Dr. Robert Roswell Discusses DEI and his Work with the ABIM DEI Committee

Dr. Robert Roswell is Associate Dean for Diversity and Inclusion at the Zucker School of Medicine at Hofstra/Northwell where he also serves as Associate Professor of Science Education & Cardiology. Board certified in internal medicine and cardiovascular diseases, he is co-Director of the Cardiac ICU and the Associate Cardiology Fellowship Director at Northwell Health’s Lenox Hill Hospital. Dr. Roswell serves as a member of the American Board of Internal Medicine Board of Directors and chairs the ABIM Diversity, Equity and Inclusion Committee.

Tell us about the Diversity Equity and Inclusion (DEI) work you’re doing with ABIM. What are the over-arching goals, and what are some of the challenges faced when trying to create change in an organization and in a way that will affect so many physicians?

 The DEI work that I’m doing at ABIM is linked with the DEI work that I’m doing in many different platforms and I think we’re at a particular point where DEI is really front-and-center. The DEI work I am doing with ABIM is in line with the DEI platform from American College of Cardiology and also the platform at the School of Medicine and Northwell Health. For me, it’s all similar work of getting the same message out, but through different venues.

Because of COVID and racial unrest, peoples’ attention is focused on DEI. The easy part is that everyone’s ears and eyes seem to be opened now. The most difficult part is defining what equity is, what equality is and educating people about the definitions. It’s also educating people about the history and all of the deep psychological and social interactions that interplay between our history, our subconscious, our implicit mind, actions and health outcomes. And I think that is the most difficult part, because we can go back in history and see what happened, but is difficult to actually explain and understand how history plays into our subconscious and then affects our actions in the current day-to-day, and perpetuates health disparities.

We need to make those connections very clear for people — to show people what healthcare disparities are — but, more importantly, why they’re there. And I think that the other difficult thing is responding to, ‘why haven’t we seen them before’? And ‘we’ve heard about them, but why haven’t we seen them before’? And ‘we’ve heard about them, but why haven’t we done anything about them for so long’? That’s where the conversation starts to get really difficult, when you try to discuss those particular questions.

You get frustration on both sides because one side has been seeing health inequities for so long and has been oppressed by them and another side is just delving deeper into it. It’s great that we’re delving deeper into it, but some people are like, ‘well, where were you, you know, 10 years ago, 15 years ago,’ which is what sets up a little bit of the tension and interplay. But from my perspective, I’m happy that we’re advancing it, moving forward. 

 Recognizing that there are these problems, what change would you like to see at ABIM and how will you make these changes?

 ABIM is an assessment organization and really, assessment drives learning. What I just explained is that we’re at the point where learning is a critical component in dismantling structural racism and advancing health equity. In the ABIM, DEI Committee, what we’re trying to do is advance health equity through the kind of learning that can be enhanced through assessment. Medical Education is steeped with literature that shows assessment drives learning and we’re basically using that platform to advocate and try and advance health equity the best that we can as an assessment organization.

I want to note that we use ‘DEI’ a lot but most people are moving to ‘EDI’ because equity is actually giving people the opportunity to achieve their goals, their greatest capability. Let’s say, for example, for educational equity, getting a diverse slate of students into medical school and making sure that it’s a possibility for everyone, regardless of race, ethnicity or gender. That’s the first step in ensuring diversity.

You have to have equity, if there’s no equity then there’s no diversity. And just to double down on that — equity is giving people what they need so that they can accomplish their true capability — versus equality, which is giving everyone the same thing. I always describe this in terms of copays for medications, so, if I make $100,000 and my copay is $10 and somebody makes $20,000 and their copay is $10 and someone else makes, $10,000 a year and their copay is $10 — that’s equality — that’s giving everyone the same thing. But someone who makes $100,000 probably doesn’t need the $10 copay and they probably could pay even more versus the person who makes $20,000 a year.

Equity in this example, is looking at the differences in what people make and ensuring that everyone can afford the prescription. For the person who makes $100,000 the copay may be $50, where for the person who makes $10,000 there may be no copay or a $5 copay. And that’s the principle of equity. Getting equity in education is getting people through the pipeline so that there’s diversity in medicine. Without equity, you can’t have diversity. After you have diversity, then you have to work on inclusion. You just have added individuals of different races or ethnicities, but are you giving them the opportunity to be promoted, to strive, to get paid the same way and are they a valued person or member of the team?

What we’re doing at ABIM is really trying to use assessment to drive learning about equity.

