Health Equity

Q&A: This pediatrician is confronting inequities in GI care

Timothy M. Smith , Contributing News Writer

As a pediatrician, Hannibal Person, MD, sees advocacy as intrinsic to his role. But being a subspecialist in pediatric gastroenterology and hepatology adds a special urgency to his goal of undoing health inequities among America’s kids.

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Dr. Person is an assistant professor of pediatrics at the University of Washington School of Medicine and medical director of the Gut-Brain Health Program at Seattle Children’s Hospital, where his clinical interests center on disorders of brain-gut interaction that lead to chronic gastrointestinal (GI) disorders, such as irritable bowel syndrome, functional dyspepsia and functional heartburn. His research has been published in Current Gastroenterology Reports as well as in Progress in Neuro-Psychopharmacology & Biological Psychiatry.

Hannibal Person, MD
​Hannibal Person, MD ​

“Almost all children with these conditions are poorly treated,” he said in an interview conducted at the 2023 AMA National Advocacy Conference, in Washington, which included visits to congressional offices. “They have symptoms that people often don't quite understand. There are no great treatments that fix these disorders overnight. And there's no blood test or endoscopy that readily identifies them.”

But even within pediatric patients, he noted, some routinely get better care than others.

“Children of color with these disorders may be more likely to be subject to less evidence-based treatment, less subspecialty care and maybe even overtesting,” said Dr. Person, an AMA member. “We need to know more. There’s this signal about racial disparities in pediatric GI that has not been fully explored through robust inquiry. Research into it is growing, but it seems to me health inequities are still on the back burner for many in terms of what's getting funded and what people are working on.”

So last year when Dr. Person spotted a social media post announcing 11 openings in the second cohort of the Medical Justice in Advocacy Fellowship, an initiative from the AMA and the Satcher Health Leadership Institute at the Morehouse School of Medicine, he quickly clicked the link.

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The fellowship aims to prepare the next generation of physician advocacy leaders to generate and exchange solutions and drive meaningful policy and structural changes. The 14-month program begins with a three-day intensive and features monthly virtual trainings, as well as regular mentor engagement.

“It was completely aligned with where I see my career going in terms of enhancing my skills, and in terms of advocacy through this model of justice,” said Dr. Person, whose research projects include the implementation and assessment of anti-racism curricula. “I saw the previous cohort and the amazing projects they were working on around the country, and I knew I had to apply.”

Now about halfway into the fellowship, Dr. Person took time to speak with the AMA about how it is furthering his career goals.

One of the biggest ways: helping him learn to look beyond his immediate environment to create change at the system level.

AMA: What prompted you to make health equity and anti-racism central to your work as a physician?

Dr. Person: From early in my medical training, I perceived that we weren't really getting health equity work right, especially as it related to physician education. I sat in all these lectures that were, I think, reasonable attempts to try to help medical trainees do better in terms of caring for diverse populations of patients. But they often boiled down to just one-hour lectures on caring for the African American patient. They were valiant attempts and somewhat helpful, but they were a bit misguided.

That early experience really motivated me to get more involved—not only in medical education, but also in medical education research. I’ve learned that what we need to do is incorporate all these aspects of anti-racism, cultural humility and other perceptions of care through an equity lens in everything we do. It should be baked into medical training ... not left to one-off lectures.

AMA: What are some of your research areas?

Dr. Person: My clinical interests center on disorders of brain-gut miscommunication that leads to chronic gastrointestinal symptoms in children, but the bulk of my research and work outside of the clinical setting is directed at racial health equity—not only in pediatric GI but also across the spectrum of pediatric health care. Also, I do research on educational interventions for health care practitioners and medical trainees to help facilitate their anti-racist transformation and participation in anti-biased behaviors to close the racial health equity gap.

One area that is, I think, fairly well researched is pediatric liver transplant, and that's an area where I'm focusing a lot of my research. Certainly, we have seen racial health disparities in terms of pre-transplant morbidity and mortality and children of color not getting equal treatment as it relates to some aspects of the transplant-listing process. There are also signs that, beyond other social determinants of health, race independently predicts worse outcomes for children of color with chronic liver disease. That likely reflects the impact of structural and other racism.

I see this all the time on the gastroenterology side of my work, where families of color are more likely to have gastrointestinal symptoms dismissed, particularly when they experience chronic pain, which echoes findings from other studies about how pain in the Black body is treated.

AMA: It seems many people think GI issues are particular to people of European descent. Does that come into play?

