Health Equity

Why inclusion should be part of every conversation in health care, with John Paul Sánchez, MD, MPH

Jul 19, 2023 . 29 MIN READ

Moving Medicine

Why inclusion should be part of every conversation in health care, with John Paul Sánchez MD, MPH

Jul 19, 2023

Speakers

John Paul Sánchez, MD, MPH, executive associate vice chancellor, University of New Mexico Health Sciences Center Office for Diversity, Equity and Inclusion
Sara Berg, MS, senior news writer, American Medical Association

Host

Todd Unger, chief experience officer, AMA

Listen to the episode on the go on Apple Podcasts, Spotify or anywhere podcasts are available.

Transcript

Dr. Sánchez: “I think it's really about viewing a person holistically...So it's important for a physician or a practitioner to always be mindful of that, taking the time to understand who the patient is in front of them, where do they live, what's the community that supports them, who cares for them, what's their support network, what are the conditions that they're returning to after being discharged from the hospital or an urgent care setting, whether they have the support for follow-up and continuity of care, and thinking of other professions that help support the patient in addition to ourselves, such as nursing, social work, physical therapy, and so forth...”

Unger: That’s Dr. John Paul Sánchez, executive associate vice chancellor at the University of New Mexico Health Sciences Center Office for Diversity, Equity and Inclusion.

What drove Dr. Sánchez to medicine was to have an impact on health inequities. But no one was talking about them. In this episode, Dr. Sánchez shares his passion for embedding equity, DEI best practices and his own journey in medicine. He discusses all this and more with AMA senior news writer, Sara Berg. Here’s Sara.

Berg: Hello, I'm AMA senior writer Sara Berg. Today, I'm with Dr. John Paul Sánchez, who serves as executive associate vice chancellor at the University of New Mexico Health Sciences Center Office for Diversity, Equity and Inclusion. Dr. Sánchez has extensive knowledge of national DEI best practices and leadership experience.

Dr. Sánchez: It's a pleasure. Thank you for having me, Sara.

Berg: Of course. Today, we're going to hear directly from Dr. Sánchez about his work and experienced approach to implementing change and aligning with DEI at an organizational level. Dr. Sánchez, how has your work in diversity, equity and inclusion influenced your approach to patient care?

Dr. Sánchez: Thank you, Sara. I think that's the core question. So I would say that the great thing about diversity, equity and inclusion is that it gives you a better appreciation of inequities in communities that we live in or communities that we're a part of. It's those same communities that our patients come from. So, by getting a better understanding of various inequities by chronic disease, infectious diseases or even living conditions, we could provide more of a holistic care for our patients. For me, as an emergency medicine practitioner, that's extremely important. We're not only trying to stabilize a patient in the emergency room, but really also trying to understand the support network or system that'll be in place for the patient after discharge. And as we think about that, we need to consider social determinants of health.

Berg: Can you share some examples of how you've promoted diversity and inclusion within the medical field throughout your career?

Dr. Sánchez: Well, I am a proud product of many pipeline and pathway programs, even starting as early as a college level student. For me, just as I've benefited from a variety of these programs that have enabled me to explore not only a career in medicine but also in public health, it's been really important for me to be a part of those programs and give back. And even after benefiting from certain programs, I continued to serve in some capacity as a medical student, and during residency and fellowship, and currently as a faculty member. In my current role within the HSC Office of Diversity, Equity & Inclusion, we have a number of pathway programs, really K through 20, similar to other academic health centers across this country.

And I encourage everyone to even take a couple of hours to be a part of these programs, either serving as a teacher or an educator of an interactive workshop. Today, I actually spent an hour with high school students teaching them how to splint. It could be as simple as that or being involved in helping them with their CVs, their personal statements as they apply to their next educational level or aspiring to run a program as a director or even as an assistant dean.

Berg: Awesome. Can you share more of your medical career journey with our listeners?

