Health disparities Q&A

Jonathan K. Han, MD, is program director of the UPMC St. Margaret Family Medicine Residency Program.

Winfred T. Frazier, MD, MPH, is medical director of the UPMC St. Margaret New Kensington Family Health Center and associate program director of the UPMC St. Margaret Family Medicine Residency Program.

Both are family medicine physicians at the UPMC St. Margaret New Kensington Family Health Center, where they care for the medically underserved and teach family medicine residents and medical students. Dr. Han was the founding physician for UPMC New Kensington Family Health Center in 2001 and his interests include integrated behavioral health, medication-assisted treatment (MAT), social justice and advocacy, and narrative medicine. He is a coauthor of The Human Side of Medicine, a book offering the view of three generations of family physicians on 21st-century medicine.

After completing his faculty development fellowship at UPMC St. Margaret and his master’s in public health at the University of Pittsburgh, Dr. Frazier joined the family medicine residency faculty at the University of Texas Medical Branch (UTMB), where he was associate program director and medical director of the largest of UTMB’s three residency clinics. He returned to UPMC St. Margaret and the New Kensington Family Health Center in 2020, where he now focuses on patient care, residency education, primary care dermatology, and addiction medicine.

What led you to become a doctor and to specialize in family medicine?

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Dr. Frazier: My mother is a pediatrician and both grandparents were nurses. Growing up, I was surrounded by stories about people they cared for, so I knew at an early age I wanted to be a doctor.

I entered a joint college/medical school program with the University of Houston and Baylor College of Medicine. After completing all the different clinical rotations, family medicine resonated with me the most. I liked being able to see all different kinds of medical problems. But what really attracted me to the specialty was the deep connection I could establish by seeing patients on a long-term basis and taking care of their families.

When it was time to apply for a residency, I was ready to leave my home state of Texas and see a different part of the country. I ended up in Chicago, where I met my future wife, who also is a family medicine doctor. I worked at an underserved clinic on the city’s South Side while she completed her family medicine residency. We then decided to travel the country together as locum tenens physicians. It’s something like traveling nurses, but for doctors — providing medical care in understaffed communities.

When we decided to settle down, I wanted a faculty development fellowship program where I could both work and gain the skills that I needed to become a family medicine educator. I had heard a lot about Pittsburgh — and specifically the program at UPMC St. Margaret. I ended up doing a three-year fellowship there and earned my Master of Public Health degree at the University of Pittsburgh at the same time. It was an invaluable experience.

I was a typical Texan: The only thing I knew about Pittsburgh was the Steelers. But I came to love this city during my three years here. After our first child was born, my wife and I moved back to Texas to be near family. But when the opportunity presented itself to move back to Pittsburgh and work at UPMC St. Margaret and the Family Health Center in New Kensington, I jumped at the chance. You might say I kind of boomeranged back.

Dr. Han: My parents were Korean immigrants who met while attending seminary school in Kentucky. Our family eventually settled in Ohio in the 1960s, where my father became the state’s first Korean Protestant minister.

Although they weren’t in medicine, my parents were always role models for me. As I think about it, family medicine has a very pastoral connection. We see and care for people holistically as human beings; we don’t simply treat diseases.

As a first-year medical student at Northwestern University in Chicago, I had the opportunity to take service electives. I chose hospice, which was then an emerging discipline. I spent several months with a nurse, doing home hospice visits on the city’s South Side. I still can remember riding in her little car in the dead of Chicago winters, knowing that I was seeing a powerful part of medicine in practice.

I went on to do electives with the Indian Health Service in Montana and Alaska, and in Liberia, West Africa. The people leading these clinics were all family medicine doctors. They seemingly could do everything — from delivering babies to stitching up lacerations. Working with and learning from them was a powerful and transformative experience. They embodied everything I thought being a doctor was all about when I was growing up.

