think about is we think about disparities is where people have to live, where people have to work, what work they're doing. So if we think about our essential workers are frontline workers, infrastructure critical infrastructure workers. If these groups are disproportionately represented by races or ethnicities, clearly they're gonna be more likely to be impacted. And I think that that does bear out in the data knowing what we know. We can certainly think about actions to reduce the risk of Contracting Cove in 19. But there are again some occupations that simply don't allow us to be able to follow the known recommendations if we think about the risk factors for Kobe 19 hospitalization itself. We know that medical conditions underlying medical conditions play a huge role. I know we've heard that, um, looking at differences between known core morbidity such as asthma, with a 1.5 percent excuse me 1.5 time increased risk of, um, hospitalization all the way up to having multiple of these processes, uh, much mawr increasing the risk of hospitalization related to Kobe 19. Another important point is that the race and ethnicity point added to all of these increase one's risk that much more so. We've got to think about not Onley these co morbid diseases as respect er's, but also the ethnicity and race of the patients that were treating in and of themselves as a cause. If we're going to think about ways to mitigate these risks, Yeah, all of this data is available on 100 website publicly available. Um, I welcome you to go and look and see the up to date information that's available now, I'd like to introduce the first of our Panelist professor of medicine for the Mayo Clinic, Alex School of Medicine. Also, Vice Dean, um, consulted in hematology and oncology and chair of the Mayo Clinic School of Medicine Education Subcommittee. Dr. Cologne. Thank you, Dr Cologne, for joining us today on our panel on health care disparities and co vid the medical subspecialty perspective. We're going to start off with our first question, which is what are some of the health disparities seen in oncology? Thank you, Dr Donaldson. So that's a great question to cancer. Cancer disparities had Bean recognized since the 19 seventies. It was the first time that there was data about cancer incidents and cancer mortality in different races and ethnicities. Andi was actually cancer was one of the first subspecialties or one of the first areas. Whether these parodies were noted once that data became available. So ever since then, ever since then, we've been aware of these disparities, the most striking disparities that were noted back in the 19 seventies. And that was a report, a publishing cancer that was reporting on the changes from 1950 1967. Once that data was available on the report was that there was a 20% increase in mortality from cancers among African Americans compared to whites. And that really started the whole area of concern about these disparities and actually a significant part of those disparities that were described back then related to smoking and lung cancer. That for some reason, there was a significant increase in smoking among African Americans accounting for that particular increase. But since then, cancer, these parodies had persisted not just among African Americans but also among Native Americans and Hispanics for multiple different cancers. Although the magnitude of the disparities had decreased somewhat, but they still persist Onda. There are disparities in multiple cancers. There are multiple factors that contribute to those disparities. Socioeconomic status is one of them. That relates to lesser access to health care as a big contributing factor. Eso for example on breast cancer. Um, even though African Americans and Hispanics have a lower incidence of breast cancer compared to whites in our country, when you look at, uh, the younger age group, the women who are less than 40 years old. Actually, African Americans have a higher prevalence of breast cancer on a much higher mortality when you look at it at all ages. African Americans, even though they have a slightly lower incidence of breast cancer, they have a significantly higher mortality from breast cancer. Um, and Hispanics have a lower prevalence of breast cancer and a lower mortality compared to whites. But again, when you look at the younger patient population age 40 or less, even though they're incidents is a little lower, their mortality is is higher, an equivalent to the that of white. So it's something that we see among African Americans, Hispanics and also Native Americans, is, uh, that the cancer occurs at a younger age and have a worse prognosis, and there is a new increased number off patients who have the more aggressive breast cancers in breast cancer would be what we call the triple negative breast cancer, which are the cancers that don't express estrogen receptors nor progesterone receptors on don't have amplification off her, too. So there are probably some environmental reasons. And there is a jet, probably a genetic component that explains why were seeing the cancers at a younger age. And we've seen a nexus s number off the, uh, the more aggressive breast cancers. The environmental component could be related to the lower access also related to the stress associate ID with low socioeconomic status and prejudice, which may contribute some way to that. And also the genetic factors that explain the younger the woman is the higher the incidence of genetic component to their disease, although the prevalence of three genetic component doesn't seem to be different between African Americans, Hispanics and whites. But there may be some other genetic components that we haven't recognized yet. So that's an example. For example, also in prostate cancer, African Americans have a higher incidents and higher mortality from prostate cancer than whites. Hispanics have a higher prevalence off gastric cancer, and different areas among the Hispanic population have a higher prevalence of gastric cancer compared to other areas of the Hispanics, our