Dr. Sánchez: Sure. So I think like many of you who are listening today, we were drawn to medicine because we had witnessed an health inequity in our community, or saw a family member die from disease, have significant morbidity and mortality. For me, I was born in '74 and grew up in the 80s during the HIV/AIDS crisis, and I remember going to a funeral of a family member who had passed away from AIDS. And it was the experience of not only seeing this family member, or hearing of this family member having died, but the taboo nature of discussions around HIV/AIDS, also known as GRID back in that day, seeing how people were uncomfortable talking about what he had died from, reading in the newspaper and seeing on TV how people were succumbing to the illness in very brief periods of time, and there was no effective treatment. Most concerning was the heightened discrimination that individuals who had been become infected were facing, and incredible isolation from family, their loved ones, their community, dying by themselves. Even the health care system struggled to provide compassionate care for those people who had become infected.

I couldn't imagine what that experience was like, but I knew, and even at an early age, I feared of becoming infected and dying in that same fashion very quickly, alone and isolated. And it drew me to want to not only get my MD to prevent or to think about treatment modalities to keep people from dying, but also to concurrently get my MPH and explore what factors were contributing to people becoming infected, and for certain communities to be disproportionately impacted by HIV/AIDS, not only those individuals who identified as men who have sex with men, or those individuals who identified as gay, but all communities. And we know that during that time, and even today, the HIV and AIDS prevalence is significant within communities of color; Hispanic/Latino and African American/Black communities. And so that was a major driver for me pursuing clinical medicine, but also public health.

Berg: That's very powerful, very moving. It sounds like a great journey that you took, and really inspiring. What motivated you to focus on pre-faculty development and how has it contributed to increasing diversity among medical professionals?

Dr. Sánchez: So I can think back to my early days of attending medical school, and how excited and honored I was to be able to attend medical school and attend medical school in the Bronx where I grew up at the Albert Einstein College of Medicine. I knew it was going to be heavy in science, molecular and cell biology, anatomy, histology. And as I was going through the coursework in the first couple of months, I also expected that we would be talking about many of the things that I just mentioned that drove me to medicine, understanding why there were health inequities in my community in the Bronx and New York City and similar communities across the country, communities of color.

What I noticed in sitting in the classroom was two things. One, that wasn't the case. Very rarely, if at all, did we talk about those conditions, those ailments, those diseases that were disproportionately impacting Hispanic/Latinos, individuals of LGBT identity in the Bronx or anywhere in the country. And that was really disheartening because really what drove me to medicine was to have an impact on those inequities. And there wasn't a space in the classroom through the curriculum to discuss that in a day-to-day basis, even in a month or in a year.

Berg: Wow.

Dr. Sánchez: The second thing that I think was really surprising is that many of the people who were teaching weren't from the community.

Berg: So it's a lot of, you wanted to see more people look like you so that you can reach more of that community?

Dr. Sánchez: Absolutely. I was hoping to have lecturers that would bring those topics up, engage the students, have a robust discussion of what's going on and how we could be more effective, what are the best practices? What could we do in the future to change those health inequities? So it wasn't in the curriculum, it wasn't being brought in the classroom and it didn't seem like the individuals who were teaching the materials were ready or prepared to have those discussions. And that really inspired me to think about how can we diversify the academic medicine workforce? How do we move to further bring in greater representation and diversity of lecturers, faculty, researchers and leaders? And that really helped shape my interest in diversifying academic medicine.

Berg: Do you think we're moving that needle so far, making some sort of an impact on that?

Dr. Sánchez: Well, I think the needle is always moving, and I think we're hopeful that the needle is moving in the right direction to really address health inequities. I do think we've seen improvements in curricular content in medical schools, definitely. There's a lot more materials that you can glean and find in the published literature. Mediportal is one of the journals where you could find many new publications, teaching and learner assessment materials that support DEI-related work. And I've been able to be a part of Mediportal and help build that DEI collection. And we have seen a slight bump in the number of diverse faculty that I think can speak more to those health inequities that exist within the Hispanic/Latino, African American and Native American communities. But the reality is that this increase has been minimal, minimal when you consider the magnitude of health inequities that are affecting those communities.

I mean, still currently, only about 10% of faculty in our allopathic medical schools are of those three groups, and that fluctuates across medical schools. And like I said, only 10%, yet in the general population, about a third of U.S. inhabitants and residents are African American, Native American or Hispanic. So we still have quite a bit to grow to reach parity. It's not only about a number, but you do need a workforce that comes from the communities most affected with these conditions to better describe them and better engage the future generations of clinicians on how to address these health inequities. So I'm hopeful. We're making progress.