I did my residency in San Francisco at the height of the AIDS epidemic. We didn’t realize it then, but we were living in such a historic time. We were caring for young people who were dying within days from respiratory problems caused by organisms rarely encountered prior to HIV. It’s something we can now readily treat, but back then we had little idea of what was happening or — more importantly — why.

By the time I graduated from residency, two drugs were available to treat AIDS. I think there are many parallels that can be drawn between that time and what’s happening now with COVID-19. The knowledge we have today about immunology really exploded with AIDS and it led to much of the technology we take for granted today. It’s gratifying to see that over time AIDS has gone from being an incurable disease to a chronic illness we can manage — like diabetes.

As family medicine doctors who are members of racial minorities, you’ve been on the front line of a global pandemic working with patients who face measurable health disparities — all during a time of civil and political division. How have these challenges affected you?

Dr. Frazier: As doctors, our primary goal is to help you to stay healthy. So, when a patient declines an evidence-based solution that we can recommend with confidence, it can place a strain on the trust that we work so hard to build.

For many doctors, COVID-19 has taken both a physical and emotional toll as we watch our patients die, sometimes every day. That was very hard at the beginning of the pandemic — and in some ways, it’s even harder today now that an effective vaccination is available. Yet some patients still decline to get vaccinated.

And as much as we all want COVID-19 to go away, it’s likely to be with us for a long time to come. That’s why it’s so important that we figure out how we can work together to move forward.

We all have our own beliefs. It’s not a matter that my belief is right, and your belief is wrong. Instead, it’s about figuring out where we can find common ground. Many people don’t trust the medical profession or certain treatments — and we must recognize that some of that mistrust is deep-seated and generational.

The important thing is that we, as doctors who specialize in family medicine, do not give up. We have to work hard to discover the root of that mistrust with each individual patient. Being honest and available really does make a difference.

Dr. Han: As family medicine doctors, there’s also a significant public health/prevention dimension to our work. If we care about our patients, we must also care about the communities in which our patients and their families live and work, because they play an integral role in health.

The widespread availability of the COVID-19 vaccine is forcing us to confront the morality and ethics of being part of a community. The pandemic hasn’t only laid bare the structural racism and immense economic and health disparities that exist in our society. It also revealed the profound issues of trust, connection, and social isolation that pervade these conversations and are root causes of the problems we face every day in our communities.

In so many public conversations, the loudest voices are saying: “I don’t need to do this. I don’t need to protect other people, it’s about me.” We’ve lost the concept of the common good, which asks: Shouldn’t we care about others? Aren’t we mutually interdependent?

As Dr. Frazier says, it’s important that we as family medicine doctors continue to try to connect with people, to gain their trust. We do so by keeping our doors open, by being as nonjudgmental as possible, and by working together to address the problems — medical and beyond — that afflict our patients and the community. That model of inclusion and care sends a powerful, moral example.

During this time of legislative and political change, what efforts would you like to see happen that could make your work as family medicine providers and educators more fruitful and effective?

Dr. Frazier: I earned my master’s of public health with an emphasis in health policy because I believe health policy plays a major role in advancing both public health and medicine.

The policies that are decided on Capitol Hill have a huge trickle-down effect — and that includes your medical care. These policies can impact our ability to take care of patients, which is our vow, our purpose. It can be very frustrating to have nonphysicians make decisions that have the power to limit our care and ultimately threaten our patients’ health.

During my fellowship in Pittsburgh, I went to Washington, D.C. I met with politicians to advocate on some of the issues being debated that impact patients daily. One of them was the opioid crisis that’s affecting so many people here in western Pennsylvania.

As physicians, we need to be aware of what’s happening politically, and actively advocate for or against policies that we know have the potential to hurt our patients — whether on a local, state, or national level.

Dr. Han: Medical expenses are the number one cause of personal bankruptcy in the United States. Giving people greater access to health care is probably the most important thing we can do from a public policy perspective. It can make a profound difference: Before the Affordable Care Act, nearly 23% of the patients at UPMC St. Margaret New Kensington Family Health Center were uninsured. Now that number has dropped to about 3%.