population and then as you also have the smoking related tumors, which they're The prevalence depends on on the prevalence of cigarette smoking on. Then you have the HPV independent tumors, where access plays a huge role particularly, for example, in cervical cancer. So if the women don't have access to Pap smears or they're not having HPV vaccination, then they have a much higher prevalence. And that seemed in the Hispanic on the African American populations. Yeah, that's great information and transitioning to the impact of Covic on your practice. What have you guys found in the oncology world as it regards toe access and Covic, or just any conditions associated with co vid and oncology? Yeah. No, I mean, Corbyn has affected all of us in all areas of medicine, in oncology, in particular because of the potential devastating effect of Accavitti infection on a cancer patient who is undergoing chemotherapy, and the concerns that if the patient gets copied right after chemotherapy, their outcome maybe worse. So there have bean registries off cancer patients that get covered, national and international registries that have been created and data is coming out regarding thea the risks off dying from covet. If you have cancer on the data is not conclusive. Cancer patients have a higher prevalence of commerce abilities that had been associating with higher mortality from covet like hypertension, heart disease and obesity. So it isn't clear whether those come abilities are the reason why there had been an increased mortality seen in cancer patients or whether it is related to the cancer disease per se. Some of the data from those large registries suggests that perhaps long cancer patients in particular may be at higher risk on he mythological malignancy. Patients may be at higher risk, but but it isn't totally clear. It seems like if the patients that had chemotherapy within a short time off getting coveted there may be at high risk of having a worse outcome. But even that the data there is not conclusive as well. The data is, uh, confusing, because many times, for example, if a patient has a metastatic lung cancer was undergoing treatment and gets covet and develops respiratory problems many times, the fact that they have metastatic cancer plays a significant role in their decisions to undergo further aggressive management off their Kobe disease. On that is noted in some of the scientific reports that have been published since the cockpit pandemic, where, for example, in one of the reports, it stated that only 20% of the patients with cancer who died off Cove it where were receiving respiratory support. So that to me tells me that many times the decision is made not to proceed with more aggressive treatment because of the metastatic cancer. So it may not be that they had a higher mortality from the cancer is just a decision was made not to proceed with aggressive management. Eso there's It's a confusing aspect, but it definitely has had an impact for us because we, because of the concerns which are right, concerns about whether the patients who receive chemo have a higher mortality from covet. We have bean very proactively testing all of our patients before each cycle of chemotherapy. And if they test positive and if it is in their best interest not to receive the chemotherapy, try to withhold the chemotherapy until the covet infection clears and then resuming the chemotherapy at that point. So that's sort of how we have approached it. Thank God. In our practice where we are, we have not had a no overwhelming covered infection situation. Eso it hasn't bean. I hasn't had a huge impact on our practice at this time. That's great. Are there any other safety precautions you're taking within the institution or within your clinic? For those patients who may be called Kobe positive or just in general, trying to make sure that the patients who are negative and coming to see you are protected Yes way have bean limiting the number off the family members who can come with the patient for their chemo or can be with them in the room to one of the most. We test every patient who comes into the building for fevers, and we asked them if they had had any symptoms that suggest active, coveting infection. And if so, we don't allow them to come to the building. We've tried to minimize the staff who is in the building, uh, trying to have the stuff that that is not essential to be in the building to, uh, to serve us from home, run and coming. We screen all the stuff before they come in the building for symptoms off coverage. We also have mandatory masking Andi social distancing among the staff and among the patients on the practice. And we're constantly sterilizing and cleaning our facilities to try to minimize, minimize spreading off the disease. So those are some of the measures that we have established here throughout the Mayo Clinic to not just in our practice of oncology. Yeah, certainly there's lots of kids or patients and just patients in general who are very concerned about their risk factors outside of the hospital. In regards to Covic, are there any recommendations were given to patients when they're not in hospital getting treatment in order to protect themselves? Yes, we stress to them the importance of social distancing and mask on. DTI tried to avoid contact with anybody who has any symptoms trying to minimize contact with other individuals. Try to avoid indoor space where there's a lot of where there's crowds. Andi, those are some and then to report to us any symptoms way. Try to stress to the patients that our facilities are probably a safe place for them to come and to have their care that they need. So it's very important because they're significant concern that patients are not coming to receive the treatment that they need and that that's gonna have a very negative impact on their survivor ship of their cancer. So we try to stress that to the patients who not delay the care that they need in view of the copy pandemic. Um, great. Any final parting thoughts or about health care disparities, or what you