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EPISODE 135: PERSPECTIVES - Dr Monisha Kumar, FNCS

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Description

In this week's episode of Perspectives, Dr Nicholas Morris is joined by Dr Monisha Kumar, FNCS, Professor of Neurology at the Hospital of the University of Pennsylvania to discuss the threats to diversity, equity, and inclusion in neurocritical care.

Contributors

  • Monisha Kumar, MD

    Monisha Kumar, MD FNCS
    BOD Liaison to INCC & Interim Chair of WINCC for the Neurocritical Care Society
    Associate Professor of Neurology, Neurosurgery and Anesthesiology and Critical Care
    Vice Chair, Quality for the Department of Neurology
    Medical Director, Neuro ICU at the Hospital of the University of Pennsylvania (HUP)
    Chair, Penn Forum for Women Faculty

    Dr. Kumar is a neurointensivist and clinical researcher whose area of expertise is in coagulation derangements associated with severe brain injury. She is triple boarded in Neurology, Vascular Neurology and Neurocritical Care. She is an Associate Professor of Neurology, Neurosurgery and Anesthesiology and Critical Care, Vice Chair of Quality for the Department of Neurology, Director of the HUP Neuro ICU, the Physician Lead of the HUP Neuroscience Clinical Effectiveness Team and the former Director of the Penn Neurocritical Care (NCC) Fellowship Program. She has devoted her life to promoting and advancing women of all stripes. She obtained a Bachelor of Arts degree at the University of Michigan and was the first person to create a concentration in Women’s Health and Women’s Studies in the Honors College. She obtained the Doctor of Medicine degree from Medical College of Pennsylvania (MCP)-Hahnemann School of Medicine, a school she intentionally chose for its commitment to the education of women and the care of the underserved. She is passionate about community service and social justice. She completed a residency program in Neurology at MCP-Hahnemann and completed fellowship training in Neurocritical Care at the joint Massachusetts General Hospital/Brigham and Women’s Hospital Partner’s Program. During her tenure at Stanford University, she was part of an all-woman clinical division which was in many ways, revolutionary, for such a nascent field.
    As the Director of the Penn Neurocritical Care Fellowship, the top-ranked program consistently matched more women than men, likely due to the influence and optics of a woman in leadership. As the first woman ICU Director at HUP, she served on the COVID Clinician Surge Council and helped lead Penn Medicine’s response to the pandemic. She also spear-headed the transition of inpatient clinical Neurosciences to the New HUP Pavilion. As a member of the Neurology Department’s IDARE (Inclusion, Diversity and Anti-Racism Efforts) Steering Committee and Co-Chair of the IDARE subcommittee on Intradepartmental Equity, she worked to standardize the procedure for requesting Family Medical Leave, updated the verbiage of departmental policies to be modern and inclusive, created forums for non-physician members of the department, identified funds for the professional development of staff, and sought out awards to recognize the contributions of URM staff. She serves on the scientific programming committee for the American Stroke Association, on the Neuroscience Section of the Society for Critical Care Medicine (SCCM) and on the Board of Directors of the Neurocritical Care Society (NCS). She was the former chair of the NCS Guidelines Committee and is chairing the guideline update on anticoagulant reversal in intracranial hemorrhage, a joint venture between SCCM and NCS. During her tenure as the Neurocritical Care Society’s Guidelines Committee Co-Chair she worked to increase women’s representation on both international guidelines and in leadership positions and participated in research chronicling gender representation on international guidelines.

  • Nicholas A. Morris, MD

    Assistant Professor and Fellowship Director
    Division of Neurocritical Care and Emergency Neurology
    Department of Neurology
    University of Maryland School of Medicine Medicine

  1. 00:00:20
    Hello, and welcome to the Neuro
  2. 00:00:21
    Critical Care Society podcast. I'm your
  3. 00:00:23
    host, Nick Morris, and today I have a
  4. 00:00:26
    very special guest, Dr. Mona Kumar.
  5. 00:00:29
    Dr. Kumar is a full professor of
  6. 00:00:31
    neurology, neurosurgery,
  7. 00:00:33
    anesthesiology, and critical care,
  8. 00:00:35
    vice chair of quality for the department
  9. 00:00:37
    of neurology, director of the neuro ICU
  10. 00:00:39
    at the hospital of the University of
  11. 00:00:40
    Pennsylvania, departmental diversity
  12. 00:00:43
    search advisor, co-chair of the Inside
  13. 00:00:45
    Departmental Equity Committee and past
  14. 00:00:47
    chair of the Penn Forum for Women
  15. 00:00:49
    Faculty. She served on the NCS board of
  16. 00:00:51
    directors and has previously served as
  17. 00:00:54
    the board liaison to the inclusion and
  18. 00:00:55
    neuro critical care committee. And
  19. 00:00:57
    prior chair of the women in neuro
  20. 00:00:59
    critical care committee, she has been a
  21. 00:01:01
    lifelong proponent for advancing women's
  22. 00:01:05
    careers of all stripes and has been a
  23. 00:01:07
    huge influence and advocate for
  24. 00:01:10
    inclusion in neuro critical care. And
  25. 00:01:12
    that's what we're going to talk about
  26. 00:01:13
    today. Dr. Kumara, welcome to the
  27. 00:01:15
    podcast.
  28. 00:01:18
    It's really amazing to be here. Well,
  29. 00:01:21
    thanks so much for taking out time from
  30. 00:01:23
    your day to do this. And you've taken
  31. 00:01:24
    out a lot of time from your life really
  32. 00:01:27
    to pursue this, but to me really seems
  33. 00:01:30
    like a calming, in advancing diversity,
  34. 00:01:33
    equity, and inclusion, particularly
  35. 00:01:34
    within our field. Can you tell me,
  36. 00:01:36
    where did this come from? When did you
  37. 00:01:38
    get passionate about this?
  38. 00:01:42
    So I think that I'm someone who's just
  39. 00:01:44
    been passionate about sort of this work
  40. 00:01:45
    for a long time I mean, even before I
  41. 00:01:47
    came to medicine, I worked in homeless
  42. 00:01:50
    shelters, domestic violence shelters.
  43. 00:01:52
    I worked for at-risk youth around LGBTQ
  44. 00:01:57
    issues and housing insecurity. And so
  45. 00:02:00
    that's just sort of the person I want to
  46. 00:02:03
    be and think that I am. I will say that
  47. 00:02:05
    I think I got a little derailed when I
  48. 00:02:08
    got into medicine, sort of felt like I
  49. 00:02:10
    needed to walk that very narrow path of
  50. 00:02:13
    academic medicine and didn't really.
  51. 00:02:19
    I don't know, stay true to the person
  52. 00:02:21
    that I was. And I think that as I've
  53. 00:02:24
    advanced in my career, I felt a little
  54. 00:02:27
    more agency in defining my life for
  55. 00:02:30
    myself. I think it's sad that it took
  56. 00:02:33
    sort of getting to the rank of professor
  57. 00:02:35
    before I felt like I could do those
  58. 00:02:37
    things. But I would actually say that
  59. 00:02:39
    it was medical students who really sort
  60. 00:02:41
    of helped me pivot into the space I had
  61. 00:02:45
    the great fortune of facilitating a
  62. 00:02:49
    doctoring course with first year med
  63. 00:02:51
    students, and we actually followed the
  64. 00:02:53
    cohort out to graduation that graduated
  65. 00:02:55
    last year. And, you know, in sort of
  66. 00:02:58
    really helping them, I understand their
  67. 00:03:00
    own identities so that they could bring
  68. 00:03:02
    their best selves to being doctors. I
  69. 00:03:06
    realized I'd forgotten who I thought I
  70. 00:03:08
    was And so it was because of that that I,
  71. 00:03:13
    you know, sought the position to be the
  72. 00:03:16
    chair of the Penn Forum for women
  73. 00:03:18
    faculty. And after that it just sort of
  74. 00:03:22
    snowballed into opportunities to really
  75. 00:03:25
    just go where my passions truly lie.
  76. 00:03:29
    Yeah, that's really cool. Can you tell
  77. 00:03:31
    me around what year did that happen,
  78. 00:03:34
    where you started to take on these roles?
  79. 00:03:38
    It really was like 2018, I think before
  80. 00:03:42
    sort of George Floyd and Arbery and some
  81. 00:03:46
    of the kind of collective awareness as a
  82. 00:03:50
    society. So, I think they graduated,
  83. 00:03:56
    I think it's almost a year two now, and
  84. 00:03:58
    then we started the first. So, yeah,
  85. 00:04:00
    somewhere in that like 2018 time point
  86. 00:04:04
    And one of the things I think that
  87. 00:04:06
    really also kind of made me come to this,
  88. 00:04:10
    I think, is one part of my job that I
  89. 00:04:12
    really love is taking care of patients
  90. 00:04:15
    and speaking to them and their families.
