An Everyday Practice: Creating a Culture of Belonging to Transform Health Care

An Everyday Practice: Creating a Culture of Belonging to Transform Health Care

On March 11, 2020, the World Health Organization officially declared the COVID-19 virus a pandemic. Two days later, on March 13, Breonna Taylor, a 26-year-old Black woman working as an emergency medical technician, was killed by the police in her apartment. Ten weeks later, on May 25, the world watched a viral video of George Floyd, an unarmed Black man, being killed by Minneapolis police officer Derek Chauvin. The tragedy sparked massive Black Lives Matter protests in at least 140 U.S. cities and across the world, with millions of people taking to the streets against police violence.

Amid a national climate of virulent political dissent and economic uncertainty, the pandemic left us vulnerable in unexpected ways and triggered a series of complicated challenges: misinformation, quarantines, fear, ongoing racial injustice, COVID-19 deaths, and a race to find a vaccine. Some have opined that with the world in lockdown, deep within the confines of our collective conscience, a conundrum emerged: When the world is diagnosed with a virus, will people begin to look for cures to other viruses that plague society, like racism?

Of course, the road to eradicate the world of social ills like racism is, to paraphrase Dr. Martin Luther King Jr., tied to the long and slow bending arc of the moral universe. While these historical events raised national awareness around equity, they only made the Department of Medicine more resolute in its mission and ongoing work in health disparities, diversity, equity, and inclusion. Work such as forming a Diversity and Inclusion Council in 2018 and a Medicine Residency Diversity Committee, revamping the faculty search committee’s processes, and launching awards programs for diversity work has expanded the department’s understanding of what it takes to create an inclusive culture. But by fall 2020, after almost a year of multiple social and political inflection points in America, it became clear that the arc was bending only incrementally, and the work could go further.

On Nov. 13, 2020, Robert A. Harrington, MD, chair of the Department of Medicine, announced the appointment of Wendy Caceres, MD, clinical assistant professor of primary care and population health, and Tamara Dunn, MD, clinical assistant professor of hematology, to the new roles of associate chairs of diversity and inclusion for the Department of Medicine.

“Wendy and Tamara are uniquely suited to these roles,” says Harrington. “They have been instrumental in reshaping the Department of Medicine’s priorities and culture. As associate chairs, they will represent the Department of Medicine institutionally and will help us develop strategies and metrics that move us closer to our diversity and inclusion goals.”

Begin With Belonging

As women of color pursuing careers in medicine, both Dunn and Caceres arrived at Stanford with a passion to heal as well as a commitment to elevating diversity, equity, and inclusion across every facet in health care. They met after the historic and turbulent 2016 presidential election at a series of networking events hosted by the Stanford University School of Medicine.

“I had been a med student and resident here and Tamara had been a resident and fellow, but our work had never overlapped,” recalls Caceres. “It was a challenging time, with everyone in a state of shock after the election, and the community was getting galvanized around the racist rhetoric coming out of the White House.”

Less than a year later, that racist rhetoric boiled over into hate-fueled violence and death at a “Unite the Right” rally in Charlottesville, Virginia. Many across the nation were horrified. But violent, racist incidents continued. As the national attention on race heightened, it became clear to Caceres and Dunn that their work in diversity and inclusion might take on a deeper meaning.

As the nation became more polarized, the idea of cultivating safe spaces and reevaluating what it meant to be true to one’s authentic self at work became more and more important. And although Dunn and Caceres come from different backgrounds and parts of the country, their origin stories were rooted with the same ingredient: belonging.

From an early age, they learned the importance of fostering community—holding fast to an almost inarticulable feeling that instills one’s sense of pride, safety, and destiny—in the midst of an often-exclusionary, sometimes hostile world.

Wendy Caceres, MD

Caceres was nurtured within a tight community of color where a need to create safe spaces started at home. As she grew up in the Washington Heights neighborhood of New York City, a community of people mostly from the Dominican Republic, her early childhood was informed by colorism.

“My family is from a country that’s very mired in black-white tensions,” she says, referring to the colonial shared history between Haiti and the Dominican Republic. “And in my family, I have people of all skin tones, and I grew up not understanding why my lighter-skinned relatives would say, in my mind as a child, mean things about my darker-skinned relatives, who I adored. I always thought it was unjust.”