guys have been dealing with from oncology that you want to share with our viewers? Yeah. No, I I think the copy pandemic has uncovered the huge disparities that exist in health care in our country. On Dio to a great extent, that's due to our health care system on how it is designed and established. Andi, Hopefully, um, action will be taken to address his disparities. Eyes definitely needed is not something new eyes, something that has bean existing for a long time. Andi, Historically, for centuries, pandemics had always affected the lower socio economic status individuals and unfortunately, it has not led to action to solve those problems. But we've we've made some progress and hopefully with the increase awareness within our society, this will bring very much needed change eso that we can eliminate this disparities that I think personally and I'm speaking just for myself. I believe health care is a human right on he's, and it's something that every human should have access to. Andi shouldn't be dependent on whether they have a job or not, or whether they lost a job or whether they can afford health insurance or not. Andi, I think it's a moral obligation for health systems, particularly non for profit health system, to proactively address his health care. These priorities that exists in our country. Great. Thank you. That was really valuable information. And I'm sure everyone will get a lot out of it. I appreciate your time and your participation. Thank you, Dr Donaldson. Have a good day. Thank you very much for that perspective, Dr Cologne. Now I'd like to move to another specialty with us today. We also have the director of clinical practice for dermatology here in Mayo Clinic in Florida. Dr. Yemi Sakombi. She's an associate professor of dermatology. She's also an associate program director for the dermatology residency program. She's co chair of the Mayo Clinic. Alex School of Medicine, Diversity and Inclusion Council. Dr. Sakombi. Thank you so much, Dr Porter, for the opportunity to speak and talk about the disparities as we deal with this cove in 19 Pandemic as it pertains to my specialty in dermatology. Now dermatology. As you all know, it's the study of the skin and the skin being the largest organ in the body. It's also, of course, the specialty that we use for this political and social constructs that we call race. So determining the skin type of determine once one's race is based on what the skin looks like, typically what we call our Fitzpatrick skin types. I mentioned this as an introduction because when we look at the United States and we look at what we expect in the future with race by the year 2050 we estimate that about half of the United States population will actually be considered skin of color. Them is there will be more darkest skin types than we have the lighter skin types. The reason why that's particularly important is when we look at health disparities as it relates to dermatology. Just in general way cannot have this conversation before without considering what we have in terms of dermatology Workforce. As Dr Porter mentioned, we have about 13 to 14% of the United States population is considered African American black skin types. However, when we look at our dermatology workforce, about 2 to 3% of dermatologists are skin of color. Dermatologist. When we look at our Hispanic population with 16% Hispanics, we have only about 4% represented in dermatology. This huge disparity when we look at the field in general has significant effects. When we think about how we approach our patients of color has significant effect, as we think about research opportunities and therapeutic options for patients who have skin of color who are seen by dermatologists. More concerning is Recently we've been looking at survey data, and we have about 47 to 50% off dermatologists graduating from training programs within the United States, stating that they do not have comfort level off. They do not feel prepared to take care of patients off color because they were not trained adequately representing all skin types. This is problematic when we think about skin cancers or we think about inflammatory Dermot Oh sis, I'll use melanoma as an example. Melanoma is the most deadly skin cancer. About 100 100,000 Americans, or so we'll have a new diagnosis of melanoma in the year 2020 About 7000 folks patients will die off the diagnosis from their melanoma. Now, if you look at race in melanoma, melanoma is actually a disease more commonly seen in Caucasian skin. So the lighter skin types, in fact about 20 times more likely compared to dark skin types. If we looked at the numbers about 20 to 30 per 100,000 in terms of incidents of melanoma in Caucasian skin versus about one per 100,000 in black skin. Despite this disparage incidence of melanoma, if you had melanoma as a black person, you're more likely to die of melanoma than Caucasian person. That's problematic. When we look at the five year survival for melanoma, it's about 92% in a Caucasian and about 74% in African Americans. This lets us know that even though the diagnosis is 20 times more common or, more likely in a Caucasian skin, if you're black and you have melanoma, you're more likely to die off your melanoma than someone off a lighter skin tone on. I think that when we look at the data, you try to break it down. They've looked at things like, Is it an access to care problems? Certainly, that plays a role when you look at the numbers of dermatologists and access to dermatology issues with, of course, low socioeconomic status and access to insurance. All of these play a role in the late diagnosis of patients of color with melanoma. However, if you were to control for insurance and also actually control for a stage of diagnosis, the definitive treatment for melanoma is surgical is a surgical modality. However, we've done studies showing that the time to definitive surgery comparing a Caucasian patient to a patient of color. The lack time is problematic. So not only are we dealing with the disparity in terms of late diagnosis, dealing with desperate