  91. 00:04:18
    occurred to me one day that
  92. 00:04:22
    I feel more of a bonus to take good care
  93. 00:04:25
    of patients when there's another person
  94. 00:04:27
    that I'm responsible to. So if there's
  95. 00:04:29
    someone at the bedside and I know that
  96. 00:04:31
    I'm gonna talk to them the next day, I
  97. 00:04:34
    feel like I need to really be on top of
  98. 00:04:36
    it and know all the details and do all
  99. 00:04:38
    of those things. But then I realize
  100. 00:04:41
    like, well, you don't have the
  101. 00:04:42
    privilege or the luxury of having
  102. 00:04:44
    someone at bedside every day when the
  103. 00:04:47
    team comes and, you know, the teams
  104. 00:04:49
    come some days, first thing in the
  105. 00:04:51
    morning and sometimes later in the day,
  106. 00:04:54
    then you might not get that sort of -
  107. 00:04:57
    that onus from
  108. 00:05:00
    the team to serve you and your patient
  109. 00:05:03
    and your loved one as well. And that
  110. 00:05:05
    really bothered me. And so I started to
  111. 00:05:08
    think about, in my personal practice,
  112. 00:05:11
    how can I follow up with families
  113. 00:05:15
    personally and directly. even if they
  114. 00:05:19
    can't be at bedside. And so I started
  115. 00:05:20
    to adopt different practices and call
  116. 00:05:23
    family members either before rounds or
  117. 00:05:27
    after rounds. And I tried to make sure
  118. 00:05:30
    that I speak to that person's designated
  119. 00:05:37
    care provider or loved one directly
  120. 00:05:40
    myself. And then I sort of started
  121. 00:05:43
    thinking during COVID, like, could I
  122. 00:05:46
    actually study this? Because in the
  123. 00:05:47
    past, like, we don't really document a
  124. 00:05:49
    lot about whether we're talking to
  125. 00:05:51
    families and how we're talking to
  126. 00:05:52
    families. But when COVID sort of
  127. 00:05:54
    provided an opportunity where no one
  128. 00:05:56
    could come in and we had to document
  129. 00:05:58
    everything, you know, could we
  130. 00:06:00
    actually look at how much time the
  131. 00:06:05
    healthcare team spends with family
  132. 00:06:07
    members? And can we think about how
  133. 00:06:10
    many times we had a formal goals of care
  134. 00:06:12
    conversation and how many times were we
  135. 00:06:15
    reaching out were those conversations
  136. 00:06:18
    and there was some attempt in my mind to
  137. 00:06:21
    sort of answer this question that's sort
  138. 00:06:22
    of been burning for me personally. And
  139. 00:06:25
    so I'm still sort of in the midst of
  140. 00:06:26
    that project and we're actually even
  141. 00:06:28
    using natural language processing to
  142. 00:06:30
    look at the content of those notes as
  143. 00:06:34
    well to sort of see whether there are
  144. 00:06:36
    different types of words being used when
  145. 00:06:38
    we talk to families with maybe different
  146. 00:06:40
    medical literacy or other biases that we
  147. 00:06:45
    may have. Yeah, that's really
  148. 00:06:47
    interesting and it strikes me it's sort
  149. 00:06:49
    of in some ways a distillation of what
  150. 00:06:53
    everyone in society needs which isn't
  151. 00:06:55
    like an advocate at their bedside, like
  152. 00:06:58
    we all need someone to help speak for us
  153. 00:07:00
    when we can't speak and that's really
  154. 00:07:02
    what you've been spending a lot of time
  155. 00:07:05
    working on in the last few years, so
  156. 00:07:07
    very neat I'm wondering, so
  157. 00:07:13
    you had mentioned this kind of early
  158. 00:07:15
    work you had done and then kind of
  159. 00:07:17
    losing yourself in what I think what we
  160. 00:07:18
    all do, which is this kind of external
  161. 00:07:21
    expectation of what it means, maybe to
  162. 00:07:23
    be an academic neuro intensivist and
  163. 00:07:24
    then finding yourself around 2018. And
  164. 00:07:28
    the cultural climate has been changing
  165. 00:07:31
    rapidly. And maybe in 2018 into 2020,
  166. 00:07:35
    this work in DEI was starting to get
  167. 00:07:38
    appreciated and even popular and we're
  168. 00:07:40
    seeing lots of papers and health care
  169. 00:07:42
    disparities and people are starting to
  170. 00:07:45
    move. What do we do beyond just
  171. 00:07:46
    documenting disparities? And then all
  172. 00:07:49
    of a sudden in the last few years, it
  173. 00:07:50
    seems like this, this work is rapidly
  174. 00:07:53
    losing popularity. In fact, it's even
  175. 00:07:55
    at risk. I'm wondering if you can
  176. 00:07:58
    comment a little bit on kind of how
  177. 00:08:00
    you're feeling about now having taken on
  178. 00:08:01
    this mantle. How are you responding to
  179. 00:08:05
    this sort of climate change that we're
  180. 00:08:06
    facing?
  181. 00:08:09
    Yeah, that's a great question, Nick I
  182. 00:08:12
    think that. on the one hand I think
  183. 00:08:15
    that because there was so much energy
  184. 00:08:17
    and enthusiasm around it, it gave voice
  185. 00:08:19
    to a lot of people and there's a lot of
  186. 00:08:21
    people in this space and that was great.
  187. 00:08:23
    I mean, I really think that I haven't
  188. 00:08:25
    seen that sort of collective attention
  189. 00:08:27
    on a problem for a long time and so it
  190. 00:08:30
    really felt like we were galvanized and
  191. 00:08:34
    we were moving forward. And how quickly
  192. 00:08:38
    it feels like the axis come down on
  193. 00:08:41
    these efforts and how swiftly and how
  194. 00:08:43
    fast and it's a very tough moment, you
  195. 00:08:48
    know, I think that I'm really concerned
  196. 00:08:52
    that A, the people who might not have
  197. 00:08:54
    been in it for the right reasons, like
  198. 00:08:55
    easily left, it's easier to leave the
  199. 00:08:59
    effort now because there isn't the
  200. 00:09:01
    support and there aren't the resources
  201. 00:09:03
    and we have to take this work on again.
  202. 00:09:07
    But the thing that I think a lot of
  203. 00:09:09
    people found is that this is what makes
  204. 00:09:11
    life worth living. and this is what
  205. 00:09:13
    makes your academic work worth doing.
  206. 00:09:16
    And so, you know, one of the things
  207. 00:09:19
    that I think was pretty amazing for me
  208. 00:09:21
    personally was really actually getting
  209. 00:09:23
    involved. I know this could sound sort
  210. 00:09:24
    of hokey in the shameless plug, but I
  211. 00:09:26
    mean, finding like-minded people within
  212. 00:09:29
    NCS really was sort of a safe haven.
  213. 00:09:33
    And I think it was really, I think
  214. 00:09:35
    that's actually what's keeping me doing
  215. 00:09:36
    the work too, is just knowing that
  216. 00:09:38
    there are amazing people doing amazing
  217. 00:09:41
    work out there And even if I don't see
  218. 00:09:43
    it in my local space, the fact that I
  219. 00:09:46
    can actually keep in touch with it
  220. 00:09:48
    across the country, across the country
  221. 00:09:51
    internationally, it feels more doable
  222. 00:09:55
    even in the setting that it's not
  223. 00:09:57
    getting the support and it's being
  224. 00:09:59
    actively sort of reversed. I feel like
  225. 00:10:02
    I have a broader network now of people
  226. 00:10:05
    who are like-minded and who really wanna
  227. 00:10:06
    push this forward. But I also feel like
  228. 00:10:08
    the stakes have never been higher.
  229. 00:10:12
    never been more worthwhile to do this
  230. 00:10:14
    work. And so, yeah, I think that
  231. 00:10:18
    that's sort of where I'm at right now.
  232. 00:10:20
    Yeah, and the stakes are high for our
  233. 00:10:22
    patients too. What do we know about
  234. 00:10:24
    disparities in healthcare and
  235. 00:10:26
    particularly within neuro-critical care?
  236. 00:10:28
    So,
  237. 00:10:31
    you know, I think that it's interesting
  238. 00:10:33
    to see the evolution. Like obviously,
  239. 00:10:36
    there are a lot of disparities, you
  240. 00:10:38
    know, even in the early 2000s, people
  241. 00:10:41
    were talking about disparities and
  242. 00:10:42
    outcomes in terms of, you know, who's
  243. 00:10:45
    getting a cardiac cat, who's getting a
  244. 00:10:48
    PCI, we know that gender disparities
  245. 00:10:50
    occur and how do women present with
  246. 00:10:53
    stroke or heart attacks versus how men
  247. 00:10:56
    present. But there wasn't necessarily a
  248. 00:11:00
    lot of action tied to the disparities,
  249. 00:11:03
    it was like we recognized it and then
  250. 00:11:05
    what?
  251. 00:11:07
    You know, I think that, you know,
  252. 00:11:10
    It's actually a little sad, like the
  253. 00:11:12
    National Academy of Medicine in
  254. 00:11:15
    2003 published unequal treatment and
  255. 00:11:18
    recognized that there were inequities of
  256. 00:11:19
    care. And so not only were these
  257. 00:11:22
    inequities systemic, so like access to
  258. 00:11:25
    care and things like that, but it was
  259. 00:11:27
    actually even on the part of the
  260. 00:11:29
    providers that we are in, that our
  261. 00:11:33
    biases impacted how we delivered care
  262. 00:11:36
    and that these were actually associated
  263. 00:11:38
    with poor outcomes. In neurocritical
  264. 00:11:42
    care specifically, I think that it's
  265. 00:11:46
    really interesting to me to see - we
  266. 00:11:47
    know that stroke outcomes differ by race.
