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January 18, 2022By MedStar Team
Structural racism is one of the most pressing issues facing healthcare today. Unfortunately, academic medicine historically exacerbating the exploitation of vulnerable communities to achieve educational and research goals, especially in Black, Indigenous, and People of Color (BIPOC) communities. For example, many traditional research practices among marginalized communities highlight and, in most cases, magnify inequities in care. These can include:
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Community members are under informed about research methods and strategies.
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Researchers prioritize extraction of information from communities rather than community ownership of information.
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Researchers accrue funding, prestige, and publications (in which academics’ voices predominate over the narrative perspective of community members) without similar accrual to participating communities.
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Researchers’ understanding of questions to be answered may lack cultural context because of their incomplete comprehension of community conditions.
The relationship between research institutions and many BIPOC communities is estranged and needs mending to dismantle racial disparities and inequitable research practices. As the area’s largest healthcare provider, MedStar Health is committed to do the work needed to address these issues in everything we do in order to advance health equity for everyone we serve.
“Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” – Dr. Martin Luther King, Jr.
(March 25, 1966 speech to the Medical Committee for Human Rights)
Advancing Health Equity in Early Childhood and Family Mental Health Research
MedStar Health investigators Arrealia Gavins, Celene E. Domitrovich, Christina Morris, Jessica X. Ouyang, and Matthew G. Biel recently published research emphasizing the need to co-learn and to co-develop research with community members themselves to prioritize benefits for both participants and researchers. “Advancing Antiracism in Community-Based Research Practices in Early Childhood and Family Mental Health” was published in the Journal of the American Academy of Child & Adolescent Psychiatry. This work was done through the Early Childhood Innovation Network (ECIN), a community-based partnership between two academic medical centers (MedStar Georgetown University Hospital & Children’s National Health System) and several community-based organizations in Washington, DC that strives to provide support to families through caregiver and child mental health services, family peer support, child social and emotional learning, initiatives to address social determinants of physical and mental health for families, and place-based support to families within select communities.
In this study, researchers found that to begin to undo the inherent inequities within academic medical research, particularly in studies involving children and caregivers, investigators need to consider how best to build equitable, long-term partnerships with communities through Community-Engaged Research (CEnR) or more specifically, Community-Based Participatory Research (CBPR). CBPR offers an alternative to traditional non-participatory research with a collaborative, strengths-based orientation that equitably involves researchers, community members and other stakeholders in all phases of research while embracing their unique expertise.
Recently documented increasing rates of depression, anxiety, and suicide in BIPOC youth, compounded by the disproportionate impact of the COVID-19 pandemic on BIPOC communities, has heightened the urgency for progress in community-based research.
The research team started to utilize CBPR practices to advance antiracism in their clinical research work in child and family health along with working with BIPOC communities. This approach to integrate CBPR practices into the development, implementation, and evaluation of community-based interventions seeks to support early childhood mental health in primarily Black communities in Washington, DC.
Making an Impact: Insights & Lessons Learned from CBPR
Through this work of the EICN, the research team found five valuable lessons from applying CBRP principles to research collaborations in community settings.
Intervention Practices
Lessons Learned and Applied
ECIN launched a group-based mindfulness parenting program to explore how to support the emotional health of parents at a Head Start early education center with the intention to reduce caregiver stress and enhance caregiver-child relationships.
Lesson 1: Invest the time to build trusting relationships
Providers set up several discussion groups with community partners and medical center-based researchers to review proposed assessment tools to be used with children and families receiving psychotherapy services.
Lesson 2: Involve community partners in the development of the intervention theory of change and measurement strategy
Clinical staff organized peer specialists to provide support to families with young children through 3 evidence-based strategies: enhancing parents’ knowledge about caregiving with young children;optimizingparent use of existing resources; and increasing parents’ access to social supports.
Lesson 3: Create interventions in partnership with community members
Clinical staff providedearly childhood mental health consultation (ECMHC) in preschool classrooms to enhance educators’capacitiesto support early childhood development and to recognize early signs of mental health concerns
Lesson 4: Interpret findings in partnership with community members
ECIN membersparticipatedin formal antiracism training with external experts to incorporate antiracism principles into ECIN’s operations and into the culture of the Network. ECIN formed a Racial Equity Community of Practice (RECOP), that supports 8 intervention teams in developing practices that advance racial equity goals.