Growing up, Caceres was fiercely protective of her grandmother, who she describes as “essentially Black.” When Caceres became an attending physician, her grandmother unfortunately was diagnosed with a rare occurrence of two simultaneous lung cancers—so Caceres flew to New York once a month to go to her medical appointments and advocate for her.

Says Caceres: “I had to make sure she was getting all the care that she needed when she was getting her oncologic treatment. I would be at her side at clinic visits with the specialists, at her side while she was hospitalized, at her side when we transitioned to hospice—and I do not think they expected to have a Stanford-trained physician as her granddaughter at her side much of the time. There were also times I was not there, and those times the classic things were missed. We’ve all read the literature of how Black people’s pain is dismissed. Her pain in her arm at a clinic visit was dismissed when it turned out to be cervical radiculopathy from the tumor impinging on her spine, a missed diagnosis quickly leading to quadriplegia that was also missed in a busy New York City ER after a fall at home. By the time I arrived as she was arriving home after discharge from the ER and did my own physical exam, I called 911 to get her back to the hospital to get the appropriate diagnosis. And I was at her side when, on reviewing everything, I helped my family transition to hospice. It was something I had to do, and I hope it made a difference.”

Tamara Dunn, MD

Dunn had the benefit of being part of a close-knit African American community in Kansas City, Kansas, and watching her dad, a dentist, provide oral health care to his patients.

“My interest in medicine came from my dad. Many of his friends were Black physicians, and they inspired me,” says Dunn, who is the first medical doctor in her family. “My story reemphasizes how much representation matters. It is invaluable to see people who look like you in certain roles, because then you believe you can see yourself in that same position. It becomes second nature.”

The communities that nurtured and raised both Caceres and Dunn gave them a deep sense of what it feels like to share a common purpose and carry on a tradition of lifting as they climb.

The reason I’m passionate about diversity, equity, and inclusion (DEI) work is because it’s part of my lived experience as a Black woman,” Dunn says.

“And it’s not surprising that so many of us that come from marginalized groups want to do this work because we want to help and inspire those who look like us.”

And while helping others is often part of the reason most people pursue a career in medicine, if that calling is answered by a caregiver of color, it often comes with personal, sometimes traumatic, experiences that highlight the gaps in health care for all.

Many years ago, Dunn’s cousin had a chronic gastrointestinal issue, but her concerns were not taken seriously. There was a history of colon cancer in the family, including her mother (Dunn’s aunt), who had died of colon cancer at age 62. By the time her cousin finally received a colonoscopy, she had aggressive colon cancer that ended her life four weeks later, at age 42.

Physicians Sharing Stories

After the tragic killing of George Floyd, several staff members of the Department of Medicine shared their personal views about racism and the need to diversify medicine. Uri Ladabaum, MD, professor of medicine, penned an essay titled “Life After May 25” for Annals of Internal Medicine. In the piece, he highlights how differences in access and quality of health care resulted in a better outcome for his immigrant father compared with a colleague’s father.

“My father died of congestive heart failure in 2018 at age 82,” Ladabaum wrote. “A Black colleague recently told me that she lost her Daddy when he was 56 to heart disease complicating diabetes and hypertension. He did not have good access to health care. It is painful to face how my father, immigrant to this country by choice, saw his grandchildren thrive while my colleague’s father, descendant of slaves, did not even meet his grandchildren, largely because of the color of their skin.”

“Why are there more complications in Black

patients? Are our arteries different, or is the quality received

from the doctor different? There are a lot of times we have

to look in the mirror as physicians and say, ‘Do we care enough?’”

“Why are there more complications in Black

patients? Are our arteries different, or is the quality received

from the doctor different? There are a lot of times we have

to look in the mirror as physicians and say, ‘Do we care enough?’”

It’s a question the Diversity and Inclusion Council has addressed by focusing their efforts on diversifying the ranks.