  267. 00:11:52
    Black Americans who have strokes nearly
  268. 00:11:55
    have twice the mortality than white
  269. 00:11:57
    Americans do. We know that in TBI
  270. 00:12:00
    outcomes, the CDC has reported that
  271. 00:12:02
    outcomes vary by race So if you're an
  272. 00:12:06
    American Indian or Alaskan native, your
  273. 00:12:09
    outcomes are - particularly worse after
  274. 00:12:12
    a TBI. And that's from everything,
  275. 00:12:14
    from acute treatment, to rehab, to
  276. 00:12:16
    cognitive therapies after, which is
  277. 00:12:20
    pretty demoralizing, I think. It's
  278. 00:12:22
    really hard to recognize that.
  279. 00:12:26
    And so I think, but like once it's
  280. 00:12:29
    brought to your attention, then I think
  281. 00:12:31
    you can make change. And so one of the
  282. 00:12:32
    things that I'm feeling a little more
  283. 00:12:34
    optimistically about is that obviously
  284. 00:12:37
    an interesting observable hemorrhage,
  285. 00:12:38
    there's a lot of effort now on new
  286. 00:12:41
    treatments, and it's really sort of an
  287. 00:12:42
    exciting time. But the AHE is also
  288. 00:12:45
    recognizing that looking at race, the
  289. 00:12:48
    way we've looked at race is not
  290. 00:12:49
    necessarily the right way. We're using
  291. 00:12:51
    a social construct to diagnose a genetic
  292. 00:12:55
    and biological process, and those
  293. 00:12:58
    things don't mesh. And so it may be
  294. 00:13:01
    more important to think about the way
  295. 00:13:04
    the JNC-8 taught me to treat
  296. 00:13:06
    hypertension is actually antiquated and
  297. 00:13:08
    old, and there's never been proof.
  298. 00:13:10
    about how, you know, why we give or
  299. 00:13:14
    why we used to treat hypertension with
  300. 00:13:16
    certain medications for certain races,
  301. 00:13:18
    that none of that was ever born in any
  302. 00:13:20
    actual study, and it was all sort of
  303. 00:13:22
    theorized, but not actually true, and
  304. 00:13:25
    that there are now efforts to really say,
  305. 00:13:27
    okay, well, let's look at the running
  306. 00:13:29
    access, let's look at actually treating
  307. 00:13:32
    patients
  308. 00:13:35
    not according to race, but including
  309. 00:13:36
    people from all racial categories into
  310. 00:13:38
    research so that we can study this the
  311. 00:13:41
    right way.
  312. 00:13:43
    So I think that in my mind, like stroke
  313. 00:13:46
    and TBI are probably some of the biggest
  314. 00:13:48
    diseases that
  315. 00:13:50
    we treat in neurocritical care, and I
  316. 00:13:51
    think that they're easy starting places.
  317. 00:13:54
    Absolutely. You mentioned these
  318. 00:13:57
    inherent or implicit biases, right,
  319. 00:13:59
    the kinds of biases that all of us have
  320. 00:14:03
    that we have, even sometimes without
  321. 00:14:05
    recognizing that we have them and that
  322. 00:14:07
    affect our behavior. Elisa University
  323. 00:14:10
    of Maryland where I work and I'm
  324. 00:14:12
    guessing at University of Pennsylvania
  325. 00:14:13
    where you work, this has come to light
  326. 00:14:16
    and institutions are brought about a
  327. 00:14:18
    series of implicit bias training courses.
  328. 00:14:22
    Do we know how these courses actually
  329. 00:14:25
    affect disparities? Are they improving
  330. 00:14:27
    things?
  331. 00:14:30
    To be honest, I don't know the data on
  332. 00:14:33
    how well they're working or not working
  333. 00:14:37
    I do think that it's offering a language
  334. 00:14:41
    around recognition though. I think
  335. 00:14:44
    self-reflection should be paired with a
  336. 00:14:49
    debrief and review of action. One of
  337. 00:14:51
    the things that we're doing at Penn that
  338. 00:14:53
    I'm really excited about is
  339. 00:14:55
    interdisciplinary simulation to really
  340. 00:14:58
    talk through events as they happen so
  341. 00:15:01
    that we can feel comfortable saying to
  342. 00:15:03
    one another, Hey, I'm not sure that
  343. 00:15:05
    that was was received in the way you
  344. 00:15:07
    intended it. So really trying to think
  345. 00:15:10
    through calling each other out when
  346. 00:15:14
    there are issues that are coming up that
  347. 00:15:15
    might indicate inherent bias or implicit
  348. 00:15:19
    bias and creating an atmosphere in which
  349. 00:15:25
    every member of the team feels like they
  350. 00:15:27
    can offer their perspective and
  351. 00:15:29
    viewpoint on how a patient interaction
  352. 00:15:31
    goes I think we really have to leave
  353. 00:15:34
    these hierarchical
  354. 00:15:37
    paradigms aside and move towards the
  355. 00:15:41
    collective because I love it when the
  356. 00:15:45
    patient and their families really feel
  357. 00:15:47
    that the med student understands their
  358. 00:15:48
    needs because that means that we are
  359. 00:15:51
    meeting that person's needs. That's all
  360. 00:15:53
    that matters. And so making sure that
  361. 00:15:55
    those types of things are incorporated
  362. 00:15:57
    into the way we practice and deliver
  363. 00:16:00
    medicine, I think, is critical. Yeah,
  364. 00:16:03
    yeah, I love that. We do
  365. 00:16:05
    interprofessional simulations as well.
  366. 00:16:08
    we work a lot of our programs off the
  367. 00:16:12
    HRQ's TeamSTEPPS program and recognizing
  368. 00:16:14
    this need for kind of
  369. 00:16:17
    stepping in when there's behavioral
  370. 00:16:19
    malpractice, I call it non-punitive
  371. 00:16:22
    ways to sort of check people and
  372. 00:16:24
    recognize that this hierarchy, which is
  373. 00:16:26
    built on not just what profession you
  374. 00:16:28
    are, but there's all the other things
  375. 00:16:30
    baked into that, right, which are
  376. 00:16:32
    racial, sociocultural, and economic,
  377. 00:16:35
    and historical, and that when we're
  378. 00:16:39
    rude as the, you know, attending
  379. 00:16:42
    physician to kind of, as we punch down
  380. 00:16:44
    sometimes, or sometimes when we punch
  381. 00:16:48
    up, if we will, that it's not just
  382. 00:16:50
    what's happening between those two
  383. 00:16:51
    individuals, but it's really
  384. 00:16:55
    kind of representing some larger forces
  385. 00:16:57
    at play that everyone kind of gets, and
  386. 00:16:59
    then it has a much larger impact than we
  387. 00:17:02
    think it does, doesn't it? Absolutely.
  388. 00:17:05
    I think it sort of permits bad behavior.
  389. 00:17:09
    It sort of extends bad behavior, and it
  390. 00:17:13
    really limits voice. I mean, we were
  391. 00:17:15
    talking before about using your voice to
  392. 00:17:19
    make change, and it really quashes any
  393. 00:17:23
    other types of voice, or I'm not going
  394. 00:17:26
    to disagree, I'm not going to put
  395. 00:17:28
    myself in that position. And so it
  396. 00:17:30
    really squelches any different opinion
  397. 00:17:34
    or viewpoint And I think up-standard
  398. 00:17:37
    training is something that we should
  399. 00:17:39
    really be focusing a lot more on. I
  400. 00:17:42
    find it even very hard for myself to
  401. 00:17:44
    call things out in the moment. And so,
  402. 00:17:48
    but I'm becoming much more confident in
  403. 00:17:50
    doing that. And I really think that
  404. 00:17:52
    that actually is a skill that can be
  405. 00:17:56
    imparted easily to everybody. And
  406. 00:17:58
    that's why I love the team steps, and I
  407. 00:18:00
    love, you know, giving everybody
  408. 00:18:02
    language to say, Hold on. I'm not
  409. 00:18:07
    comfortable. with this. So I'm
  410. 00:18:08
    concerned about this. You know, I
  411. 00:18:10
    think it really does help to sort of
  412. 00:18:13
    pause, take a time out, and say, Let
  413. 00:18:16
    me just make sure I understand this
  414. 00:18:18
    right because I don't want this to
  415. 00:18:20
    become the culture of our institution or
  416. 00:18:23
    unit or our team. So
  417. 00:18:26
    I think that that's it's critical.
  418. 00:18:29
    That's great. I'm glad to hear you all
  419. 00:18:31
    are incorporating that in your
  420. 00:18:32
    institution too That speaks to my heart.
  421. 00:18:36
    Maybe we
  422. 00:18:38
    can kind of change stories. We'll do
  423. 00:18:39
    another podcast on Simp. It's just
  424. 00:18:42
    another way that we can use simulation,
  425. 00:18:44
    that a lot of people don't really
  426. 00:18:45
    consider.