Dr. Person: Yes, there’s such a huge cultural component. When someone has chronic abdominal pain and changes to their bowel habits, how you perceive that could be dramatically different based on your upbringing and where you live. But certainly, making the public information … and the community-based interventions more inclusive is so important to getting members of historically marginalized communities to participate, to feel seen and represented, and to get better care.

Here’s the thing: Most of these conditions can be diagnosed with just a good history and physical. You don't need any bloodwork. It's all about taking the time and creating a relationship with the family and collecting the appropriate history. My suspicion is that—for all of the patients in our existing health care model—where visits are rushed and we don't always get the time we want ... this is an issue.

But I wonder, for families of color, whether the overtesting could represent an attempt at getting everything done and getting the patient in and out, along the lines of, “All your tests are negative, so … goodbye!” versus taking the time to form a collaborative relationship with the family and working with them over time in a model of shared symptom management.

AMA: Does prior authorization play a role in pediatric GI inequities too?

Dr. Person: It does. I have so many stories, but the classic example is a child admitted with symptoms of a flare of inflammatory bowel disease and it's their time of diagnosis. So, they come into the hospital with horrible bloody diarrhea and lab abnormalities. They get their endoscopy, and the subsequent biopsy results are consistent with inflammatory bowel disease—and it's severe.

In the hospital setting, we have some leeway to give them a biologic treatment and to give it in an aggressive fashion in order to help control the severe inflammation we see. Then it's not unusual that we give what we think is an appropriate medication at a higher dose given their illness. But then we apply for them to continue that treatment when they leave, and all of a sudden, within a week or so, we're getting a refusal saying the insurer doesn't approve the medication even though the child has already started it, or they don't approve it at that dose.

We try to tell the insurer: “This is severe illness. We need this dose.” With a lot of these treatments, you need the next treatment in just a couple of weeks, like for infliximab. So, it's not just bad care; it’s needlessly stressful for families already grappling with their child's diagnosis. No one wants to hear, “We’re glad your child is better after they received this treatment, but it isn't on our formulary."

AMA: So how has the Medical Justice in Advocacy Fellowship helped your advocacy efforts so far?

Dr. Person: It's been fantastic. We meet every month. We have speakers and opportunities to work on our projects. Plus, the program has done such a fantastic job of encouraging a sense of closeness and community—amongst the fellows, and with our sponsoring faculty and other mentors—that I get so excited to see everyone. I want to hear how their projects are going.

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AMA: And what is the nature of your project?

Dr. Person: I'm really passionate about anti-racism education for health care practitioners, so my project is a pilot curriculum for pediatric liver transplant teams in anti-racism from caring for children with chronic liver disease to the process of applying for and getting through transplantation. I'm finalizing the curriculum right now—looking at all the research, shoring up my metrics. My hope is to start piloting the curriculum by the late spring or early summer.

It will be about 12 hours total. There are four, two-hour workshops and then about an hour between the pre- and post-work each time, so it's a pretty significant commitment. It won’t happen in a weekend—it will run for several months—so there will be some time to not only do the work but also reflect on the practice skills and build your skill set.

AMA: Would you tell our readers about one useful tool or resource you have picked up from the Medical Justice in Advocacy Fellowship that stands out?

Dr. Person: Advocacy for me as a pediatrician is inherent to my role, but previously I had seen it as very internal to my institution, so speaking up at meetings, trying to direct institutional resources, that kind of thing. But this whole world of legislative advocacy—going to Capitol Hill and speaking to members of Congress and pushing the needle on reform and other things that dramatically affect health care across this country—was one I didn't know.

So, I would say the leading skill I've acquired has been related to looking beyond my immediate bubble and appreciating how high-level advocacy, legislative advocacy, can serve my patients and the communities I treat. Just since starting the fellowship, I had a meeting with a local state representative, and we're now talking about potentially putting together a bill to look at some issues we're having with the funding of treatments. So, it's gotten the ball rolling there and given me some real perspective and skills in that space.

AMA: And what would you say to physicians who may be interested in the Medical Justice in Advocacy Fellowship?

Dr. Person: The fellowship fosters a sense of community and collaboration. A lot of physicians care deeply about medical justice in advocacy, but we do this work in a vacuum. We might be the only person in our division or even in our institution who's really doing the work. It's not lonely work, but you suffer from lack of collaboration, outside ideas and other support.

One of the beautiful aspects of this fellowship is people with similar interests from all over the country come together, support one another and innovate together. It makes the work of health equity research and advocacy a lot less lonely. And a lot more productive.