Berg: I'm hopeful too. I think we can do it. Could you discuss some key findings or insights from your publications that have highlighted the experiences of people from historically excluded racial and ethnic groups in health care?

Dr. Sánchez: Absolutely. So back in 2008 with colleagues, I was able to form an initiative titled Building the Next Generation of Academic Physicians, also known as BNGAP. And the focus of BNGAP has been to work with medical students who are leaders of various organizations, such as the Medical Student Section of the AMA, the Latino Medical Student Association, the Student National Medical Association, ANMS and APAMSA, to think about what are the factors, the facilitators and the barriers that influence their interest or career intent towards becoming a future faculty member, or senior leader within our academic health centers, or more specifically, our medical schools. And so, I went around and I did focus groups and surveys with students of all these great organizations. And we picked these organizations because students who are part of these organizations have declared that they want to be leaders. They want to be leaders in addressing health inequities.

So, I really wanted to understand how do we keep them within our academic medicine workforce to become faculty and senior leaders? And what we learned is that they were really knowledgeable about the steps to becoming an OB-GYN, a pathologist, a surgeon, an ER practitioner, but they didn't even know that they were good enough or smart enough to become a future faculty member, or to be a dean or a vice chancellor of an institution. No one had called on them to think about those positions, no one had defined or described those positions to them, no one had explained the importance. So fundamentally, it was about initially creating materials just to give them a definition and an explanation of what is a faculty member or what it means to be a dean of student affairs, or a dean of education or dean of diversity, equity and inclusion. So knowledge is key.

Berg: Yeah, knowledge is key. That's really wonderful. And I think that's great work, and hopefully, it continues. In your work, you emphasized an intersectional lens when examining the experiences of different groups. How does this approach contribute to a more comprehensive understanding of health disparities and patient care?

Dr. Sánchez: Absolutely. So I think the good thing is that medicine has moved to look at an individual beyond a disease, to look at an individual holistically to better understand what were the factors that contributed to that person being inflicted with a certain condition, really thinking about social determinants of health as a way of coming up with more prevention modalities, thinking about the most effective treatment modalities, and then also the support systems in place to help an individual thrive and remain functional despite a condition. I think it's really about viewing a person holistically. And sometimes when we use the word intersectional, we're only thinking of one identity or two identities, and the reality is an individual's existence and identity could be very fluid.

So it's important for a physician or a practitioner to always be mindful of that, taking the time to understand who the patient is in front of them, where do they live, what's the community that supports them, who cares for them, what's their support network, what are the conditions that they're returning to after being discharged from the hospital or an urgent care setting, whether they have the support for follow-up and continuity of care, and thinking of other professions that help support the patient in addition to ourselves, such as nursing, social work, physical therapy and so forth. So, I'd like to think that we're moving beyond this notion of looking at a patient through an intersectional lens, but really treating a patient holistically, not only through the lens of medicine, but really the health professions, a team-based approach to optimizing care and outcomes for the patient.

Berg: Okay. So, it goes beyond just what happens in the doctor's office. It includes every aspect of their life.

Dr. Sánchez: Absolutely. Absolutely. And it's not just a disease. It's looking at the conditions that led to that person developing that illness and how do we prevent them from getting a recurrence or getting sicker.

Berg: So, you were the editor of the book Succeeding in Academic Medicine: A Roadmap for Diverse Medical Students and Residents. What are some important strategies or recommendations you provide to support the success of people from historically excluded racial and ethnic groups in the medical field?

Dr. Sánchez: Well, one, thank you for sharing the book. Myself, and I had over I think about 30 incredible colleagues from across the country who represent different identities contribute to this book with a particular focus on women, racial, ethnic minoritized individuals, and sexual and gender minoritized individuals. And we have focused the book to provide best practices for those groups because we know those three groups have been historically underrepresented within the academic medicine workforce. The book is really written to encourage and inspire and provide knowledge and skills to medical students, residents and fellows, who collectively, we can call them pre-faculty, because we want them as pre-faculty to stay on track and become eventually faculty within our allopathic and osteopathic medical schools.