with access to care, we have to figure out when they do get the diagnosis. Why are they getting treatments later? All of these air problems that currently plagued the specialty when we look at inflammatory door Matos is particularly, I like to use a disease that commonly affect black women, a condition that I'm interested in refer to as 190 super TVA. It's a condition that deals with inflammatory boils Nah, Jal's abscesses, a current in the inguinal areas in the x illa and you know, we have all of we know all of the risk factors. It's more common at least three times more common in a black person than in a Caucasian person. However, when we look at treatment options and we look at the clinical trials and how we've decided on our standard of care for this particular problem, or all of our trials were done in Caucasian skin, and once again we see that lack of representation, which lets us know when we're taking care of patients. How do we know that we're treating our skin of color patients appropriately when we didn't even try the treatments in these patients? When we look at emerging data with some of our complicated Dermot asses like psoriasis, a topic dermatitis, the data stays the same thing. Emergent treatments. New treatments are not often offered to skin of color on, they're not usually getting the standard of care. So I tie in my point about the workforce because I think that the lack of representation in our workforce spirals down to whereby we're not looking at these diseases were not studying the diseases that are currents can of color patients on. Of course, when you look at the disparities, we don't have enough access. And all of this just comes upto a big issue that has become the forefront in dermatology. Now, when we think about the Cove in 19 Pandemic and how it's affected our dermatology practice recently, just like most medical specialties, we've had to reevaluate what we've consider urgent. A difficulty dilemma, actually, because dermatology is known for more be a lot of morbid conditions, not necessarily increased mortality. The conditions. So here we are deciding what's urgent and really triage in on what we find is sometimes this chronic dermatitis is such as this 190 super TVA. They get put in the non urgent category, and so we have this lack time where patients are suffering and do not have access to care for these problems on. Of course, we have to think about safety issues we've incorporated tell the dermatology, as most as most folks have had to do on important component in that is considering. Is this going to become a new social determinant of health because to have a good telly dermatology visit. You need, of course, great Internet access, and you need access to technology. And when we look at the data in terms of folks who can afford thes, we know that they're definitely not the patients from low socioeconomic status. And so that further expands the disparity as we care for dermatologic conditions during during this pandemic. Now we have patients who have inflammatory dermatitis is that we tend to treat with immuno suppressive medications. Thes medications modified the immune system sometimes suppress the immune system on when you're dealing with an infection, such as co vid 19 off course. Physicians now worry about discontinuing medication initiated medications while we're dealing with a deadly pandemic. Now, patients who have had chronic conditions Ah, lot of the patients. The data has shown that while it's okay to keep patients on the condition on the medication, I'm sorry you have tow have constant contact with your doctor, reevaluating deciding whether it's okay to continue. The immuno suppressive medication on the recommendation has been released that if you do actually have a new dermatologic condition, inflammatory condition that might require these immuno suppressive immuno module A Torrey treatments most dermatologists air holding off, waiting for things to calm down because of the risk of increasing of altering the immune system during during the pandemic. Finally, when I think about the exposure off the disparities within within dermatology, I think of in the early days when our colleagues in Europe were reporting dermatologic findings and patients with Cove it 19 everyone was reporting where what organs might be involved in Cove it and that the literature from Spain literature from Italy. We started getting data about cutaneous manifestations of cove it shortly here within the United States, we started reporting cutaneous manifestations Off Cove in 19. What was particularly important was there was a variety off clinical presentations that informed either actually severe disease. There were presentations that actually represented clue to early diagnoses. There were presentations that suggested a patient might do well, and so we were all yearning for for publications and the scientific literature to help us learn, learn about the manifestation so that we could be prepared to take care of our patients. And so the publications started being reported. Um, paper that was released in May was significantly helpful in just highlighting the disparities in dermatology because by the time we looked at over 130 or so images in our medical literature during the pandemic, none off. The clinical images showed patients with Fitzpatrick skin types five and six, so that would be a skin color such as mine that's considered a skin color that does not burn. That's how we determine the Fitzpatrick skin types. And so I when, when those of us who are skin of color dermatologist take a look in the literature on. We're in the process of trying to educate our colleagues about skin of color. It becomes problematic where there is nothing in the literature showing you what you're looking for, which prevents you from teaching your residents prevents us from educating our future learners about Dermot ASUs, specifically when they when they looked at the data of all of the photos that were in the literature about cutaneous manifestations of cove it 92% of the images represented