“We feel that starting with diversifying and educating our department, we will serve our patients better as a more diverse community,” Dunn says. “Educating people who are not from underrepresented backgrounds, and even those who are, to ensure our environment is anti-racist—this is going to directly help change the culture by addressing some of the deleterious downstream effects of structural racism, like implicit bias.”

An Imperative to Diversify

According to the U.S. Census, new population projections indicate that the nation will become “minority white” by 2045. The statistics indicate that whites will make up 49.7% of the population in contrast to 24.6% for Hispanics, 13.1% for Blacks, 7.9% for Asians, and 3.8% for multiracial populations. These trends are being tracked between 2018 and 2060 and show the combined racial minority populations growing by 74%. Conversely, the aging white population will see only a modest growth through 2024 and then experience a long-term decline through 2060.

Despite these changing demographics, a glaring dearth of racial and ethnic diversity among full-time faculty at U.S. medical schools persists. Many doing the work in DEI have said that the most powerful statement we can make is to diversify the field. As patient populations become more diverse, care providers must reflect changes we see in society. This is why the push to diversify the Department of Medicine has been a top priority in recent years.

“There are studies, even by those in our department, that show if physicians and patients have shared backgrounds or experiences, what’s known as concordance, then the patient is more likely to follow the advice that the physician is more likely to offer,” Caceres explains. “We’re trying to make sure that our processes for hiring diverse faculty continue, with the leadership of Bob Harrington and Cathy Garzio, vice chair and director of finance and administration. She has also been a major force in diversifying the Department of Medicine.”

Beyond Disparities

From cancer to cardiovascular health to the COVID-19 virus, communities of color continue to be hardest hit by disparities in health and health care. By the end of 2020, as the pandemic raged on and the death toll mounted, the systemic gaps in our health care policies and practices only highlighted what people working in the DEI space already knew: People of color live shorter, sicker lives.

In a study from the American Heart Association’s COVID-19 Cardiovascular Disease Registry that sought to identify racial/ethnic differences in presentation and outcomes for patients hospitalized with COVID-19, considerable disparities were identified.

Led by Fatima Rodriguez, MD, assistant professor of cardiovascular medicine, researchers found that “Black and Hispanic people made up 58% of all patients hospitalized for COVID-19 and 53% of those who died from the disease.” Comparatively, in the sample, non-Hispanic white people made up only 35.2% of hospitalized people and 21.1% of patients who died from the disease. Additionally, despite being almost 10 years younger than non-Hispanic white patients, Black patients had the highest rates of diabetes, hypertension, and obesity, all of which have been associated with adverse COVID-19 outcomes.

Racial disparities also exist in federal funding for health research. A 2011 National Institutes of Health report, “Race, Ethnicity, and NIH Research Awards” concluded that Black investigators are 10.7% less likely to receive NIH funding compared with white counterparts, even after controlling for factors such as education, training, and experience. According to the study, this is because researchers from underrepresented backgrounds are often more likely to study minoritized communities, and the lack of diversity among research faculty may directly impact the inclusion of Black and brown participants in research studies.

In study after study going back to the early history of medicine education to today, researchers continue to highlight gross inequities in health care. But how do we go beyond addressing the symptoms of social determinants of health and mainstream policies to address root causes?

“If you think of what a Department of Medicine does, it’s the classic tripartite mission of clinical care, research, and education,” Caceres says. “Our roles are broad enough so that we’re trying to influence an equity lens in all the spheres. It should not be just a niche side thing where ‘this group of people’ does health disparities. But that’s what we’ve been doing. These issues need to be central and core to what everyone does, or nothing will change.”

All of Us: Inclusion 2021

In February 2021, the Diversity and Inclusion Council launched Inclusion 2021, a yearlong virtual celebration of diversity with engaging monthly programming and events to make inclusion a practice across the department.

The program kicked off with Black History Month Grand Rounds, which brought nationally recognized diversity and inclusion leaders such as Quinn Capers IV, MD, associate dean for faculty diversity and vice chair for diversity and inclusion in the Department of Internal Medicine at UT Southwestern, and Rhea Boyd, MD, MPH, pediatrician and child and community health advocate, Palo Alto Medical Foundation and UCSF Benioff Children’s Hospital Oakland, to speak about issues such as the critical need to diversify faculty and the politics of representation in health care.