And some of the recommendations or some of the strategies that we take through the book is, one, giving them fundamental knowledge. As mentioned, it's really important to explain to students what it means to be a faculty member or dean or vice chancellor or another type of administrator within the medical school, how what they're currently doing right now is preparing them to be future successful faculty or senior administrators. So, for example, many of our faculty are teachers and educators, and our medical students, our own residents are often engaged in teaching and developing curriculum. So, it's good just to remind them, "Look, the teaching and the curriculum development you're doing right now at the medical school in religious entities out in the community, that's giving you a foundation that I want you to continue to build on so that you could be a more effective clinician educator, or teaching faculty member in the future."

And just making that connection for individuals does multiple things. One, it connects the dots, but two, it lets them realize that they're good enough and smart enough to hold this esteemed position. Often students, when they see a faculty member in stage, they're looking at them in awe. And you'll hear, especially from students of color, "Oh, I can never be a faculty member. I'm never as good. I'll never be as good. I'm not as smart as that individual." And that's simply not the case. With time, you acquire all this information, but you definitely have the assets and the foundation to be a future faculty member. So, it really helps to address imposter syndrome.

In the book, it helps students think about building diversity capital as a means to becoming a future faculty member or senior administrator. And I think also, another important piece that we focused on in the book is, as I mentioned, most of the co-authors are individuals of communities underrepresented within academic medicine. So as students are reading these chapters, they're also reading the personal narratives of the chapter co-authors, and they're seeing stories and images of individuals who identify, once again, as women, LGBT, African American, Hispanic, Native American. And that in itself is very powerful, especially if they don't have those individuals teaching in their medical school.

Berg: Right. Do you have any specific success stories you can share?

Dr. Sánchez: So, I would say what I always tell students that I run into is that I share information about becoming a future faculty member or becoming a dean, not because I want everyone to come back to me every time they see me in the hallway and say like, "Yes, yes, Dr. Sánchez, I'm going to be a faculty member or dean." Absolutely not. I want you to be a critical thinker. I want you to be happy in your professional journey. It's so much more impactful and powerful for me when I hear a student come up to me and say like, "Look, Dr. Sánchez, I read the book. I went to the seminar. I'm thinking about the information. I know I'm good enough. I know I have the knowledge and skills to eventually be a faculty member. Right now, I haven't decided, but I'm still thinking about it. Can we set up a meeting? Because I still have additional questions."

That's what I really enjoy and I appreciate from students because they're critically thinking about this as a career opportunity. And what's beautiful within BNGAP is that we've been able to develop a network where those conversations continue to happen on our monthly conference calls. Now, we've established, similar to AMA has chapters within medical schools, now we have BNGAP chapters where those type of conversations are happening between faculty and students within medical schools. And so, we're starting to not only develop a network, but a lot of opportunities for these type of discussions to occur to keep people thinking about it and engaged and on track to become future faculty member. And we're in the process of videotaping some of these narratives so that they can inspire other medical students and residents.

Berg: Wow, that's really cool. What advice would you give to a young person of color who is interested in pursuing a career in medicine? Where should they start?

Dr. Sánchez: So, the good thing is, as mentioned, I am a proud product of many pipeline and pathway programs. I think we know that medical schools across the country, whether osteopathic and allopathic, are developing K through 20 programs. It's critical for students who are interested in becoming a future physician to become engaged with these programs, at any time. You can start as early as high school, or college or even post-BACC. And it's not only about doing these programs once. I want you to consider continuity in your professional development. I want you to do one of those pathway programs every year, maybe every summer or during every academic year.

And the reason why is because, one, it keeps you engaged with that network that's going to support you, guide you, advise you, mentor you, and most importantly, sponsor you for your next step, whether it's getting into medical school, or whether it's succeeding at the MCAT or getting into another program. So, one, it's critical to get into a pathway program, and then it's critical to stay on track with pathway programs and stay engaged every step of the way. Even during residency and fellowship, there's pathway programs for professional development, including academia.

Berg: Do you think also getting involved with organizations like the AMA and some of those sections, is that helpful as well?