  427. 00:18:47
    But let's sort of move the focus back to
  428. 00:18:51
    you gave this really wonderful keynote
  429. 00:18:53
    speech at NCS last year that helped I
  430. 00:18:57
    think a lot of people connect some dots
  431. 00:18:59
    that maybe they hadn't connected before
  432. 00:19:01
    in the way that really quite frankly
  433. 00:19:05
    political action affects us at the
  434. 00:19:08
    bedside in neurocritical care. And I'm
  435. 00:19:10
    wondering maybe we can go through a few
  436. 00:19:12
    of those political actions and talk
  437. 00:19:13
    about kind of what their ramifications
  438. 00:19:16
    are for us as neuro-intensivists. And,
  439. 00:19:18
    you know, to take a role from our
  440. 00:19:20
    trauma, or a line from our trauma
  441. 00:19:21
    colleagues, you know, where is our
  442. 00:19:24
    lane, right? That we've heard this,
  443. 00:19:26
    you know, stay in your lanes type of
  444. 00:19:27
    rhetoric. So, the first one you talked
  445. 00:19:30
    about was really affirmative action, I
  446. 00:19:32
    think. And the students for fair
  447. 00:19:34
    admissions versus Harvard College and
  448. 00:19:36
    UNC. And can you tell us a little bit
  449. 00:19:40
    about, you know, some people might
  450. 00:19:42
    think, well, that's for schools,
  451. 00:19:44
    right? These are, we're under graduate
  452. 00:19:45
    education. Why does this affect what I
  453. 00:19:48
    do in terms of taking care of patients
  454. 00:19:49
    in the neuro ICU?
  455. 00:19:53
    Sure, so I think we have to start by
  456. 00:19:55
    saying that diversity actually does
  457. 00:20:00
    improve outcomes because if you don't
  458. 00:20:02
    believe that, then it's not gonna make
  459. 00:20:03
    sense I think, kind of how this is.
  460. 00:20:06
    unfolding. But we actually know that
  461. 00:20:10
    diversity improves healthcare outcomes.
  462. 00:20:12
    It actually improves outcomes in nearly
  463. 00:20:15
    everything. And that's really because
  464. 00:20:18
    it minimizes groupthink. And so it
  465. 00:20:21
    brings cognitive diversity to the table.
  466. 00:20:24
    And so when you have cognitive diversity,
  467. 00:20:27
    really you're opening up to more
  468. 00:20:29
    possibilities and really can lead you
  469. 00:20:31
    down the right road. And so it's been
  470. 00:20:33
    shown in finance, it's been shown in
  471. 00:20:35
    the lab, research labs, and it's been
  472. 00:20:38
    shown in education that really health,
  473. 00:20:41
    that diversity improves outcomes in
  474. 00:20:43
    every discipline and medicine is no
  475. 00:20:46
    different. We also know that
  476. 00:20:49
    affirmative action improves diversity.
  477. 00:20:52
    And we know this because different
  478. 00:20:55
    states have actually had affirmative
  479. 00:20:57
    action bans over the course of the last
  480. 00:21:00
    couple decades And so, most notably,
  481. 00:21:03
    California actually instituted a ban of
  482. 00:21:05
    affirmative action. in 1996, and one
  483. 00:21:08
    of the things that we can study is that
  484. 00:21:10
    what happened before the ban and what
  485. 00:21:12
    happened after the ban, and it was very
  486. 00:21:14
    clear before the ban, there was a lot
  487. 00:21:16
    more diversity, and not just diversity
  488. 00:21:18
    of African Americans, but diversity
  489. 00:21:20
    with Latinx
  490. 00:21:23
    people, AIAN people, there was just a
  491. 00:21:25
    lot more diversity across the board.
  492. 00:21:28
    And then after the ban, within two
  493. 00:21:31
    years, it was actually very quick, the
  494. 00:21:34
    number of Latinx students in particular
  495. 00:21:37
    dropped precipitously. It was like a 40
  496. 00:21:40
    drop at the UC school. And they were
  497. 00:21:42
    actually able to look at the cohort of
  498. 00:21:45
    people who comprised that drop, and
  499. 00:21:47
    like they could see like those patients,
  500. 00:21:49
    who wouldn't have gone to this school,
  501. 00:21:51
    they didn't get into UC Berkeley, they
  502. 00:21:52
    didn't get into UCLA. So where did they
  503. 00:21:54
    go and what did they do? And it's like
  504. 00:21:56
    a pretty linear relationship between not
  505. 00:21:59
    getting into those schools, getting,
  506. 00:22:02
    you know, doing, like, having fewer
  507. 00:22:04
    job opportunities. and not getting sort
  508. 00:22:07
    of the long-term compensation that they
  509. 00:22:10
    would have gotten and if they'd gotten
  510. 00:22:12
    into these other schools. And so, I
  511. 00:22:15
    think it's very clear to say that if you
  512. 00:22:17
    don't get into one of those schools in
  513. 00:22:19
    the undergraduate level, you're not
  514. 00:22:21
    gonna get to the graduate level and then
  515. 00:22:23
    you're not gonna get into these
  516. 00:22:25
    competitive professional jobs. And so,
  517. 00:22:28
    I think that's the relationship between
  518. 00:22:31
    diversity and, eventually,
  519. 00:22:33
    specifically medicine or medical school.
  520. 00:22:37
    Now, in terms of what the cases were,
  521. 00:22:39
    so the students for fair action versus
  522. 00:22:41
    Harvard, which is a private college and
  523. 00:22:44
    the same SFFA and UNC, which is a
  524. 00:22:47
    public university, they took those
  525. 00:22:50
    cases on at the same time because it
  526. 00:22:52
    basically looked at undergraduate
  527. 00:22:55
    admissions in those two areas. And what
  528. 00:22:58
    they basically said was that that the
  529. 00:23:02
    precedent that had been. that of
  530. 00:23:04
    affirmative action was overruled. And
  531. 00:23:07
    they said it's because in the case of
  532. 00:23:10
    Harvard, Asian students were
  533. 00:23:13
    discriminated against because they said
  534. 00:23:16
    that even though they had higher test
  535. 00:23:17
    scores and higher extracurricular
  536. 00:23:20
    activities, they rated less as a group.
  537. 00:23:24
    And so that was used as a stereotype,
  538. 00:23:27
    which is part of the Equal Protection
  539. 00:23:28
    Clause. It's not allowed to be used in
  540. 00:23:30
    stereotype And then at UNC, they were
  541. 00:23:33
    saying that it was about a white student
  542. 00:23:36
    who didn't get into the undergraduate
  543. 00:23:38
    class in 2014, that he had been
  544. 00:23:40
    discriminated against because
  545. 00:23:44
    students from underrepresented groups
  546. 00:23:46
    had a higher standing in the admissions
  547. 00:23:48
    process. And so those were the two
  548. 00:23:50
    companion cases that overturned
  549. 00:23:54
    affirmative action in the undergraduate
  550. 00:23:56
    setting
  551. 00:23:59
    Great, and so you. This obviously is a
  552. 00:24:02
    threat, as you said, to enrollments in
  553. 00:24:05
    professional schools and really who's
  554. 00:24:07
    becoming a doctor and who's working at
  555. 00:24:10
    the bedside. And what do we know about,
  556. 00:24:14
    does it matter whether we have a diverse
  557. 00:24:17
    workforce as physicians in the neuro ICU
  558. 00:24:21
    and how well we represent our patients?
  559. 00:24:25
    Yeah, it actually really does. And
  560. 00:24:27
    there are data looking at if you have a
  561. 00:24:31
    diverse physician work group. So for
  562. 00:24:35
    example, there was a study done, I
  563. 00:24:38
    just published last year, that looked
  564. 00:24:40
    at the number of black family care
  565. 00:24:43
    providers or family practitioners in
  566. 00:24:45
    certain counties. And they looked at
  567. 00:24:48
    from 2000, like just epochs and times.
  568. 00:24:51
    So 2009, 2014, and like 2019. And
  569. 00:24:55
    when they looked at the number of
  570. 00:24:57
    providers over that time, they also
  571. 00:24:59
    looked at life expectancy black people
  572. 00:25:01
    in those counties. And just by having
  573. 00:25:03
    providers in their counties that shared
  574. 00:25:07
    their racial makeup, their life
  575. 00:25:09
    expectancy went up. If you have the
  576. 00:25:13
    state of Florida, look at nearly two
  577. 00:25:15
    million births. And if the race of the
  578. 00:25:20
    infant or the neonate was the same as
  579. 00:25:22
    the race of the provider, their
  580. 00:25:25
    mortality was halved. That's pretty
  581. 00:25:28
    remarkable,
  582. 00:25:31
    you know And I think if we all thought
  583. 00:25:34
    to ourselves, like if we could see
  584. 00:25:35
    ourselves in our patients, or if we
  585. 00:25:38
    feel some kinship with their family,
  586. 00:25:40
    some dynamic, I think we all know.
  587. 00:25:43
    It's a human nature to sort of give a
  588. 00:25:45
    little more and try a little harder.
  589. 00:25:47
    And so whether that explains all of the
  590. 00:25:51
    disparity, I don't think so. But I
  591. 00:25:54
    definitely think that that's part of it
  592. 00:25:56
    And so, you know, even West Point. in
  593. 00:26:00
    terms of the military. They feel that
  594. 00:26:02
    it's very important for the leadership
  595. 00:26:05
    in the military to mirror the troops
  596. 00:26:08
    because if you're gonna defend your
  597. 00:26:09
    country, you need to know that
  598. 00:26:11
    everybody has skin in the game. And so
  599. 00:26:13
    I think it's really critical that that's
  600. 00:26:15
    how health care is for sure. Yeah, and
  601. 00:26:20
    yet recently we've had health
  602. 00:26:23
    representatives who are really claiming
  603. 00:26:25
    the opposite that patients are getting
  604. 00:26:27
    inferior care because we have a more
  605. 00:26:30
    diverse workforce who has quote unquote,
  606. 00:26:34
    take an advantage of these affirmative
  607. 00:26:36
    action rules to get to positions that
  608. 00:26:39
    they don't belong and that's completely
  609. 00:26:41
    against what all of the data really
  610. 00:26:43
    support. But this is really a threat.
