“There has been a lot of work on health equity for years, and it has been a slow process,” says Joseph R. Betancourt, MD, MPH, chief equity and inclusion officer of Massachusetts General Hospital (MGH). “COVID-19, in a very aggressive way, has demonstrated the impact of being inattentive.”
Health equity is the principle that quality of care should not vary based on patient characteristics, such as race or ethnicity. Racial and ethnic disparities in quality of care contribute to disparities in health outcomes and higher costs — and radiology is not exempt.1
“The work on health equity from a clinical standpoint has been driven by an understanding that if we care about quality and safety, then we need to monitor the variations in quality of care based on personal characteristics,” Betancourt says. “It has been this steady kind of drip, drip process — not comprehensive and not holistic,” he says. “What COVID-19 has really done is draw attention to all factors, all at once, that create systemic disparities in healthcare.”
A recent spotlight on long-standing social injustices has drawn out a new moral sense within the medical community — we need to do better than we’re doing, Betancourt says. “Facing down inequities is not just about what happens inside the walls of healthcare, but what is happening outside as well,” he says.
“Community has become so important during this pandemic,” says Shlomit A. Goldberg-Stein, MD, associate professor of radiology at Einstein Medical School and director of operational improvement for the department of radiology at Montefiore Medical Center in the Bronx, N.Y. When you are in touch with your community, you have a better chance of hearing, locally, their healthcare needs and concerns with getting services during COVID-19 and beyond, she says. “With COVID-19, we are
seeing different groups of people with different ideas around the country behave in very, very different ways in terms of social responsibility — fear or no fear, compliance or no compliance.”
This mixed response puts underrepresented minorities (URMs) — who already face many risk factors — more at risk during the pandemic, Goldberg-Stein says. These groups already have higher rates of hypertension, diabetes, and asthma. They are also disproportionately affected by housing issues, crowding, public transportation, and all the things that set people up for poor outcomes during a pandemic.
“Our staff come directly from the community we serve,” Goldberg-Stein says. “So when you have this sense of community responsibility and caring — maybe more importantly a thread of shared language, understanding, and experiences — there is a much better level of coordination and communication,” she says. “And we promote from within, especially in radiology.” That leads to diverse imaging leaders, imaging managers, and operations managers, she says. “Many have long-term relationships with patients and providers.”
These types of relationships break down barriers to equity in healthcare. “Right now, we’re dealing with patients fearful to return for care,” says Goldberg-Stein. It matters when leaders can communicate through a diverse staff — it encourages more outreach, Goldberg-Stein believes, and help direct necessary and appropriate imaging care delivery.
What could be scarier for patients facing COVID-19 than an inability to communicate with the healthcare professionals dedicated to helping them? Language barriers are often a challenge for underserved communities trying to navigate the healthcare system. COVID-19 compelled some institutions to act quickly to help patients marginalized because of their native language or cultural differences.
“Our goal with RadTranslate™ was to provide simple, one-way communication — and to free up interpreter services for more complex two-way patient encounters,” says Marc D. Succi, MD, executive director of the MESH™ Incubator at MGH. “The application gives the patient a better care experience in their native language.” MESH is an in-house innovation group and prototyping lab developed within the MGH radiology department to create targeted products and services that meet real clinical needs at the ground level (read more at acr.org/MESH-MGH).
COVID-19, in a very aggressive way, has demonstrated the impact of being inattentive.
RadTranslate (www.radtranslate.com) plays audio clips in multiple languages to help RTs and nurses care for patients during exams and procedures. Any institution can access the tool, which features clips on screening mammography, COVID-19 screening, and other imaging services.The idea for the tool was brought to Succi by the Diversity, Equity, and Inclusion Committee at MGH, who keenly identified the need early in the COVID-19 crisis.
Before implementing the tool, Succi says, “Our only other option was to speak with an interpreter in-person or on the phone — a big delay — or to mime instructions in broken Spanish or Mandarin. That’s sub-optimal patient care and not inclusive,” he says. “This application was and will continue to be crucial during COVID-19 in our clinics.” Betancourt hopes efforts like this will help address patient challenges like inadequate communication, a lack of trust between physicians and underserved patients, and implicit bias and stereotyping. If COVID-19 hasn’t demonstrated the link between social determinants and healthcare inequity, Betancourt asks, what kind of burning platform will it take?
The pandemic has ignited a call for a change in thinking about those most in need — and how the country’s overall health is interconnected. Things are different now, Betancourt says. “We’ve never had a real-life case study that shows how underinvestment in public health — particularly in the care of more vulnerable communities — can shut us down,” he says.
“Before COVID-19, a handful of vocal medical experts, advocates, and activists were trying to get leadership to care and invest in more equitable care,” Betancourt points out. “Now those voices are amplified twenty-fold, and a lot more people have witnessed, front and center, the impact of disparities in ways they never comprehended.”
“I have spent most of my career talking about the cost and quality-and-safety value case for addressing disparities,” Betancourt says. “This is the first time I can actually lead with why these things are important from a social justice and equity standpoint.”
Even so, he says, there is no denying that from a cost and quality-of-care standpoint, not integrating health equity work into the fabric of an institution and into the community comes at everyone’s collective peril. “Leaders who may have considered this before but not invested in it or leaders who felt it was important to address but who nibbled around the edges — these groups may now have the courage for bigger, bolder, more comprehensive things,” Betancourt hopes.
There is also a real opportunity for rising radiologists to move the needle on health equity. It will still require resources, leadership, and accountability, he says. “But every generation seems to be more active than the last — understanding what is happening in a deeper way,” Betancourt says. “It is critical to leverage those voices right now. It is already starting to happen, and it is energizing.”
Listening and acting based on what continues to unfold around the pandemic is incumbent on radiology leaders who are building teams that will best serve all patients. “I think it means a lot to communicate authentically with your patients. That’s what having a diverse staff is about,” Goldberg-Stein says.
“If we survive a pandemic but ignore the things that have surrounded it — the other social injustices and inequities of care — we haven’t really conquered the problem or shown strong leadership,” Goldberg-Stein says. “Number one, we’re all in this together. But number two, leadership matters.” When you model the right behavior, when you say the right things, it can have a very powerful and profound effect on the people who are listening, she says.
There is no question that URMs were hit harder than other populations when the pandemic broke. “A virus doesn’t discriminate between zip codes,” Goldberg-Stein says. “We really need to get away from this concept that one group or one portion of the population is more important or deserving than the other. A lot of patients have suffered through COVID-19 — young, old, privileged, and not. We’re all interconnected — all of humanity is connected.”
“Before, during, and after COVID-19, we need to be closely focused on patient access — care for all our patients,” Goldberg-Stein says. “If you understand that everyone matters, and you understand your community, you can accomplish quite a lot.”