Caucasian skin, so our so called Fitzpatrick's skin types 123 those air skin types that typically burn. We had 6% representing Fitzpatrick skin type force without be a lighter brown hue, but a color that might still burn on then, none at all. In the medical literature demonstrating these skin types that we need toe learn these skin types that might represent early clues these skin types that might represent significant outcomes or poor outcomes. There are no photos for us to learn from. Even more worrisome is when you look at that and think about the data that Dr Porter presented or the data that we're all aware of that you have 13% off our population. Being African American, we have this disparate number of patients with co vid 19 so about 30% so disproportionate to the population itself. And so we know we have patients who have co vid 19. We know we have patients who have cutaneous manifestations of covert 19 but there were none to be found for us to teach our learners for us to learn and to help prepare ourselves to take care of these patients, we discovered that the Pernia, like what we refer to as chill blames in dermatology type presentation can be an early clue to diagnosis on. Do you have to think about the disparity of the folks? The 47% dermatologist who say they're not comfortable. They're not prepared. They don't feel comfortable taking care of dark skin types. Isn't it possible that they've missed this diagnosis? That could have been an early clue that could have been picked up early. That could lead to a better outcome than the delayed presentations that might have occurred. Similarly, when we looked at a conditioned the same condition 190 Super TVA and we looked at the co morbidity is associated with that is hypertension, diabetes, cardiovascular risk factors, smoking Some of the things Dr Porter talked about when he was referring to the the risk factors for co vid. So now we have a significant overlap between the risk factors of cove in and risk factors. Off 190 super TVA, Andi the black patients. The black female patients are the ones most likely to have this condition. So now the idea being is there even an increased risk in these patients for covert 19 because they certainly share all the co mobility's of covert 19 on. On top of that, there are on immune modulator torrey medications. We suppress their immune systems to help them deal with this awful disease. All of these things expose the disparities that occur in our specialties. On our need to really change the way we look at things to make sure that we have curriculum preparing our train needs to take care of patients of color on, of course, to allow the growth of the specialty so that we have more physicians of color in this specialty so that we're prepared to care for our patients. Thank you for that perspective, Dr Sakombi. We will come back together, toe, discuss a few more points following our next Panelist. I'd like to present Dr Marcia Robinson. Dr. Robinson is jointly appointed in neurology and in family medicine. She is the medical director for Palliative Care It Mayo Clinic in Florida. Dr. Robinson. Thank you, Dr Porter. So when we think about palliative medicine, we think about really a specialty that aims to recognize, prevent and alleviate suffering of all forms for people that have a seriously advanced medical condition. And we try to really improve quality of life for people at any age and any stage independent of whether the goal is curative or to provide care as people are undergoing therapy for perhaps terminal conditions so the senator advance Palliative care suggests that about 94% of hospitals that have 300 beds or more have a palliative medicine team. About 72% of hospitals that have at least 50 beds or more have a palliative medicine team. But what we know is that about 60% of hospitals that are public in nature of the safety net hospitals have a palliative medicine team. And so there is already some disparity with regard to access to palliative care, particularly for minority populations. There are also more specific disparities when we think about access to pain medications minority communities. Some pharmacies are less likely. Thio carry some of the opioids that patients require, and therefore they're less likely to be able to get the pain management that they need. We think about this where it is in communication. The data suggests that particularly Hispanic and African American patients are less likely to have the same degree of empathy shown during physician and patient communication. As Caucasian patients. We think about the the spirit in the provision of preference Concordes into care, So even when wishes air, no minority patients are less likely to get the kind of care that they were hoping for. When we think about palliative care in general, a large role for a palliative care physician and providers to think about advance care planning as well. And although we know advanced care planning occurs less frequently in general than it should in the United States, there is certainly a notable difference in the completion of advance care planning in minority communities, African American and Hispanic vs Caucasian. And I think there are a number of barriers and considerations that we have to look at when we think about the reasons behind this. The first would be cultural issues, you know, particularly minority culture. It can be challenging to accept the need for palliative cure discussions about end of life care and hospice care. We think about faith and religion. If God's going toe take care of it, then why do we need toe plan? But this we think about the differences in the discussion about palliative care and hospice care. Physicians may be less likely to bring it up to patients in minority backgrounds, and then we think about the mistrust of the health care system. Many people, particularly and think about the African American community. Think about Tuskegee. But this predated Tuskegee. We think about people are slaves, taking them to the operating room and operating without the use of