  611. 00:26:46
    And maybe if you don't mind, could you
  612. 00:26:48
    talk a little bit more about this
  613. 00:26:49
    Educate Act and this idea you know,
  614. 00:26:52
    medical schools are really being
  615. 00:26:55
    compromised and maybe having to get rid
  616. 00:26:58
    of their DEI offices or any other
  617. 00:27:01
    similar type of equivalent. And this
  618. 00:27:04
    seems to me to be one of the biggest
  619. 00:27:06
    calls to action of our time, what are
  620. 00:27:08
    your thoughts? I couldn't agree with
  621. 00:27:12
    you more. And I'm outraged that even
  622. 00:27:15
    the title of this act Educate Act stands
  623. 00:27:20
    for embracing anti-discrimination,
  624. 00:27:23
    unbiased curricula and advancing truth
  625. 00:27:26
    in education, which to me is hypocrisy
  626. 00:27:29
    at its finest. When the act is working
  627. 00:27:33
    to dismantle EDI efforts in higher
  628. 00:27:36
    education, it is outrageous. And it's,
  629. 00:27:40
    I mean, it's just a shameless, I think
  630. 00:27:42
    it's brilliant. Really subversive. You
  631. 00:27:44
    know, to absolutely just and confuse
  632. 00:27:47
    people And I think they really are
  633. 00:27:49
    trying to sow confusion
  634. 00:27:52
    people don't know what these things are
  635. 00:27:54
    about. And so if the Educate Act was on
  636. 00:27:58
    your ballot, you might think that
  637. 00:28:01
    sounds like a good thing. And so, I
  638. 00:28:05
    think subversive really is the term.
  639. 00:28:08
    But, and I think they know it because
  640. 00:28:11
    the evidence is clear, that diversity
  641. 00:28:14
    in healthcare improves patient outcomes.
  642. 00:28:17
    And so, I think this is just a naked
  643. 00:28:20
    attempt to maintain the status quo, to
  644. 00:28:24
    keep those in power. It's how people in
  645. 00:28:27
    power keep power. And this is not
  646. 00:28:30
    something new in our country. I mean,
  647. 00:28:32
    we've been working to take money away
  648. 00:28:35
    from people as they gain it
  649. 00:28:38
    appropriately. We've worked to take
  650. 00:28:40
    land away from African Americans. We've
  651. 00:28:43
    worked systematically to decrease loans
  652. 00:28:47
    for people who live in certain areas so
  653. 00:28:49
    that they couldn't advance I mean, this
  654. 00:28:51
    is just the. same in the present day.
  655. 00:28:56
    What are some
  656. 00:29:00
    pragmatic steps that maybe some of the
  657. 00:29:02
    listeners can carry forward to try to
  658. 00:29:05
    combat what's going on right now on this
  659. 00:29:06
    front?
  660. 00:29:09
    OK, Nicholas, why don't you ask the
  661. 00:29:10
    hard question? That's why we invited
  662. 00:29:13
    you.
  663. 00:29:15
    You know, I think this is it. This is
  664. 00:29:17
    like - this is the million dollar
  665. 00:29:18
    question
  666. 00:29:21
    Some considerations - I think you're
  667. 00:29:23
    right. I mean, we have to actually
  668. 00:29:25
    talk about what can we do? Because
  669. 00:29:26
    what's the point of just lamenting the
  670. 00:29:28
    situation we're in if we're not going to
  671. 00:29:31
    take action?
  672. 00:29:33
    So one of the things that we're doing at
  673. 00:29:34
    Penn is we're not calling - we're not -
  674. 00:29:37
    like our pathway programs aren't about
  675. 00:29:39
    race. They're about distance traveled.
  676. 00:29:43
    Did your parents go to college? If your
  677. 00:29:47
    parents go to college and you're going
  678. 00:29:48
    to be the first one to go to college -
  679. 00:29:49
    hey, That's a huge accomplishment right
  680. 00:29:52
    there. And so maybe using that as a
  681. 00:29:54
    criteria, maybe using geography, what
  682. 00:29:57
    is your zip code? Instead of favoring
  683. 00:30:00
    the people who come from the zip codes
  684. 00:30:01
    that have more resources, maybe you
  685. 00:30:05
    look at applicants who come from zip
  686. 00:30:06
    codes and it's not about race, it's
  687. 00:30:08
    about zip codes. So I think some of
  688. 00:30:10
    those things are really important. For
  689. 00:30:13
    the listeners, I'm sorry, for the
  690. 00:30:15
    listeners, you're referring basically
  691. 00:30:17
    this idea of the area deprivation index
  692. 00:30:20
    So we can, this is widely available
  693. 00:30:23
    information that we can look up based on
  694. 00:30:25
    zip code and see basically what are the
  695. 00:30:27
    opportunities for people that live in
  696. 00:30:28
    this area?
  697. 00:30:30
    Absolutely, and it's actually, the ADI
  698. 00:30:33
    is really, it's so granular, it gets
  699. 00:30:36
    down to the US Census to find block. So
  700. 00:30:41
    you can look at, because I know in
  701. 00:30:42
    Philadelphia and I suspect in Baltimore,
  702. 00:30:45
    one block this way, one block that way
  703. 00:30:47
    and it can be a very different sort of
  704. 00:30:49
    situation And so sometimes zip code is
  705. 00:30:51
    too big. an area, but you can actually
  706. 00:30:54
    use these area of the area deprivation
  707. 00:30:57
    index that I think Dr. Amy Kind from
  708. 00:30:59
    the University of Wisconsin actually
  709. 00:31:00
    created a beautiful map and she has
  710. 00:31:02
    actually color coded it to make it more
  711. 00:31:05
    kind of visually clear that, you know,
  712. 00:31:08
    these are the areas that have the
  713. 00:31:10
    highest resource. And these are the
  714. 00:31:14
    areas that have the lowest and they and
  715. 00:31:16
    they take in information from everything
  716. 00:31:17
    from schools to access to food and
  717. 00:31:20
    groceries, you know, to parks and
  718. 00:31:24
    things like that and really kind of come
  719. 00:31:25
    up with an understanding of our country.
  720. 00:31:29
    And you know, and what you can see is
  721. 00:31:30
    that like on the coast, you know,
  722. 00:31:32
    there, there's a lot more blue, which
  723. 00:31:34
    is coded for higher, you know,
  724. 00:31:35
    increased affluence and increased wealth,
  725. 00:31:38
    not just monetary wealth, but resource
  726. 00:31:41
    wealth. And then in more of the central
  727. 00:31:43
    part of the country and in the south,
  728. 00:31:45
    you see more of the crimson, which is,
  729. 00:31:48
    you know, where there's fewer resources.
  730. 00:31:51
    And coupled with this is access to
  731. 00:31:53
    healthcare, right? I mean, we know
  732. 00:31:56
    about the urban rural divide as well.
  733. 00:31:58
    And so we're sort of depleted in certain
  734. 00:32:02
    parts of our country and it's critically
  735. 00:32:06
    important that we find a way using,
  736. 00:32:10
    it's a little more creative than using
  737. 00:32:14
    race, which is sort of an easy mark.
  738. 00:32:17
    But to be honest, I think we have to
  739. 00:32:19
    admit that sometimes race wasn't the
  740. 00:32:22
    right measure. Sometimes if you're from
  741. 00:32:28
    a high social and economic status and
  742. 00:32:30
    you have a lot of resources, race might
  743. 00:32:33
    not be the best marker, although
  744. 00:32:35
    acknowledging that people - It's pretty
  745. 00:32:37
    robust. It's pretty robust than even
  746. 00:32:39
    people from, if your skin is black or
  747. 00:32:43
    dark, even if
  748. 00:32:46
    you have money in your pocket, not
  749. 00:32:47
    protected from theills of racism. So I
  750. 00:32:52
    think that one thing that we can do is
  751. 00:32:55
    really to think differently for pathway
  752. 00:32:57
    programs like how we can bring
  753. 00:33:02
    the resources to people who could use
  754. 00:33:04
    them most. I think it's important to
  755. 00:33:07
    employ a holistic review, look at
  756. 00:33:09
    people in the totality and not try to
  757. 00:33:12
    strip them down to a couple of different
  758. 00:33:14
    factors about themselves I think that
  759. 00:33:16
    that doesn't tell the whole story.
