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Ep. 110 - Medicine: Color, Culture and Equity Pt. 3 (Dr. Stephen Pedron)

episode 110

Ep. 110 - LiveWell Talk On...Medicine: Color, Culture and Equity Pt. 3

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Host: 
Dr. Dustin Arnold, chief medical officer, UnityPoint Health - St. Luke's Hospital

Guest: Dr. Stephen Pedron, physician, UnityPoint Clinic Maternal Fetal Medicine

Dr. Arnold:
This is LiveWell Talk On...Medicine: Color, Culture and Equity. I'm Dr. Dustin Arnold, chief medical officer at UnityPoint Health - St. Luke's Hospital. Today's podcast is another installment in our mini-series where we discuss topics related to diversity, equity, and inclusion. Returning the podcast today is Dr. Stephen Pedron, physician at UnityPoint Clinic - Maternal Fetal Medicine, to discuss black maternal health, patient centered care, and solutions he's seen in his practice. Welcome back.

Dr. Pedron:
Hey, how are you Dustin?

Dr. Arnold:
I'm well. You know, Steve, I mean, it's clear it is measurable that black perinatal mortality and maternal health, is worse than compared to the Caucasian population. And I'd like to just kind of approach that today from your standpoint, how you see the discrepancy and what we could possibly do about it. You know, I think we want to be careful, you don't take an outcome and not look at it scientifically and see how we can figure out this problem. Because whether or not you believe it's systemic racism or not, it's a fact, it's there, it's measurable and we've got to do something about it, right? What has been your experience?

Dr. Pedron:
It depends on your— First, yes, it's all scientific. It just depends on your definition of the science. What's the science? If your science is sociology and your science is economic and historic and institutional and baked in, then yes, there's definitely disparity. There's a big problem if you're a science is biologic, and is there a difference between the black patients' propensity to have a bad outcome compared to the Caucasian patient? Doubt it. I don't think that's there. I think it's all social and economic.

Dr. Arnold:
That's my casual observation of that. I mean, I know that, you know, they can list things as eating habits, obesity, smoking, prenatal care, alcohol consumption. But those are all problems in the white population too. You know, it's not like it's limited to black people. But it truly is present. What has been your experience with, let's just start with nutritional deficits, that you see in your patient population as compared to perhaps a more affluent population.

Dr. Pedron:
That's a great question. If you, let's just take your average population. Even if there is a difference in eating habits, there's a reason for their difference in eating habits. Again, that's baked in. It's social. It's cultural. It's something that is developed in our society as a consequence of X, whatever that X is. Economics, living conditions, food deserts, areas that don't have good access to food, I think all of that is societal. Let's take a specific population though, of our African immigrant population. We have huge dietary challenges in that population because they're just, I don't know, aren't enough African grocery stores, or there's a difference in the content of African food. There's a higher prevalence of carbohydrate, which predisposes to glucose intolerance in pregnancy. So I think any way you slice it, there's a big cultural and societal difference. Does that answer your question, Dustin?

Dr. Arnold:
Yeah, you did. I mean, well, you reinforce one of my prejudices is that if patients that live on country club drive are less likely to get readmitted than the patient lives on someplace on the Southeast side of Cedar Rapids from, you know, the 800 block to the 15th hundred block. That's just an observation. And I think part of it is social situation, a social network support system. I know we won't find one single solution to this problem, but we got to keep trying and I refuse to give up just out of my competitiveness. I like to win, and I want to keep driving forward on this. I will say having grown up in poverty, your reward system is different. You know, when the tax return would come in May, we got Kentucky fried chicken. We never got that. You know, so you celebrate it. We didn't go on vacation someplace, right? We celebrated with some sort of: Oh, I'm just going to say it, gluttony of food as a celebratory event. And I think that is also some of the things that people that are in poverty do that too. You know that's just a social thing that they can reward themselves. And therefore, I think eating poorly just follows with poverty quite honestly. Despite all the measures that we put in place, particularly school nutrition, breakfast, and lunch, and the backpack program here in the Cedar Rapids schools is highly successful and worth the effort. But we still see poor nutrition in the adolescent population that goes into adulthood.

Dr. Pedron:
Yeah, food is a reward. If your reward food is Kentucky fried chicken, as opposed to a salad. That's, you know, a salad at a country club, let's say. Really, just put a stark contrast there. Then that's going to affect your health. Here's another concept that I'm keen on and have been for a while. And that's the concept of weathering. And the concept of weathering says that the environment that you're exposed to takes its toll, it has its effect on your catecholamines, your epinephrin, your norepinephrine, your cortisol, it raises your blood pressure. It causes you to be predisposed to a variety of illnesses. This concept of weathering just wares African-American patients down. It wears patients of color down. It wears down their system, their body, their constitution, to predispose them to more illnesses. And just as a hopeful example, let's take a look at OB shortage, OB provider shortage in rural areas, which is us. That absolutely hits patients of color where they live. They don't live in affluent areas. They don't have access to care. They don't have transportation, they can't get to their provider. There is tremendous opportunity to provide more providers for those patients, but the entire society needs to step up and work on those tools for those patients. I'm preaching a little bit.