anesthesia. We think about, uh, grave diggers and playing up bodies of African Americans while people were learning anatomy. We think about what it's still going on in the health care system. So it's not even just a history of mistrust, but even a current time of mistrust of the health care system. Then we also think about just general access to care. If you're less likely to be diagnosed early on and begin to get a diagnosis much later in the disease course, it could be more challenging toe. Just have a diagnosis and then move to thinking about end of life care. So those were just some of the considerations with regard to disparities that we see, particularly in palliative care, maybe just a few considerations, particularly in the time of co vid. When we think about palliative medicine, we think about four essential things that the teams provide that we help with symptom management. We help caregiver support, we help with goals of care and we help with advanced care planning. We think about symptom management. Usually we're at the bedside, seeing our patients being close to them, being able to evaluate and examine them. And during the time of Covic, because of a need to try to decrease exposure to the virus. We've been doing much of this virtually and so some of the symptom management. While we can see on video or zoom calls or in conversations on the phone, people can tell us what some of the symptoms are. It becomes a little bit more challenging to ensure that we are adequately capturing all of the symptoms that patients have, and we think about caregiver support. We think about the necessary visitor restrictions and hospitals or in residential facilities, and therefore we're trying to figure out how do we provide support to care givers in a very unusual circumstance. And some of that includes being proactive in terms of calling family members that includes involving the interdisciplinary palliative care team and so getting the social worker involved to provide some emotional support. Two caregivers having the chaplain or spiritual advisers involved, provide some support for caregivers and then having the clinicians also available to be able to give regular updates as well on their loved ones. Conditions. We think about goals of care. Many people say. Can you really do that? Virtually? Can you establish report? Can you have a connection with patients and their family members? Virtually. And what we found was that, yes, we can. In fact, our procedure is the conversation, and some might say we're even uniquely tailored to a time such as Kobe because we're able toe have those conversations with our patients and family members, whether that's in a virtual for matter on the phone. But we have had Thio take some considerations in mind. And so when family members are bringing their patients, particularly to the hospital, and when they see them walk in with perhaps a little shortness of breath and being called a few days later, there's a discussion about intubation, or perhaps withdrawal of life sustaining measures. It can be challenging to have those conversations when loved ones have not seen, uh, their their loved one and the patient in the hospital for a long period of time. And so we've had to figure out how do we bring people together using virtual technologies they can at least try to see their loved ones were trying to have these very challenging conversations. The last thing is advanced care planning, and so and we think about not only the patients who are directly impacted by Kobe, but there are certainly patients in the hospital as well that we're sitting down with and discussing what people's wishes and preferences are for end of life care. And we have toe think about those patients and some of the indirect consequences of they needed procedural changes and institutional policies that have gone into place because of co vid and really thinking about How do we support these patients that they're thinking about their wishes with other medical conditions that may lead to end of life care With regard to some of the safety precautions? As I mentioned, we are doing much more from a virtual standpoint in an effort to reduce exposure that we're following CDC guidelines apart of palliative medicine, which is an umbrella term in terms of focusing on quality of life for people with serious advanced medical conditions. Uh huh. Hospice care is in that realm, and so we think about hospice care. We think about specific care for people who have, ah condition where life expectancy a six months or less if the condition progresses in its normal fashion. And so, uh, hospice teams are often going toe people's houses. And so they've been following CDC guidelines about what PP needs to be worn on. Also counseling family members and loved ones and caregivers about how to reduce exposure at a very critical time in people's lives, where touching hand holding being at the bedside is often thought to be very important. And so there have been some necessary accommodations made for the hospice teams and palliative care teams going into the homes, particularly during the time of Cove. It thank you for that perspective, Dr Robinson. Now, I'd like to ask a few follow up questions if I could, and also bring back doctor Succumb. Be, um I find it interesting that a lot of the points that we've all spoken of, uh, kind of have a similar foundation. So it crosses all specialties, um, and even crosses the things we talked about it. It crosses disease. Diagnosis. Um, it talk, it crosses into how we perceive the care that we receive and I guess. One of the first questions I'd like to ask doctors accompany you mentioned. Race is a social construct and the damage that that has done to your specialty. And I guess what I would ask is do you feel that the data that is present right now that is based off of this off this social construct that we've created will bore out as Mawr and more people, um will will fit that mixed race definition? I think so. I I think I think that that's you know, when you look at the data, even when you look at