  760. 00:33:19
    Utilizing standard rubrics for
  761. 00:33:22
    interviews and for
  762. 00:33:25
    promotion and other leadership
  763. 00:33:26
    opportunities, this is really critical
  764. 00:33:28
    because this is where the implicit bias
  765. 00:33:30
    comes in. This is the oh my gut
  766. 00:33:32
    instinct is that that person is the
  767. 00:33:34
    right person or the right fit when if
  768. 00:33:37
    you look at them you know and see you
  769. 00:33:39
    know well how many papers have they've
  770. 00:33:41
    written or you know what are their
  771. 00:33:43
    teaching scores or things like that you
  772. 00:33:44
    can start to get a fuller picture and a
  773. 00:33:47
    more equitable
  774. 00:33:50
    assessment of each candidate against the
  775. 00:33:52
    other, and then you can make a more
  776. 00:33:53
    educated decision about who to choose
  777. 00:33:56
    and how. I really worry about, we're
  778. 00:33:59
    going through our fellowship applicants,
  779. 00:34:01
    probably as you are right now. And when
  780. 00:34:03
    we sit together as a group, and every
  781. 00:34:05
    once in a while you hear the line, oh,
  782. 00:34:07
    I think they'd fit in really well here.
  783. 00:34:09
    I always, I used to say that. And now
  784. 00:34:13
    it kind of makes this, the hair on my
  785. 00:34:15
    back and the neck stand up, 'cause I'm
  786. 00:34:17
    not sure what that means And to me, it
  787. 00:34:20
    almost feels like a red flag that we're
  788. 00:34:22
    going somewhere we shouldn't be going.
  789. 00:34:24
    'Cause maybe, as you said, if
  790. 00:34:25
    diversity really outcomes, maybe we
  791. 00:34:26
    better leads to
  792. 00:34:29
    don't want someone who fits in. Exactly.
  793. 00:34:33
    I think who's gonna bring us something
  794. 00:34:34
    new? Who's gonna bring us some
  795. 00:34:37
    different way of looking at things that
  796. 00:34:38
    might be the most innovative? I think
  797. 00:34:42
    that fits. sort of thing, all it does
  798. 00:34:45
    is just narrow your scope. It doesn't
  799. 00:34:47
    broaden your horizons. And I think
  800. 00:34:49
    that's really the most critical to
  801. 00:34:52
    meeting our patients' needs, where they
  802. 00:34:54
    are, meeting our trainees' needs to
  803. 00:34:56
    where they are, meeting our staff's
  804. 00:34:58
    needs, where they are. I mean, I
  805. 00:34:59
    think so many things benefit from the
  806. 00:35:03
    diversity that different perspectives
  807. 00:35:04
    bring and different people bring.
  808. 00:35:08
    I think the other things that we can do
  809. 00:35:10
    is we can really work to retain our
  810. 00:35:15
    faculty. So one of my kind of newer
  811. 00:35:18
    roles is that I'm chairing a society for
  812. 00:35:22
    clinician scientists at Penn, because
  813. 00:35:25
    we learned that there's a lot of early
  814. 00:35:27
    attrition of clinician scientists here.
  815. 00:35:30
    And we're trying to figure out why that
  816. 00:35:31
    is. And our vice dean for faculty has
  817. 00:35:34
    really tried expertly to put numbers on
  818. 00:35:39
    these things and to interview people and
  819. 00:35:40
    figure out, you know. Why are you
  820. 00:35:43
    leaving? Where are you going? Some
  821. 00:35:44
    amount of attrition, you know, is good.
  822. 00:35:46
    Hey, they're taking a better position
  823. 00:35:48
    somewhere else because We've helped make
  824. 00:35:50
    them successful But when they're leaving
  825. 00:35:53
    within a year within a couple years, it
  826. 00:35:56
    makes you think whoa Maybe we're not
  827. 00:35:58
    meeting them where they are. Maybe they
  828. 00:36:00
    think they're supposed to be doing
  829. 00:36:02
    something even though they're meeting
  830. 00:36:03
    their metrics Maybe someone's making
  831. 00:36:06
    them feel that they don't belong and if
  832. 00:36:09
    that's the case then we need to fix
  833. 00:36:10
    those problems So that's sort of my new
  834. 00:36:13
    passion project for right now And also,
  835. 00:36:17
    you know, I think thinking about it's
  836. 00:36:19
    not just So there's what are things that
  837. 00:36:22
    you can do you can do term limits,
  838. 00:36:24
    right? Like Has your division chief
  839. 00:36:27
    been division chief for as long as you
  840. 00:36:29
    can remember? Well, maybe we need to
  841. 00:36:31
    change that maybe we need to give other
  842. 00:36:33
    people opportunity to be in those
  843. 00:36:36
    leadership roles to think differently
  844. 00:36:38
    about leadership to change how it's done
  845. 00:36:41
    and They have the skill set to then
  846. 00:36:44
    continue to advance. I think, again,
  847. 00:36:47
    it's one of those things where
  848. 00:36:48
    leadership is sort of in the hands of a
  849. 00:36:50
    few. We know this for gender, even
  850. 00:36:54
    though more women make up med student
  851. 00:37:00
    groups than men. When it comes to
  852. 00:37:02
    leadership down the road, you don't see
  853. 00:37:04
    as many women leaders in those same
  854. 00:37:06
    roles and why, and the same thing goes
  855. 00:37:09
    for URM on a much grander scale. So how
  856. 00:37:12
    do we keep that from happening? Well,
  857. 00:37:14
    things like term limits can actually
  858. 00:37:15
    offer solutions that are practical and
  859. 00:37:17
    pragmatic.
  860. 00:37:19
    I also think about your research lab.
  861. 00:37:24
    Diversifying your research lab might be
  862. 00:37:25
    something that you can do on the local
  863. 00:37:27
    level. Editorial boards, a lot of
  864. 00:37:30
    editorial boards, they all look very
  865. 00:37:32
    similar And so having more diverse
  866. 00:37:35
    opinions and diverse voices might
  867. 00:37:38
    actually allow for different types be
  868. 00:37:41
    published with the same attention to
  869. 00:37:43
    detail. And we'll put in the shameless
  870. 00:37:47
    plug for NCS, but the more people that
  871. 00:37:50
    come from that look different, that act
  872. 00:37:52
    different, that think differently,
  873. 00:37:53
    that join together in a medical society
  874. 00:37:56
    can also change the tenor. And the
  875. 00:37:58
    attention, right? I mean, medical
  876. 00:38:01
    societies get to define what things they
  877. 00:38:03
    take on in the same way, the people who
  878. 00:38:06
    make those decisions. And that's
  879. 00:38:08
    medical societies, national societies,
  880. 00:38:11
    medical, your home institutions,
  881. 00:38:13
    universities, all of those things, the
  882. 00:38:15
    priorities get defined by the people in
  883. 00:38:17
    charge. And if these are our priorities,
  884. 00:38:20
    then we need to send to those ranks so
  885. 00:38:22
    that we can be a part of making those
  886. 00:38:24
    decisions. Well, you do have the hard
  887. 00:38:28
    answers to hard questions, it turns out.
  888. 00:38:29
    So I think those were, that's a whole
  889. 00:38:32
    list of things that seem actually
  890. 00:38:35
    achievable, although hard to do I would
  891. 00:38:38
    also put in a plug for NCS. you know,
  892. 00:38:41
    I'm always amazed how similar kind of
  893. 00:38:43
    people look at NCS. And if people are
  894. 00:38:47
    listening to this podcast who think
  895. 00:38:48
    maybe I don't belong there, well, we
  896. 00:38:51
    have a home for you. It's the inclusion
  897. 00:38:52
    and neurocritical care committee in the
  898. 00:38:54
    police section, and we welcome you.
  899. 00:38:57
    All right. Let's, we're coming up on
  900. 00:39:00
    time here, and I want to get to a
  901. 00:39:01
    couple of other things. So we're going
  902. 00:39:03
    to move on.
  903. 00:39:05
    Your keynote, you also described this
  904. 00:39:07
    really interesting connection, I
  905. 00:39:08
    thought, between
  906. 00:39:10
    Dobbsby Jackson and then ultimately the
  907. 00:39:13
    UDDA revision and talking about brain
  908. 00:39:15
    death. And again, this is something
  909. 00:39:17
    where I think a lot of people had never
  910. 00:39:19
    thought that these things in any way
  911. 00:39:20
    could be connected, and yet you made
  912. 00:39:23
    these connections. So what does one
  913. 00:39:25
    have to do with the other?
  914. 00:39:28
    This is just so excited for me. So
  915. 00:39:30
    thank you for letting me talk about this
  916. 00:39:33
    You know, I think at the heart of
  917. 00:39:35
    Dobsby Jackson, the unspoken question
  918. 00:39:38
    is, when does life begin? And so the
  919. 00:39:42
    reason that many of the states are
  920. 00:39:44
    choosing six week bands is because
  921. 00:39:47
    that's the time at which the heartbeat
  922. 00:39:51
    is observed in embryonic development.
  923. 00:39:54
    And so if the heartbeat is what many
  924. 00:39:59
    people are using to define life,
  925. 00:40:03
    then the heartbeat may be what is used
  926. 00:40:07
    to define death and as a
  927. 00:40:09
    neuro-intensivist, that's not always
  928. 00:40:11
    true. We had death by neurologic
  929. 00:40:13
    criteria as defined by the UDDA. And
  930. 00:40:18
    so it gives me pause, like what if we
  931. 00:40:22
    can't do brain death determination
  932. 00:40:24
    anymore?