Dr. Frazier and I also believe in the critical importance of having a multidisciplinary team of health providers that includes social workers, behavioral health and trauma-counseling specialists, dieticians, and pharmacists. Each is essential to delivering the best possible care for our patients and the community. But that model is costly; it needs to be reimbursed and it needs to be incentivized so health systems can make it part of their care. It’s all connected to money, policy, and priorities.

Medicine has always been political. Anything that involves access and money is going to be political. As a result, there will always be competing ideologies and competing priorities.

As physicians and health care providers, we have tremendous responsibility for protecting our patients and the public health. Yet local, state, and federal politics increasingly threaten our ability to do our jobs. For example, legislation introduced (and thankfully overturned) in Florida would have prohibited physicians in that state from asking patients about guns in the home. Safe storage and access to firearms is imperative to prevent accidental injury and death, especially in children. Other legislation now under debate include threats to women’s reproductive rights.

As educators helping to prepare a new generation of family health doctors, what can be done to reverse the disparities, biases, and microaggressions seen in health care and society?

Dr. Frazier: At UPMC St. Margaret, we’re having monthly discussions about race with our family medicine residents and fellows. Just having that conversation is hard, because talking about race can be very uncomfortable. But these are conversations that must be had. It’s been especially helpful for participants to share insights and concerns from their patients, as well as issues in their own lives.

As we discuss microaggressions and macroaggressions, we’ve incorporated something called “upstander training.” We all know a bystander is someone who idly watches an act of aggression. An upstander is a person who does something about what they see in order to educate the group about the harm and hurt associated with the micro- or macroaggression and support the person who was targeted.

Those monthly discussions also help us learn to combat health and racial disparities by learning what constitutes a disparity, what disparities exist, and what we as care providers can do to help patients experiencing these disparities.

There are usually many, many different reasons behind disparities. That’s why, as I noted earlier, it’s essential to get to the “why” behind them. It’s important that we talk with patients about any previous mistreatment they’ve experienced in the medical system. We must understand that institutional and structural racism is not only a historical fact, but a current truth we still must address.

And as a medical community, we need to admit that racism was —and is still — a big deal. Hearing and validating what patients tell us is key.

Dr. Han: In April 2021, Health Affairs — which is a leading journal of health policy thought and research — examined the top four medical journals in the world. It found that these publications almost never publish scientific articles that specifically name racism as a driver of poor health outcomes.

In fact, of the more than 200,000 total articles published over the past 30 years in the New England Journal of Medicine, The Lancet, the Journal of the American Medical Association, and the British Medical Journal, fewer than 1% included the word “racism” anywhere in the text. Of the articles that did, nearly 90% were predominantly opinion pieces — not scientific investigations. That is now changing.

COVID-19 and the Black Lives Matter movement have revealed so much that requires our immediate attention as health care professionals. They have inspired a major turn toward acknowledging and taking action against structural racism in society — and that includes medicine.

If we’re interested in health equity and truly improving the health of communities, we have to address racism and be comfortable talking about it. When something is uncomfortable and you talk about it and deal with it, things get better because it’s not hidden somewhere, it’s not disrupting everything, it’s not perpetuating inequalities.

It’s such an exciting time to be in medicine. The COVID-19 pandemic has catapulted us into a new way of educating our residents and medical students — and rethinking our own responsibilities as physicians. That’s why you’re seeing physicians “go outside their lane” on issues like gun control because it is an issue that directly impacts their patients and public health.

We are coming together to ask: Who are we as doctors? Where are we going? What kind of future do we want to create? If we’re serious about health equity and taking care of people, we need to address these issues because they profoundly and negatively impact the health of our patients, communities, and the medical profession. We have to be intentional about the future we want to create.

We are questioning what we do and why we do it — and asking how we can create a healthier and more just society. Those questions will have a lasting impact on medical education and training today and for years to come.

Editor's Note: This article was originally published on , and was last reviewed on .

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