Asking difficult questions, facing hard truths and challenging long-held norms — while at times uncomfortable, these actions are essential to addressing health equity and eliminating racism in health care settings, noted presenters at the Brigham’s Diversity, Equity and Inclusion (DE&I) Town Hall on May 26.
One important conduit for this work is the systemwide United Against Racism (UAR) initiative, explained Brigham President Robert S.D. Higgins, MD, MHSA, during his opening remarks for the event. Composed of three focus areas — health equity, community health and workforce equity — UAR seeks to identify and eliminate racist barriers, systems and actions inside and outside of Mass General Brigham.
Additionally, the Brigham recently established a new multidisciplinary team, the Communication Resource Committee, to advise the Office of the President and Office of Strategic Communication on responding to external events, including those involving issues of racial justice and health equity.
“To really move the needle in dismantling racist systems, we need to address these issues on a number of fronts,” Higgins said. “Real change also requires that we engage the highest levels of our organization while also supporting local efforts and projects.”
A Catalyst for Change in Prostate Cancer Care
The DE&I Town Hall spotlighted two projects at the Brigham — both supported with UAR grants — that are working to address health inequities and structural racism in clinical settings.
Quoc-Dien Trinh, MD, FACS, of the Division of Urological Surgery, discussed the Mass General Brigham Prostate Cancer Outreach Clinic (PCOC), a joint program between the Brigham and Massachusetts General Hospital (MGH) that seeks to make high-quality, affordable prostate cancer care accessible to more men of color.
The clinic, which Trinh co-founded with MGH colleague Adam Feldman, MD, MPH, was created to address the disproportionate burden of prostate cancer among Black men, who are 22 percent less likely to receive treatment for the disease compared to white men.
“Even in Massachusetts, despite the access to insurance, there’s a disparity in access to care,” said Trinh, who also serves as director of Ambulatory Clinical Operations for Urological Surgery, co-director of the Prostate Cancer Program for Dana-Farber Brigham Cancer Center and a core faculty member of the Center for Surgery and Public Health.
In designing the program, Trinh and Feldman met with Black men across Massachusetts to better understand the current barriers to care. Inconvenient services, high costs and mistrust of large health care systems ranked high among the reasons the men interviewed said they avoided care at academic medical centers like the Brigham and MGH.
Rather than relying on a conventional approach of waiting for patients to seek care, PCOC was founded on the principle that providers must be more proactive with outreach and education to connect patients with the care they need, Trinh explained.
A community health worker helps patients navigate appointments, a collaboration with the Department of Quality and Safety proactively identifies at-risk patients who lack referrals, and partnerships with third-party organizations are helping to build trust with local communities.
“The vision is to use PCOC as a catalyst to bring our communities compassionate prostate cancer care,” Trinh said.
Identifying ‘Blind Spots’ in Behavioral Health
Meanwhile, a UAR grant-funded multidisciplinary training program developed in collaboration with faculty from the Brigham, Brigham and Women’s Faulkner Hospital (BWFH) and MGH Emergency Departments (EDs) is addressing how to reduce racial bias and provide trauma-informed care when managing agitated patients.
Dana Im, MD, MPP, MPhil, director of Quality and Safety and director of Behavioral Health for Brigham Emergency Medicine, explained that the project was inspired by a study led by Emergency Medicine resident Jossie Carreras Tartak, MD, MBA, and senior author Wendy Macias Konstantopoulos, MD, MPH, MBA, vice chair for Diversity, Health Equity and Inclusion for MGH Emergency Medicine, in close collaboration with Tom Sequist, MD, MPH, Mass General Brigham chief medical officer, and his team. The multi-institutional research team looked at the use of restraints for patients under an involuntary hold during an emergency psychiatric evaluation. After examining data from 11 EDs across Mass General Brigham, they found that Black and Hispanic patients experienced higher rates of physical restraint in the ED.
Following that 2021 publication, the Brigham’s ED team launched its Emergency Medicine Antiracism and Trauma-informed (ART) Interdisciplinary De-escalation Training Program, which approximately 120 ED staff — including physicians, nurses, support staff, security officers and psychiatrists — have completed to date.
“We felt that, in order to address the disparities in the ED that were highlighted in the study, we couldn’t just present the numbers to our staff and ask them to provide unbiased care,” Im said. “We really had to equip and empower them to provide equitable care.”
Initially launched as a pilot to reduce racial bias during de-escalation, the program, led by Emergency Medicine fellow Farah Dadabhoy, MD, has been expanded to include trauma-informed and antiracism principles. It will be used to train all ED staff at Brigham and BWFH. A similar training program has been implemented in MGH ED as part of the UAR collaboration.
An important component of the training is standardizing the way agitation is assessed and addressed, Im explained. When designing the program, Im and her colleagues learned from their interviews with ED staff that while one clinician might perceive a patient as violent and in need of restraint, another clinician might see the same patient as upset.
In addition to developing a consistent description of agitation, the team developed a team-based algorithmic approach to deescalating ED patients in an agitated state to ensure equitable care.
“We tell our trainees to think of a patient who comes to mind when EMS calls and says there’s a 55-year-old intoxicated male picked up at Forest Hills station. Then juxtapose that image with the patient you picture when EMS calls in with two intoxicated males picked up at a Boston College party,” Im said. “This exercise gives us space, time and opportunity to think through our blind spots and how bias really seeps into our clinical care.”
Taking a Trauma-Informed Lens
Annie Lewis-O’Connor, PhD, NP-BC, MPH, FAAN, co-chair of the Mass General Brigham Trauma-Informed Initiative, explained how understanding the trauma a patient has experienced, including individual and systemic racism, can influence the way they experience health care settings.
“Trauma is intersectional — individual, interpersonal, collective and structural. It’s an event, series of events or set of circumstances that’s experienced by an individual as either physically or emotionally harmful, and the key to it is that it has long-lasting effects,” said Lewis-O’Connor, who also serves as founder and director of the C.A.R.E. (Caring Approach to Resiliency & Empowerment) Clinic.
Trauma-informed care (TIC) is a set of principles that providers can incorporate into their practice to improve the quality of care by building trust, create safe spaces and empowering patients and staff, while also strengthening peer support and interdisciplinary collaboration.
“In fact, TIC does not require you to do more work; rather, it suggests a way to reframe how we work,” Lewis-O’Connor said. “It’s a strength-based framework. It’s about not asking ‘What’s wrong?’ but rather ‘What’s happened?’ and ‘How has that impacted you?’”