  933. 00:40:26
    What are the implications of that? So
  934. 00:40:28
    one, I think that
  935. 00:40:31
    it is a very confusing state for a lot
  936. 00:40:34
    of people, and so if we lose the legal
  937. 00:40:36
    ability to define death by neurologic
  938. 00:40:39
    criteria, well. then we may be
  939. 00:40:42
    increasing the number of patients in our
  940. 00:40:44
    healthcare system who we would have
  941. 00:40:48
    defined as debt. I mean, we don't have
  942. 00:40:50
    medical treatments for and that we don't
  943. 00:40:52
    think, you know, will improve.
  944. 00:40:57
    And so that sort of takes that away.
  945. 00:41:01
    And then also we do define brain death
  946. 00:41:08
    and then they have, and patients or
  947. 00:41:10
    families have the option to pursue organ
  948. 00:41:13
    donation. And if we don't have brain
  949. 00:41:16
    death and the number of organs goes down.
  950. 00:41:19
    And so
  951. 00:41:21
    last year there were 100, 000 people on
  952. 00:41:24
    the transplant waiting list and 40, 000
  953. 00:41:28
    organs were transplanted. So not
  954. 00:41:31
    everybody who needed an organ got an
  955. 00:41:33
    organ.
  956. 00:41:36
    And that worries me There's already been
  957. 00:41:39
    disparities. in the organ allocation
  958. 00:41:42
    process, you know, how do you define
  959. 00:41:46
    who needs an organ more than another
  960. 00:41:48
    person, and some of those decisions
  961. 00:41:51
    were sort of opaque to the public for a
  962. 00:41:54
    long time, and there have been efforts
  963. 00:41:57
    to really make that more equitable. But
  964. 00:41:59
    again, that was an area where there was
  965. 00:42:01
    significant and inherent inequity. It's
  966. 00:42:06
    also, these diseases aren't equitable
  967. 00:42:09
    You know, four times as many
  968. 00:42:11
    African-Americans have kidney failure
  969. 00:42:13
    than white Americans, but
  970. 00:42:18
    more organs get transplanted for white
  971. 00:42:19
    Americans than black Americans. So
  972. 00:42:21
    right there, there's inequity. There's
  973. 00:42:23
    also the type of organ transplanted.
  974. 00:42:26
    More living donor organs go to white
  975. 00:42:29
    Americans than black Americans. And so
  976. 00:42:32
    why is that a problem? Well, the
  977. 00:42:33
    outcomes are better for living organ
  978. 00:42:36
    donors are living.
  979. 00:42:40
    organs that were donated than from the
  980. 00:42:42
    dead donors. And so, you know, that
  981. 00:42:46
    keeps me up at night. That makes me
  982. 00:42:48
    worry, like, how are we going to meet
  983. 00:42:50
    the needs of patients who need organs
  984. 00:42:53
    for transplantation if we lose the
  985. 00:42:56
    definition of death by neurologic
  986. 00:42:59
    criteria? And it actually, you know,
  987. 00:43:02
    I think we've all recently, in recent
  988. 00:43:05
    past, we know that there's a lot of
  989. 00:43:07
    confusion in the lay press about, like,
  990. 00:43:10
    what is brain death? And so with that
  991. 00:43:13
    confusion, you know, normally you
  992. 00:43:16
    would say, like, just take a timeout
  993. 00:43:17
    and make sure everybody's on the same
  994. 00:43:18
    page, but we really can't afford to do
  995. 00:43:20
    that because people's lives are in the
  996. 00:43:21
    balance. So how do we update the UDDA
  997. 00:43:26
    in a seamless way? Well, you know, in
  998. 00:43:29
    this current political moment,
  999. 00:43:33
    it's proving to be too difficult the
  1000. 00:43:36
    United Law Commission or the ULC who
  1001. 00:43:39
    writes the UDDA. They're lawyers.
  1002. 00:43:41
    They're not doctors. They're informed
  1003. 00:43:43
    by a panel of colleagues of ours, among
  1004. 00:43:47
    others, but they're not doctors
  1005. 00:43:50
    themselves. And so I read in nature
  1006. 00:43:53
    last year, this was really concerning
  1007. 00:43:56
    that one of the commissioners of the ULC
  1008. 00:44:01
    was around in the 1980s when the UDDA
  1009. 00:44:04
    was first drafted. And he was a
  1010. 00:44:06
    proponent of death by neurologic
  1011. 00:44:09
    criteria. But now he's actually decided
  1012. 00:44:13
    that he's not. And he actually, his
  1013. 00:44:15
    day job is to work for a pro-life
  1014. 00:44:19
    organization in DC. And so I think he's
  1015. 00:44:23
    making the connections between, you
  1016. 00:44:26
    know, access to abortion and brain
  1017. 00:44:28
    death. And so, you know, that's very
  1018. 00:44:31
    worrisome. Yeah, well, thank you for
  1019. 00:44:34
    bringing that point forward. And I
  1020. 00:44:35
    think. I'm one of those people who
  1021. 00:44:38
    hadn't really considered this that
  1022. 00:44:40
    deeply, the connections between these
  1023. 00:44:41
    two issues, but I think you're right
  1024. 00:44:43
    that they're real, and we need to deal
  1025. 00:44:45
    with them. And
  1026. 00:44:48
    I'm also worried. You mentioned that
  1027. 00:44:50
    the UDDA revision is on pause or hiatus,
  1028. 00:44:54
    and I think Ariane Lewis has written
  1029. 00:44:56
    about this recently,
  1030. 00:45:00
    and the
  1031. 00:45:03
    most recent journal in neurocritical
  1032. 00:45:03
    care, and she talked a little bit about
  1033. 00:45:04
    how the first iteration really describes
  1034. 00:45:07
    the determination is left up to best
  1035. 00:45:09
    medical standards. And I think a lot of
  1036. 00:45:12
    us are worried, and I think she hinted
  1037. 00:45:14
    at it in her article that there's been a
  1038. 00:45:18
    politicization of what are medical
  1039. 00:45:20
    standards. And this is affecting
  1040. 00:45:23
    everything from brain death to gender
  1041. 00:45:25
    affirming care to a host of other
  1042. 00:45:28
    areas. And it's really, really
  1043. 00:45:30
    worrisome
  1044. 00:45:32
    I totally agree, and I think, you know,
  1045. 00:45:35
    even to continue this. the comparison
  1046. 00:45:38
    between access to abortion, which is
  1047. 00:45:41
    now, because there are no federal
  1048. 00:45:44
    protections, are defined by the states,
  1049. 00:45:48
    the UDDA is a federal protection, and,
  1050. 00:45:52
    but it's still defined locally by the
  1051. 00:45:55
    states, and that's what's causing a lot
  1052. 00:45:57
    of the confusion, because you can be
  1053. 00:45:58
    dead in one state and not dead in
  1054. 00:46:00
    another. And so, part of the reason
  1055. 00:46:03
    that we want the UDDA to be updated is
  1056. 00:46:06
    to give that federal level of
  1057. 00:46:10
    standardization that it can do. And yet,
  1058. 00:46:13
    we're seeing that play out with the
  1059. 00:46:15
    abortion debate and how you can't get an
  1060. 00:46:18
    abortion in one state, but you can get
  1061. 00:46:20
    an abortion in another state. It's
  1062. 00:46:22
    causing a lot of confusion among
  1063. 00:46:23
    providers who are at those state borders.
  1064. 00:46:27
    What can they do? And it's reducing
  1065. 00:46:28
    access for people even within a state
  1066. 00:46:31
    that's legal, because you get a lot
  1067. 00:46:34
    more getting patients from across the
  1068. 00:46:36
    border. And so, again, I feel like it
  1069. 00:46:41
    is so in discord among the populace.
  1070. 00:46:45
    And so everyone is confused. Nobody
  1071. 00:46:48
    knows what is right. Even like all the
  1072. 00:46:50
    well-meaning people are trying their
  1073. 00:46:52
    best, but you don't wanna be on the
  1074. 00:46:54
    wrong side of the law. No one is
  1075. 00:46:57
    advocating that, but that's happening.
  1076. 00:46:59
    So I know even for me, the Penn Forum
  1077. 00:47:03
    for women faculty, that is now a group
  1078. 00:47:06
    that is coming under fire because can
  1079. 00:47:08
    you just be for a gender? And so we
  1080. 00:47:12
    have to be thinking about these things.
  1081. 00:47:15
    And I know part of the reason I went
  1082. 00:47:18
    into medicine, I felt like it was a
  1083. 00:47:19
    straighter path and I'm pretty risk
  1084. 00:47:21
    averse. I don't like being in legal
  1085. 00:47:23
    jeopardy for doing my job. And talk
  1086. 00:47:26
    about moral distress and burnout, right?
  1087. 00:47:28
    Like I wanna do what's right for my
  1088. 00:47:30
    patients, but I can't because the
  1089. 00:47:35
    government won't let me. And, you know,
  1090. 00:47:37
    I think, I don't know if I ever told
  1091. 00:47:39
    you this, but, you know, I matched in
  1092. 00:47:42
    obstetrics. My intent was actually to
  1093. 00:47:44
    do this work with my life. And, you
  1094. 00:47:46
    know, I just fell in love with the
  1095. 00:47:47
    pesky brain. But, but, you know, I
  1096. 00:47:52
    think that I had never been put in a
  1097. 00:47:55
    professional capacity to think to myself,
  1098. 00:47:57
    like, do I do the work that I know is
  1099. 00:47:59
    right and to take the consequences,
  1100. 00:48:02
    whereas a lot of my OB colleagues have
  1101. 00:48:04
    been wrestling with that decision for a
  1102. 00:48:06
    long time.