what? What what? Um well, what folks are expecting in terms of 2025 I gave the data for 2020 50 where we anticipate that half of the country will be considered skin of color. And so what that means is, this is this is the skin of color. Population would be per projected to really be become the majority on the data already suggests that you know when when we look at what we define a skin of color in dermatology. Like I said, we use the Fitzpatrick skin types and they're based on whether or not a patient burns when they're out in the sun. On the predominant skin types have been the Fitzpatrick skin types one through three with the skin types for introducing some color and then skin types. Five and skin types. Six. Being black skin because of what we're seeing in terms of interracial marriages, inter racial procreation, I think that we're going to be going down the other spectrum, whereby the Fitzpatrick skin types 45 and six will be the predominant color that will be seen on. That has significant impact when you have a specialist within the field not trained to care for that skin type. So I think it will quickly become problematic for the ability for physicians within the United States to provide good dermatologic care. Excellent points. Um, Dr Robinson for you. I mean, the first thing you said was addressing quality of life and issues that patients are dealing with, um, not necessarily end of life issues, but just quality of life. And if we think about the impact this has had on certain populations and we think about the additional grief, we think about the additional social idealization, that's excuse me, isolation. That's absolutely necessary. I mean, that's had to have major job that much more difficult. I think you're absolutely correct. This has been a very challenging time for many patients, particularly those living with serious advanced medical conditions, some of whom already we're feeling some sense of isolation. But they had caregivers, for instance, that were coming to the house to assist. They had other family members and friends who are coming to the house to assist. And as you can imagine, many of that, those people in the additional assistance has decreased during the time of Kobe. So palliative and hospice care teams have tried to be as proactive as possible and reaching out to these patients and to the caregivers who are still present to ensure that we can provide support. And sometimes it's not about managing a specific symptom or prescribing a specific medication, but it's really just letting them know that somebody is thinking of them and caring about them. And so I think we've had to be somewhat more creative and proactive delight in this time of cove, it very appreciative of the work that you do. Um, Dr Robertson, you also brought up reasons why it may be more difficult for you to provide care. Talked about cultural differences. You talked about issues with faith or religion having the discussion itself. Mistrust. Ah, you know, I think about the same reasons why there aren't Mawr minorities that air in, ah, lot of the clinical trials that we dio And you know, distrust definitely goes to the top of the list, but also just the cost itself the cost of travel. Um, you also have to add in health literacy. And so a question, Dr Sakombi, I guess, uh, especially with your interest in education and being a part of the dermatology residency, Um, with the lack of minority care providers, Do you think that that also plays a role in the lack of study, inclusion Or, you know, or do you think that this is more so just related to those baseline foundational factors that we spoke of before? No, I definitely think that it plays a huge role in study inclusion. I use myself as an example here in our local area here in Jacksonville. Within this catchment area, I represent the only black dermatologist within the area on That's particularly the reason why it's important to mention that is because of the distrust Dr Robinson has mentioned. Oftentimes I have patients who have been to other dermatologist, competent dermatologist, even who are of a different race than they are. But there is the perception that that cultural competency that they're not able to get on that build that poor and that trust that they can get now, I don't think I think that for our system within skiff in dermatology to be we need our patients to see all doctors of all skin types. The point is, though, that we need cultural competency because when you can build that report and really have that diversity in the workforce will do so much better with recruiting patients for clinical trials. And so I found myself partner with colleagues, even colleagues studying diseases that I'm not particularly interested in but invested because I know that those diseases particularly affect skin of color patients, because my presence there helps with that mistrust, because the reason why we're not getting these treatments for some of the inflammatory door mottos is I talked to you about Dr Porter is because we just don't have the data on how our skin of color. Patients respond to these treatments, even though they're the ones who bear the burden off the disease. And so I spend a lot of time educating them, saying we cannot find a solution or treatment if you don't participate in this. But that mistrust is there. And so it is. It is particularly important that the workforce looks like the country because the mistresses Onley really widened or expands when, really, ah, person who looks like them is a rare breed within the specialty. Yes, excellent points. I mean, I as you're speaking, I just think about original clinical trials on rendez severe and other treatments. And for Kobe 19 that had abysmal inclusion rates for minority popular 2025% or less population rates. Uh, it just doesn't seem like we're gonna get the answers that we need to do. If we do it that way and Dr Robinson to speak on the same topic, I would imagine that that level of cultural competency probably allows you to reach more people in your position. Would you agree with