The council’s focus around education and representation resulted in a lineup of all Black diversity leaders to present in February and one presenter in March, which is unprecedented in the department.

“Historically, we’ve usually only had a few Black speakers throughout the entire year, let alone five in a row talking about structural racism and certain disparities in their fields of study,” says Dunn. “Importantly, we will maintain this representation in the future.”

Caceres says the goal is to make issues that only get discussed during Black History Month so central that they are year-round conversations that result in building community. “I think a lot of people are uncomfortable talking about race because not everyone grew up like we did, having to talk about it,” Caceres explains. “I want to equip people with the language and tools to talk about race. More people are now interested in finding out how they can talk about it as opposed to prior times in our history.”

As part of Inclusion 2021, the Diversity and Inclusion Council will present several other engaging programs related to LGBTQ+ issues, social activism in health care, anti-racist book club meetups, and more, as well as partnering with Stephanie Harman, MD, clinical associate professor of medicine. In her role as associate chair for women in the DOM, Harman is also a key member of the Diversity and Inclusion Council, for events such as Women’s History Month and Women in Medicine.

The Road Ahead

These programs are mapping a new blueprint that will help the Diversity and Inclusion Council better fulfill its mission of “reflecting, celebrating, and nurturing diversity … to improve our collective potential to achieve in ways that benefit members of our Department, the entire Stanford community and everyone we serve.”

Some historians have predicted that 2020 may be remembered as much for being the year when a seismic shift occurred in how we perceived race and inclusion in our society as for the deadly toll wreaked by a global pandemic. This shift has given the Diversity and Inclusion Council an opportunity to present the work they were already doing to larger audiences.

Caceres says it’s all about elevating the work.

“The same way that President Biden now has a Cabinet position for science, I think what’s happened in the chair creating these roles. It’s elevating the work to a leadership group,” Caceres says. “So that this ‘lens’ is not lost in the bigger meetings when they’re talking about how to lead the department.”

Going forward, says Dunn, the council will continue to promote a broad array of diversity, equity, and inclusion ideas and activities that bring everyone into the conversation to turn moments into a movement that endures.

“We talk about this racial reckoning that’s happened after George Floyd’s murder,” Dunn says. “But in order for progress to be made, we are going to have to reeducate ourselves. We have recommended things like Isabel Wilkerson’s book Caste and the New York Times’ 1619 Project. There are a whole host of other resources on our website that people can access to ensure that they’re educated and not contributing to the problem and not perpetuating racism. It’s not going to be an overnight process. It’s taken 400 years for us to get to this point, and we’re not going to be able to overturn things overnight … but I’m hopeful. Wendy and I are thankful that we have the support of others in the department (the D&I Council in particular) and the department leadership.”

Programs Making a Difference

In recent years, the Department of Medicine has developed or participated in initiatives that focus on diversifying faculty, recognizing and awarding thought leadership in diversity, pursuing gender equity, highlighting LGBTQ+ issues, addressing health disparities, and more. Here are a few:

Chair Diversity Investigator Awards

The awards provide four grants of $50,000 each to young investigators whose research is focused on diversity, equity, inclusion, and the elimination of health care disparities.

The Annual Meharry-Stanford Initiative

A summer program designed to expose Meharry Medical College students to ongoing research in the Stanford University School of Medicine and build connections between the two institutions.

Faculty Diversity Lens

Faculty Diversity LENS focuses on increasing diversity in faculty recruitment and partners with divisions and search committees to improve recruitment efforts.

The Stanford Internal Medicine Program for Health Equity, Advocacy and Research

Stanford IM HEARs offers training and tools for residents to help address health care disparities.

The Leadership Education in Advancing Diversity Program

A 10-month program started in the pediatrics department “for residents and fellows across graduate medical education to develop leadership and scholarship skills in addressing issues related to equity, diversity and inclusion, and to improve the culture of medicine.”

Resident Working Groups

Resident working groups such as Women in Internal Medicine and the LGBTQ+ Working Group work to create supportive spaces, address unique issues of concern, and expand educational opportunities.