Dr. Sánchez: Absolutely. So there's different types of pathway programs. So I'm happy that you brought that up. So when I think about the different pathway programs that I've been a part of, sometimes I did a pathway program because there was an emphasis on MCAT preparation or in doing well in certain courses. There's other pathway programs that maybe have an emphasis on teaching or research or service. And as we know, and I've benefited greatly, being a part of AMA, LMSA, SNMA, APAMSA, ANMS, AMWA, all these organizations exist for a reason, and they exist for a reason because they bring together like-minded individuals.

They create a space to lead innovations in policy, community activism, medical education reform and they create a safe, brave space to do this work. And along the way, while being engaged, you yourself develop. So, while you're sharing your perspective, you're developing knowledge, skills, leadership skills. So, I always encourage individuals as a form of being a part of pathway programs to become a member of AMA, LMSA, SNMA, APAMSA, ANMS. I go to multiple conferences every year. So I would say do more than one. It's definitely benefited me, and I think it's important for everyone to remain engaged in that way.

Berg: Okay. How do you address the unique challenges faced by women, sexual and gender minorities, and historically marginalized racial and ethnic groups in health care, both in your research and in practice?

Dr. Sánchez: So one of the simplest ways to do this is to make sure that you create a space within your demographic section of your research where you capture respondent's identity by sex, gender identity, sexual orientation, race, ethnicity. That's critical if you're going to be able to do comparisons or stratify data analysis by those three groups that you just mentioned; women, sexual and gender, minorities, and historically marginalized racial and ethnic groups. So one, you got to collect the data. And then two, you got to be respectful and mindful of the analysis that can be meaningful in addressing health inequities in these communities. I would say those are the two most important things to consider as you aim to address challenges for these historically minoritized groups in research.

When it comes to practice, it's also being mindful there's many ways to look up how your hospital or clinic is doing in terms of serving these patients. You can do chart reviews, you could do prospective studies, you could do focus groups with community members by each of these identities and just ask about their access to quality care, what's being done well, what's not being done well and then introduce new activities, policies and procedures. But most importantly, you have to hold yourself accountable. So if you're collecting data and you identify a problem, you should propose a solution and see if that solution actually worked, not just for the first year, but if there's a sustained positive response over time. And that's really critical.

Berg: What steps do you believe health care institution should take to create a more inclusive and equitable environment for both patients and medical professionals?

Dr. Sánchez: So I'm really happy that you framed the question this way because I do believe that health care institutions are responsible for everyone that they serve and that's a part of their community. So our patients, our medical professionals, but I would also say all of our employees, our entire team that is there to support our patients. And when I think about the overall team, it's not only our learners or the physicians or the faculty. It is also those people who register the patients, those people who staff the garage, security, the cafeteria, everyone who helps create a space for patients to receive care.

I think one of the ways that we help create a more inclusive and equitable environment for all is to keep our eyes and ears open, see how situations play out, listen to conversations, ensure that they're respectful, that there's a space for everyone to feel like they belong, collect data, ongoing data from everyone that I just mentioned to see how they perceive the environment, both the social and the physical environment in which they are providing and receiving care and services. And pretty much do it on a frequent basis, but then use that data to drive change. And as mentioned, as you propose ... As I mentioned, as new policies and procedures and activities are done, evaluate that work and see if it's really making a difference. We're really good at keeping charts and monitoring outcomes based on lab work. We need to do a better job of taking the same approach to ensuring a more inclusive and equitable environment. And collecting data, evaluating and holding ourselves accountable is critical.

Berg: Do you have any success stories you've seen, or any examples of this?

Dr. Sánchez: Well, I think for me, when I think back, as a medical student, one of the things I was most proud of was helping to open the first LGBT center in the Bronx. It was called the Bronx Lesbian and Gay Health Resource Consortium. And at that time, which was really the early 2000s, there were minimal federal protections by gender identity and sexual orientation. There were some good state protections within New York State. It was a time when it was still risky to declare yourself as being a part of the community or even an ally to bring it up within the medical school classroom. So often, many students and faculty worked with community-based organizations, and that's how I came to be a part and helped co-found this particular LGBT center in the Bronx.