that? I agree, you know, we think about particularly with African Americans, over the course of their lifetimes. They're less likely to have cardiac procedures completed. Fewer life saving medications prescribed, fewer opioids prescribed. So it's kind of significantly lower spending in the last two years of life. But we think about in the last year of life African Americans are more likely to be admitted to the I. C U to receive intensive therapy such as resuscitation, mechanical ventilation, pig to placement. And so we know this data. Many palliative care physicians know this data, but the question is why? And those of us who have some first hand knowledge frequent in the African American community, able to say, Well, what are the reasons behind why African Americans are more likely toe want life prolonging measures at the end of life? And that could be, I think, challenging sometimes toe fully understand, but because I understand the culture, but because I understand that some of the religious practices and some of the concerns about faith and quote unquote playing God to play, we get to the end of life because I understand some of the language that people are using and some of the family structures on the need for ensuring that family members and community members are also on board and so less autonomy. But what is usually best for the family and best for the community that does allow me in many ways to connect with patients and provide often race concordant care, perhaps on an easier way. Yes, very excellent points. Uh, you both briefly spoke of to the piece of telemedicine while also speaking to some of the disparities that make that difficult, uh, overcoming the technical issues, overcoming Internet access issues. Can either of you speak to any best practices that might help assed faras installing such a program? So to try to reach these communities that, um, you know, historically, we haven't been able to. And so even though in in dermatology we implemented Tele Dermatology as a way to keep patients away from the clinic space and from the hospital during really the peak off the Covic 19 pandemic, one of the things that we struggled with and I think will remain a struggle as we continue to figure out how to implement dermatology, is how do you adequately examine someone's skin via video? And it's challenging because, especially when you think about the minority population, we talked about Internet access. We talked about devices having the appropriate device to be able to have a good Kelly visit. Some of the things we should think about is even language barriers, access to interpreters. All of these limit the ability to actually have a successful telly telly health visit. And so those were some of the challenges that I think are out there in terms off providing access to our communities of color, with good with goods, telly, medicine, and to incorporate that all of these things have to be really addressed. Do they have good Internet access? Do they have access to devices? How about the language barrier? Do you have some support there to help with adequate interpretation? Because it's not enough to see the patient it's really getting through to the patient on it becomes more important than even the face to face encounter to really connect with a patient. I think all of those components have to be really in place to have a successful telly medicine, medical encounter, excellent points, any additional thoughts as's faras telemedicine from your end and any lessons learned. Dr Robinson. I think all of this has to be personalized And so we can't assume that a one size fits all for all people, all patients, all families and all communities. Azad just gonna be mentioned. You know, some of the challenges that we have had making sure that we have interpreters available, because when we talk about goals of care and in the life care and hospice care, that may mean different things to different people, particularly based upon their culture. And it can be interpreted or misinterpreted. Uh, particularly when we're not using an interpreter and so ensuring that we have interpreters. Part of some of our zoom calls for our patients who do not speak English has been very important for us. The other thing, I'll say, is that incorporating family members has also been quite useful, particularly for our zoom cause. We see people at many different parts of the age spectrum, and it could be helpful toe have family members at the bedside because sometimes there's a hearing impairment as well, and it's more challenging for some of our palliative care patients to be able to hear us via zoom, and so it could be helpful toe. Have family members there ensure that we're all hearing at the same thing and to make sure that we are understanding what they're trying to say to us as well. And so I think ensuring that the environment is right, that the right people are part of the conversation, Uh, and that we have the right medical team involved with regard to medical interpreters is useful as well. Wonderful points again. I find it very interesting that this these foundational aspects of health care disparities that we see in the treatment, the diagnosis, the access when patients get treatment are they kind of run in parallel and all of our different specialties, the foundations were all the same. The problems. We're all the same. I think about the differences in the estimated G f r and serum creatinine values. And what changes in how we, uh, classify race will mean for that from a nephrology perspective and what you've just brought the light about. Some of the changes in dermatology are like I said, I e just find it very, very enlightening. And it just showcases a lot of the work that still remains to be done for us to address thes thes health care disparities. Um, I would really like to thank all three of the Panelists today. I'm Dr Cologne. Um, Dr Robinson Doctors Company. Thank you very much for your time and perspective on the different medical subspecialties. Thank you very much, Dr Porter. Thank you for having me.