  1103. 00:48:08
    But here, we absolutely are going to be
  1104. 00:48:11
    dealing with it. And, you know, I
  1105. 00:48:13
    think in my talk last summer, we had a
  1106. 00:48:16
    patient who came in, and I had to think
  1107. 00:48:19
    to myself, like, what do I do first?
  1108. 00:48:21
    I'm sure to mask you with 30 weeks
  1109. 00:48:23
    pregnant twin gestation, had a massive
  1110. 00:48:26
    cerebellar hemorrhage, you know, with,
  1111. 00:48:29
    I think, only a couple brainstem
  1112. 00:48:31
    reflexes, and, you know, it made us
  1113. 00:48:34
    all stop
  1114. 00:48:44
    Oh my God, how are we gonna manage
  1115. 00:48:44
    these situationsthat are very, very
  1116. 00:48:44
    complex? And that, to me, is a recipe
  1117. 00:48:46
    for increased moral distress and burnout.
  1118. 00:48:49
    When we can't do the things that we know
  1119. 00:48:51
    how to do because of systemic barriers,
  1120. 00:48:55
    that really, it's unacceptable and it
  1121. 00:48:58
    makes a lot of people wanna leave the
  1122. 00:49:00
    job they were called to do and that just
  1123. 00:49:04
    can't happen We can't let that happen.
  1124. 00:49:06
    I completely agree. We've covered a lot
  1125. 00:49:09
    of ground, I think. Yeah, I'm just
  1126. 00:49:13
    curious 'cause it has been a while since
  1127. 00:49:16
    your talk, which was last August and
  1128. 00:49:20
    the news cycle continues.
  1129. 00:49:24
    What else is keeping you up at night
  1130. 00:49:25
    these days? What else that we haven't
  1131. 00:49:27
    talked about, are you worried about or
  1132. 00:49:28
    should be on our radar?
  1133. 00:49:31
    I mean, I would say that the Educate
  1134. 00:49:33
    Act is one really. has me troubled. I
  1135. 00:49:38
    also, so I've had sort of the amazing
  1136. 00:49:41
    fortune of being able to give this talk
  1137. 00:49:44
    over the last year at about, I don't
  1138. 00:49:47
    know, eight or ten institutions. And
  1139. 00:49:50
    each time I give the talk, I add a
  1140. 00:49:51
    little something. And I was thinking
  1141. 00:49:54
    about how Claudia Golden, who is a
  1142. 00:49:58
    labor economist at Harvard, she won the
  1143. 00:50:01
    Nobel Prize. And then her work is
  1144. 00:50:03
    really about women and the work force.
  1145. 00:50:06
    And she credits the birth control pill
  1146. 00:50:09
    with really propelling women in the
  1147. 00:50:12
    workforce in a way that nothing else
  1148. 00:50:15
    could have done. And I can't help but
  1149. 00:50:19
    think to myself, like, well, if
  1150. 00:50:22
    access to abortion is restricted, these
  1151. 00:50:25
    issues with in vitro fertilization are
  1152. 00:50:28
    now being called into question, then
  1153. 00:50:30
    women are going to be able to plan their
  1154. 00:50:32
    careers.
  1155. 00:50:35
    their own time and that's going to take
  1156. 00:50:38
    women out of the workforce in
  1157. 00:50:40
    significant numbers. And we already
  1158. 00:50:42
    know that we don't have enough nurses,
  1159. 00:50:47
    we don't have enough advanced practice
  1160. 00:50:48
    providers, we don't have enough
  1161. 00:50:50
    physicians, 54 of whom in medical
  1162. 00:50:53
    school are women. What is this going to
  1163. 00:50:56
    do to health care and what are the
  1164. 00:50:59
    implications of that for, you know,
  1165. 00:51:03
    health care outcomes for all?
  1166. 00:51:07
    You know, I think we've talked about a
  1167. 00:51:09
    little bit about diversity and its
  1168. 00:51:12
    impact on health care. If we don't have
  1169. 00:51:14
    gender diversity either,
  1170. 00:51:16
    then I just, I think we won't be
  1171. 00:51:19
    meeting patients, you know, needs well
  1172. 00:51:22
    at all. And
  1173. 00:51:25
    I mean I could go on. I think there's
  1174. 00:51:27
    no money. And this is not even like
  1175. 00:51:29
    climate change
  1176. 00:51:32
    and, you know, affirming, you know,
  1177. 00:51:32
    gender affirming care. And I just, I
  1178. 00:51:35
    have so many personal, very deep-seated
  1179. 00:51:38
    feelings about a lot of these things.
  1180. 00:51:40
    And
  1181. 00:51:44
    I don't know how I can function through
  1182. 00:51:46
    a day without just outrage. I am going
  1183. 00:51:51
    to say that I do think that the newer
  1184. 00:51:55
    generation of physicians, nurses,
  1185. 00:51:58
    trainees, I think they do an amazing
  1186. 00:52:02
    job at really thinking critically about
  1187. 00:52:04
    this I think they value these
  1188. 00:52:06
    conversations. I think they're thinking
  1189. 00:52:09
    about things differently than we did. I
  1190. 00:52:13
    think they're questioning the status quo
  1191. 00:52:15
    more. So I have hope and I do have
  1192. 00:52:20
    faith. But I also think that like hope
  1193. 00:52:23
    and faith are not enough because they
  1194. 00:52:24
    are not active processes. We need to do.
  1195. 00:52:27
    I have to say if people hadn't heard
  1196. 00:52:31
    Alistair Martin's ink, you know, from
  1197. 00:52:34
    a couple years ago.
  1198. 00:52:37
    He's easily found on Instagram and all
  1199. 00:52:39
    sorts of places, but the impact of
  1200. 00:52:42
    voting on these specific issues cannot
  1201. 00:52:47
    be understated or overstated. It is
  1202. 00:52:52
    critically important that we recognize,
  1203. 00:52:55
    and even to this point of this educate,
  1204. 00:52:58
    if you go into the voting booth and you
  1205. 00:53:00
    don't know what you're voting on and you
  1206. 00:53:01
    see that, you might think to yourself,
  1207. 00:53:03
    oh, yeah, that's something I go for.
  1208. 00:53:05
    So being a concerned citizen who takes
  1209. 00:53:10
    their responsibilities, their civic
  1210. 00:53:12
    responsibility seriously, I think that
  1211. 00:53:15
    is really an important part.
  1212. 00:53:20
    And I think that I'm spending more of my
  1213. 00:53:22
    personal time figuring out how I can be
  1214. 00:53:26
    a responsible citizen in a way that I
  1215. 00:53:29
    just never have before And if you find
  1216. 00:53:32
    yourself in the Philadelphia airport.
  1217. 00:53:34
    at any time in the next year. Check out
  1218. 00:53:37
    this store called 1920s merch. I mean,
  1219. 00:53:40
    it is merchandising around, but it's
  1220. 00:53:43
    around the women's right to vote that
  1221. 00:53:46
    they got in 1920 and then outlines in a
  1222. 00:53:50
    pictorial form around the store the 50
  1223. 00:53:52
    years preceding a woman's right to vote.
  1224. 00:53:55
    And
  1225. 00:53:57
    for all the people who've said history
  1226. 00:53:59
    repeats itself, it really does. And I
  1227. 00:54:02
    think that there's a lot that we can
  1228. 00:54:03
    learn from history and
  1229. 00:54:07
    so I think just informing yourself is
  1230. 00:54:10
    arming yourself. And I think that
  1231. 00:54:12
    that's really where we need to go. Okay,
  1232. 00:54:15
    I love that. So let's end it there.
  1233. 00:54:17
    Thank you so much for joining us. I
  1234. 00:54:19
    learned a lot today and I learned so
  1235. 00:54:22
    much from your talk and I hope maybe
  1236. 00:54:24
    you'll come back on the podcast again in
  1237. 00:54:26
    the future to talk about some of the
  1238. 00:54:28
    many other things that keep you up at
  1239. 00:54:30
    night and keep all of us up at night and
  1240. 00:54:31
    raging through the day. If you all have
  1241. 00:54:35
    me, Nick, I'll come back for sure.
  1242. 00:54:37
    Yeah, I also just wanna thank you for
  1243. 00:54:39
    being a strong advocate for the
  1244. 00:54:41
    inclusion neurocritical care committee.
  1245. 00:54:43
    And before that, the women in
  1246. 00:54:44
    neurocritical care committee who I think
  1247. 00:54:46
    owe a lot to you and for representing
  1248. 00:54:49
    the larger group, both within our
  1249. 00:54:51
    society and beyond. So thanks so much.
  1250. 00:54:56
    Thank you, Nick, it's been a lot of
  1251. 00:54:57
    fun. All right, you have been
  1252. 00:54:59
    listening to the Neurocritical Care
  1253. 00:55:00
    Society podcast This podcast is
  1254. 00:55:03
    available anywhere you get your podcast.
  1255. 00:55:05
    Please like and subscribe. And
  1256. 00:55:07
    continuing education credits are
  1257. 00:55:09
    available for select episodes. Thanks
  1258. 00:55:11
    and check us out again.