 How does a large organization like ABIM go about changing the way physicians think about DEI or EDI? Where do you start?

 If you think about how assessment is driving learning, you have to start thinking about what we’re assessing to be a board certified physician. So, the question becomes, do other things need to be assessed to ensure that physicians — contemporary physicians — understand different aspects of medicine.

Medicine was born in a platform of pathophysiology and biology of diseases and it stood very separate from the social sciences and the social determinants of health. As a physician, you were only expected to know things like what are the pathways of, or the difference between Diabetes Type 1, Type 2? What are the receptors? What are the genes involved, et cetera?

It was not really thought that the social sciences — meaning the social determinants of health and other things that affect peoples’ health — were under the domain of medicine and I think we’re in a transition period where we’re realizing that if we really want to affect health outcomes we must involve the social sciences. Right now, we’re at a transition point where more people are looking toward the social sciences, social determinants of health and health equity and how they interplay with the biological and life sciences to produce the health outcomes that we see.

How do you reach doctors who have not experienced health care disparities personally and get them to apply their diagnoses and treatment more equitably than they currently do?

 I think the way that we reach the biggest audience is through inclusion — bring everyone to the table. And bring everyone to the table understanding that people have blind spots. There’s a lot of shame or sometimes guilt with unrecognized mistakes or missteps over the past.

It’s important to move away from the ‘you, as a White person, have a problem withholding treatment and tests to minority patients.’ To ‘what have we been doing as a society that has created a value system that has implicitly put in view that with some people you think about doing a procedure and with some people you don’t’?

Focusing on the structural issues and the reasons why things are implicit and how diplomates or physicians could see their own implicit biases without blaming them or making them feel particularly bad for having them is a way that we can move forward.

You recently published a paper “Cultivating Empathy Through Virtual Reality: Advancing Conversations About Racism, Inequity, and Climate in Medicine.” Is this what you were trying to do with your virtual reality program?

 The VR program, I thought, was a very innovative tool because what we were trying to do is use enhanced racial empathy to enhance inclusion — and you see we keep on going back to inclusion — because once the guard rails drop and once you realize what’s going on, I think you can be a partner in advancing health equity. But again, it’s understanding, and so what we did with the VR innovation was to actually enhance racial equity without pointing fingers at people and to also enhance inclusion. And we had scenarios where people experienced subtle exclusion and it made them very uncomfortable.

If you think about empathy and inclusion, what better way to view something from someone else’s perspective than to be that someone else for about 10 or 15 minutes of their life? And we found that actually doing these things and experiencing discrimination was eye-opening for many people and another way to bring people to the table and to enhance racial empathy.

 What would you say surprised most people going through the VR program?  

 There are two things that I think surprised some folks. Some participants questioned, is it really this bad, like, discrimination whether you’re a woman or a minority, does it really feel this bad? Is it this hurtful? Is it this stressful? And the answer was, you got a very light version of it and you got it or 10 minutes so. Take that and multiply it by a thousand and then do it every day for years. And I think those VR sessions serve as an important platform for good conversation and communication because it was, I think, the first time when people really understood for at least 10 minutes how other peoples’ lives are different from their own and it was eye-opening.

I think the other thing that was very surprising about the VR Initiative was that people were surprised that this could be going on right in front of them without them realizing it. We started exhibiting somehow how subtle forms of discrimination could affect people and when the person who experienced it realized that this is how discrimination could be subtle, they understood that these implicit and subtle forms of discrimination happen in front of them and have been happening for many, many years. 

 With this in mind, is there anything that you think physicians should consider when treating cardiac patients of color that they might not think about? 

 I think this gets to implicit bias and in cardiology we have guidelines. We have the American College of Cardiology, and we have American Heart Association that give you a guideline, evidence-based approach to clinical care for various diseases and diagnoses. And according to literature in our studies, it seems that those guidelines are applied very disparately. I think all physicians should go through implicit-bias training.

I think all physician practices should employ a mechanism to ensure that they’re delivering equitable care in terms of, on the back end, looking at their practices and their procedures and their prescriptions and their referrals to ensure that it’s equitable. Without going through those bias trainings, I think it’s hard for physicians, cardiologists in this example, to realize where they could fall prey to implicit bias.

So anytime you’re about to withhold a procedure or a referral, it’s I think really incumbent on a physician at that point to reevaluate— am I not doing this because of gender? Am I not doing this because of race or ethnicity or personal and socioeconomic status? If this were myself, or my family, or my mom or my dad, would I do the same thing? And that quick internal check, can help physicians ensure that things are done more equitably.