Lesson 5: Embed an antiracism focus in research structures and processes
The research team found this community-based approach to be helpful in conducting research that will have a long-lasting impact on not only the community, but also on members of the research team. During a time where BIPOC families are experiencing the effect of COVID-related deaths and grief, unemployment, housing instability, and police violence; researchers have an opportunity to be engaged in the community and work to eliminate racial inequities within academic medicine and research.
Journal of the American Academy of Child & Adolescent Psychiatry, DOI: 10.1016/j.jaac.2021.06.018
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March 01, 2019It’s a rare moment when Thomas J. Cusack, MD, MS, is not actively engaged in some activity. When he’s not on call as a neurointensivist in MedStar Washington Hospital Center’s Critical Care department, he may be found running or pedaling his stationary bike, playing with his 8-month-old daughter, or reading the latest addition to his voluminous personal library, which accompanied the New Jersey native across the country and back during his medical training.
Biggest Challenge
Indeed Dr. Cusack’s biggest challenge came when he couldn’t move at all. While cycling during an extended break between undergraduate and medical school, he was hit by a car, and seriously injured.
"I faced a lot of questions—from how would I get through the day, to whether I’d be able to use my left arm again,” he recalls. “That really piqued my interest in learning how patients and their families deal with similar challenges, particularly end-of-life situations, and how it influences their treatment strategy.”
Dr. Cusack’s yearlong recovery was aided by the loving support of his girlfriend, now wife, Lauren Drake, MD, who is now a primary care physician at MedStar Franklin Square Medical Center in Baltimore. Even with his many interests, Dr. Cusack says he never really considered another career path.
“I come from a long line of pharmacists and nurses,” he says with a laugh, “but I’m the first physician in the family.”
Love of Medicine
While at what is now Rutgers New Jersey Medical School, Dr. Cusack was active in the All E.A.R.S. program, which encourages medical students to provide social support to terminally ill patients who may face their hardships alone. After an internship at Johns Hopkins Hospital, he spent his residency at the Barrow Neurological Institute at St. Joseph’s Hospital and Medical Center in Phoenix. There, he studied under experts such as Abraham Lieberman, MD, the neurologist who helped treat Muhammad Ali for Parkinson’s disease.
Deciding he was “an East Coast guy,” Dr. Cusack returned to Johns Hopkins Hospital for his fellowship in neurocritical care. Along the way, he took time out to participate in the Himalayan Health Exchange, working in an underserved part of northern India.
The timing was good, he says, as public health conflicts in the U.S. had left him somewhat disillusioned.
“It’s just you and the patient—everything else is stripped away,” Dr. Cusack says of the experience, which also “helped rekindle my love of medicine, and see poverty in a new light.”
Teamwork and Collaboration
As part of the Hospital Center’s Surgical Critical Care team, Dr. Cusack applies his skills to all types of cases, and be a resource on neurological issues. It’s the best of all worlds, he says—a highly diverse patient population, an academic connection with Georgetown University’s medical school, and an experienced, collaborative team of physicians, nurses and support staff.
"Playing rugby and working part-time in restaurants taught me a lot about teamwork, which is important in medicine,” he says.
Having also learned the value of strong interpersonal connections, Dr. Cusack regularly dips into his extensive collection of cookbooks to prepare feasts for his family and friends.
“There’s something about almost dying that makes doing things important, even if they’re just everyday tasks,” Dr. Cusack. “I’ve seen some unbelievable acts of endurance and resilience in the face of critical challenge. Yet those patients are often most focused on the practical needs—avoiding pain or maintaining their dignity. Those are lessons I try to apply to my treatment approaches, and to my own life as well.”
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March 01, 2019Recent collaborative research sought to develop and pilot a digital interactive tool to evaluate social support and diabetes self-management among Black patients with Type 2 Diabetes. Social support can be defined as supportive actions of others that promote coping or protect against stressors.
The research team was led by Deliya Wesley, PhD, MPH, with funding from the MedStar Diabetes Research Grant. “Is social support always supportive? A Qualitative Approach to Characterizing Diabetes Self Management Among Black Patients” sought to gain experience in applying a psychosocial assessment tool, known as a Colored-Eco Genetic Relationship Map (CEGRM) to assess social support. This tool is commonly used for cancer patients but was adapted to evaluate self-management for Black patients with Type 2 Diabetes.