Dr. Arnold:
No, you're absolutely right. And I think it's something as sheltered Midwestern suburbia, which we are for the most part, we're just not aware of it. It's not that we want it to happen to people. But you know, I can confidently tell you that neither me or my loved ones will be the victim of a drive-by shooting this weekend. And can you imagine going to the weekend and be a mother of three kids, knowing that you live on the South side of Chicago, knowing that that's a risk factor for the weekend. You know, knowing you can't be with your children the whole time. I mean, that's just that's mind boggling. I mean, we don't have that. Most of the stress we have is self-induced and it just—that'll be another podcast.

Dr. Pedron:
Yeah. So first, that's a real danger. You know, you might get shot. Second, that stress, you're nailing it. That stress is what takes its toll. That stress of living in that environment, that wears you down. That's measurable. There's an author, amazing author, who worked on this. That sort of stress wears you down and pound for pound, pardon the expression, these patients have a shorter life span. These patients that are subjected to that stress have a shorter lifespan because of cardiovascular disease, because of malignancy. I'm making up some of these disorders, but for sure, cardiovascular disease is more prevalent in that group.

Dr. Arnold:
And I think we, a lot of times, we live in our bubble too. We don't understand that this is going on. I saw a special one time on West Virginia and Appalachia, and there was an Indian physician that said that, you know, he grew up in India and he said, this is worse poverty than I had where I came from that is thought to be, you know, systemic generational poverty. And it was interesting because you don't even think about, you don't think about that. And I think that has a lot of ramifications when you're impoverished. It's hard. Transportation is a big issue I see with patients, white or black. It's hard to get around, the bus system doesn't always stop at healthcare places. I do know that I just recently did it with the influenza vaccine, the Cedar Rapids transportation, the Cedar Rapids buses. They do have a category where they try to hit health care. You can click on it and you can know which buses go by what healthcare facilities, clinics, pharmacies, et cetera. So it does allow a patient to, if they have access to the internet, to look at that and try to figure that out.

Dr. Pedron:
You know, I was thinking when you were talking about the difference between other countries, say third world countries. Shortly after we started this practice in 2018, we had a patient who—this is when all of the, this is when there was this huge influx, this group of people who were walking up through Mexico from central America. Remember that?

Dr. Arnold:
Yeah.

Dr. Pedron:
One of the patients who came to our practice was this HIV positive patient who was cachectic. I mean, she was just as skinny as a rail. And we asked, I asked this patient with a translator, of course, how'd you get here? She said, she came from, I don't know, Nicaragua, I think. Or maybe it was Venezuela. I mean, she came a long way. How'd you get here? I walked, her answer was "I walked." Then she got here and she got whatever really cool, but small amount of support, we give our immigrant patients when they arrive. And she's sitting alone in her apartment with no family, she's starving, she's starving to death. She made it to America, bought the, you know, bought the lottery ticket, made it to America, walked up here. And then she's sitting in an apartment starving to death because she can't afford food here. That's tragedy.

Dr. Arnold:
Yeah. Well, and I think if I as an internist, if I had any idea how many, the percentage of my patients that are choosing between food and medications on a daily basis, I probably would quit if I really knew the percentage. I probably would just say, I give up. Because I know it's high.

Dr. Pedron:
Yeah. I've had maternal deaths, no exaggeration, that you know, they died because they couldn't afford their medication. Why? Because they're buying cereal for their kids.

Dr. Arnold:
So really to address this issue, it's not a single thing. But poverty just simply cannot be ignored. And you can't, I think, I think you're foolish as a physician, if you walk into the exam room and you treat the impoverished patient the same as the affluent patient. From a standpoint of expectations and building that doctor to patient relationship, you are set up to fail, because the advice you give to one may be successful, where it might not be to the other. And I think you really have to understand the difference in that regardless of skin color, but maybe more so in the black population. What are your thoughts on that?

Dr. Pedron:
Yeah. I think that we are obligated as a society to step up and help. I think we're obligated as a system to work on policies and processes that provide access to care. But I think we're obligated as providers to ask them what is happening with you today? Your blood pressure may be a problem. Your diabetes may be a problem, but what's up with you today? How are you feeling? If they're feeling frightened because a storm blew their apartment apart and they don't have a place to stay, we can't expect to do anything with their hypertension, diabetes until we address. I think on that fundamental level as providers, we have to at least ask the questions, so we know what they're feeling. We may not be able to change it, but at least we can start to connect with them a little bit and get at what's really happening in their world.