One of the great things that I was able to do as a medical student was really work with colleagues and help do trainings at hospitals to educate practitioners on what were the unique health issues and health disparities for LGBTQ members, and help them thinking about how they can transform their clinical space to be more inclusive and equitable, like changing their registration forms so that people could share their chosen pronoun, changing other questions so people can list their social support, who their partners were, who made up their family, changing signage and advertisements within waiting areas so you saw beautiful depictions of families that were different than what you would typically see on the news.

So, we actually built a campaign to promote primary care access for LGBT families. We launched a HealthLink line. I think the number was 866-4GAYCARE. Please don't use it now. It doesn't exist anymore, but that was just an example of different efforts—creating a phone line, advertisements. And on these beautiful posters, we would depict a lesbian couple with their kids, or a gay couple of two men or two women, or a family led by someone who identified as transgender, just different beautiful depictions of individuals and families that are part of the LGBT community. So, I would say that's one of the things that I'm most proud of and really shows how you can have a significant impact in many ways to create a more inclusive and equitable environment for a minoritized group.

Berg: Absolutely. Can you discuss any ongoing or upcoming projects or initiatives that aim to further promote diversity, equity, inclusion in the medical field that you're working on, or that you're aware of?

Dr. Sánchez: Oh my God, there's so many. We don't have enough time. We really don't have enough time, but I would say that I think one of the things that we need to do better as a community is document our DEI-related work. And I say that because I think that call hasn't been made in the past. And to this date, there's a lot of missing information on which DEI activities are the most efficacious in terms of increasing representation within the medical school class or the resident class, which medical education modules are most impactful to address unconscious bias, or to provide greater cultural competence.

And so, I think really, as we see the landscape defunding offices of DEI, as we see efforts to remove titles of position, as we see individuals pushing for DEI cultural competence, anti-racism not to be taught in the classrooms, we must be vigilant in documenting, publishing our historical, our present efforts, the current discourse that's happening, and introducing new promising and best practices. Irrespective of a loss of funding, no one can take away our thoughts and our suggestions and what we're currently doing, and we need to be mindful that we need to do a better job than prior generations of publishing our work. Not only publishing our historical work, our current efforts, but publishing better and best practices for the future. They can't take that away from us.

Berg: I feel like we need to shout that from the rooftops, the mountains, the highest peaks. What advice would you give to aspiring medical professionals from historically excluded racial and ethnic groups who may face barriers or obstacles in their journey?

Dr. Sánchez: So, when I hear this question, what I want to remind people is to pause and take a moment. Take a moment of what it means to be a historically occluded, excluded racial or ethnic individual today. It's hard, but can you imagine how hard it was 10, 20, 30, 40, 50, a hundred years ago? We still have a ways to go. I know it's still hard, but if anything, that our ancestors taught us is that we're strong enough, we're smart enough, we're resilient to succeed, that we have the assets to succeed. And if we really want to honor their contributions, if we want to honor ourselves, if we want to create a better space for ourselves and future generations, then we just have to keep on going forward. That's it. We just keep going forward. This ain't the first time. This isn't the first time or the last time, but we can learn every time and share that information with prior generations, and let them know and reassure them that we've been through this and we got through it, and we're better for it, and we're stronger and we're smarter, we're more resilient and we're going to keep going, whether it's in the community or within our medical schools or academic medicine. It's no different. You could apply the same knowledge and skills to not only survive, but to thrive, but that has to be the focus. You sit down, you cry, you shake it off, you hug each other, you hold someone's hand and you keep moving forward. That would be my final message.

Berg: I love it. That was wonderful. I think that's a great way to close out. Dr. Sánchez, it was a pleasure talking with you today. Thank you for joining me on AMA Moving Medicine.

Dr. Sánchez: Thank you, Sara, so much for this opportunity.

Berg: I'm Sara Berg. Thanks for listening. Until next time, please be well.

Unger: You can subscribe to Moving Medicine and other great AMA podcasts anywhere you listen to yours or visit ama-assn.org/podcasts. I'm Todd Unger and this is Moving Medicine. Thanks for listening.

Disclaimer: The viewpoints expressed in this podcast are those of the participants and/or do not necessarily reflect the views and policies of the AMA.