The research collaborators were Ashley Pantaleao, MA; Allan Fong, MS; Stephen Fernandez, MPH; and Mihriye Mete, PhD. These researchers from MedStar Health Research Institute, MedStar National Center for Human Factors in Healthcare, and the University of Maryland College Park found that despite having large social networks or high scores on social support measures, most participants indicated they keep their diabetes “to themselves” or don’t rely on their network for help with diabetes self-management.
The study included 35 adults that identify as Black or African American with Type 2 Diabetes located at MedStar Union Memorial Hospital and Shepherd’s Clinic in Baltimore. For the first phase of the study, 5 Diabetes Colored-Eco Genetic Relationship Maps (D-CEGRMs) were conducted using the traditional paper method and to test a new digital prototype using a tablet-based method. The second phase of the study used digital D-CERGMs using the tablet-based prototype along with standard structured surveys. By using color-coded symbols, the research team was able to identify the representation of both positive and negative social support that could relate to a patient’s diabetes self-management.
The analysis concluded that the D-CERGMs provided more descriptive outputs than the structured surveys. Participants found value in the D-CERGRM activity itself but some older patients were not as technologically adept and preferred something tangible vs. the tablet-based prototype. A majority of patients identified having fairly large social networks but most stated they do not share their health condition with their sources of support. Also, when it comes to diabetes self-management, participants shared different cultural and environmental barriers along with medical barriers such as issues with their glucose monitor and side effects of medication.
While a digital prototype was successfully developed for the D-CEGRM tool, significant modifications and adjustments are still needed. The study concluded that complex family structures led to complex interactions for this patient population and further analysis would need to be explored. Some of the emergent themes from the qualitative analysis included stigma and shame issues, caregiver burden, spirituality, and cultural factors. Findings further suggest that for Black patients with Type 2 Diabetes, social support may not always confer the same level of health-promoting benefits conducive to positive self-management behaviors. Patients overwhelmingly reported finding value in the process, reflection, and visualization of the dynamics of social support in their networks using the D-CEGRM.
This research was presented as part of the MedStar Health Teaching and Research Scholars Capstone event, which culminates both the two-year programs.
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March 01, 2019Recent collaborative research sought to assess the effect of interpersonal interaction on genderism and transphobia in graduate medical education. Leon L. Lai, MD from MedStar Washington Hospital Center and Director of Ryan White HIV Services Parts C and D at MedStar Health Research Institute conducted “Effect of a Transgender Speaker Panel on Genderism and Transphobia in Graduate Medical Education”, to examine the effects of education on transgender medical care to decrease physician bias and improve healthcare for transgender patients.
In general, the medical community has failed to provide competent care to gender minorities (transgender and gender nonbinary individuals), due to lack of medical education. This study sought to address the gap between physician genderism and transphobia associated with education in the care of gender minorities.
The goal of the research was to identify the effect of a standard lecture vs. standard lecture plus patient panel on genderism and transphobia on medical residents. An anonymous paired pre- and post-intervention survey was administered to MedStar Washington Hospital Center internal medicine residents. Attitudes towards transgender individuals were assessed using the Genderism and Transphobia Scale (GTS) before and after the intervention. The intervention was a standard hour-long Grand Rounds lecture on primary care of the transgender patient followed by a representative transgender speaker panel composed of a transgender female lawyer, a transmasculine activist, and the parent of a transgender child.
Analysis from 45 available respondents concluded that there is indeed a lack of medical school education on transgender health. 87% of primarily international medical graduates reported a median of 2 hours spent on Lesbian, Gay, Bisexual, and Transgender (LGBT) issues in medical schools while 50% reported only 1 hour or less and 80% stated the quality of this education as poor or very poor. Of the 27 respondents that completed both surveys, there was a significant difference in the change of those attending the lecture and panel compared to the lecture alone. The combination of lecture and panel significantly decreased genderism and transphobia compared to the lecture alone.
The study concluded that medical schools need to improve their education on transgender health in order to close the gap in the care of gender minorities. As a result, graduate medical education should increase the amount of time spent and the quality of education in an attempt to decrease genderism and transphobia among physicians. For next steps, Dr. Lai would like to consider a cross-over study design and obtain a larger sample to better measure sustaining attitude changes.
This research was presented as part of the MedStar Health Teaching and Research Scholars Capstone event, which culminates both the two-year programs.
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