Dr. Arnold:
Yeah. I mean, if you don't consider that social capital, is how I describe it. And you simply—you may have to compromise your medical treatment plan for that. You know, let's just take something really common. The insulin regimen for the affluent patient is different than that for the patient that is stressed with finances, you know. And if you provide the same to both of them, you might as well not even have seen the other patient because it's not going to work. And I think that's—I am happy, not happy, I don't know. I'm optimistic, let me say it that way, that we're starting to integrate thinking about social capital in our patients. That's not something you learn in medical school. That's not something that's in articles. I think I see more of it in articles than previously. I think experience builds on that as well, but it's something that really wasn't considered 10/15 years ago. You know, every patient's at the same. I mean, I've always said that you have two doctor-patient relationships. You have the fraternal, and that's the patient that you have to be their buddy and solve problems, the brother. And then you have the paternal, and that's where you say, look, no, you're going to take this medicine. And some patients want that, you know, doctors tell me what to do. Okay. And you have to be able to adapt that depending on what the patient's personality is. And I think that's even highlighted more when you start to have this lack of, this deficit of social capital.

Dr. Pedron:
Yeah. The older I get, the less paternal I am. I don't think that works very well. I think that the fraternal, if you can get an edge and you can connect, the fraternal is much more efficacious. But you're right, in a crisis patients want to just be told what to do. If it's down to brass tacks, yup. You've got to just tell them: look, for my wife or daughter, this is how I would handle it. The question is where are we going to go from here? You know, how are we going to, how do we just change the talk into action? You know, there are systems where Medicaid, for example, Medicaid/Medicare steps up and they pay, they put out, they fork out for housing, for transportation, for employment opportunities. And I think we're going to need to turn it around. We're going to need to turn the model that we're in right now big time, in order to really address these problems, Dustin. Otherwise I think it is just talk.

Dr. Arnold:
Yes. We've certainly had some events this past year that have put this in the forefront and we can't take our eye off the ball. And these are long-term solutions. These aren't stuff that's going to be changed next week.

Dr. Pedron:
No.

Dr. Arnold:
You know, I mean the deficit of African-American physicians is significant. It's disproportionate to the population of roughly 12%, not 12% of the doctors are African-American. Okay. And that's not to say that if you don't have a doctor that's your same ethnic group, he can't get good care. But there is a connection there, like you said, fraternal. But that's a generational solution. I mean, you can't fix that in the next week. You can start tomorrow, but you're not going to see return on your investment for 16 to 18 years. But that doesn't mean we don't try. You have a—I saw a flyer, you have an event coming up regarding black maternal health?

Dr. Pedron:
I do.

Dr. Arnold:
Tell me about that.

Dr. Pedron:
Well, that's a black kin. A celebration of black kin conference and I was invited to be on a panel for that conference. I think the word is out there that we care about this, that our practice cares that our system cares about this, and we do. And I think the word is out on disparity. And I think the word is out that in our specialty, in obstetrics, if we're ever going to contend with this issue of disparity, that shortage of providers of color, that's never going to get fixed in the physician population. In our specialty, that'll only get fixed in the nurse/midwifery population. So I think that they know that I'm an advocate of nurse/midwifery. And that I also see that as a nurse midwives of color as a really promising solution to delivering care in a disparate culture. I think that they just know that I'm listening, Dustin, and that my mind is open and that I'm trying to change. I'm trying to become culturally competent. I'm trying to become gender competent, gender fluent. You know, there's so much that's happening and there's so much language and there's so much eye-opening material out there right now. I think that somebody just heard that I was game to listen, that's all.

Dr. Arnold:
That's certainly believable. You've always been a good colleague and collaborative on such things. And I'm optimistic that things can be improved, but it is a long-term solution with not only financial, but also academic and thoughtful investments to make it return. And we just can't get discouraged.

Dr. Pedron:
Hmm. Okay. I'm going to try not to be discouraged then. Thank you. I'm going to work on that.

Dr. Arnold:
I am the eternal optimist by the way.

Dr. Pedron:
Yeah. Yeah. That's great. It's hard these days, you know, we're all really trying to pull ourselves up by our bootstraps to be optimistic these days. And so I'll take any encouragement I can get. That's cool.

Dr. Arnold:
Well, my door's always open if you need encouragement.

Dr. Pedron:
Yeah, I appreciate that.

Dr. Arnold:
But this has been great information. Always great to have discussion with you, Steve, on these topics. Thank you for joining me today. That was Dr. Stephen Pedron, physician at UnityPoint Clinic - Maternal Fetal medicine, discussing black maternal health. Thank you for listening to LiveWell Talk On. If you enjoyed this episode, don't forget to subscribe. And if you want to spread the word, please give us a five-star review and tell your family, friends, neighbors, strangers, about our podcasts. We're available on Apple Podcast, Spotify, Pandora, or wherever you get your podcasts. Until next time, be well.