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Professionalism
Tackling Diversity in Neurology

ARTICLE IN BRIEF

Neurologists discuss the need for expanded diversity in neurology practice and training.

When Edgar A. Samaniego, MD, was completing his stroke residency, he had a patient from the Middle East who felt uncomfortable with his examining her lower back after a lumbar puncture.

Originally from Ecuador, Dr. Samaniego didn't realize that culturally, women from the Middle East do not expose themselves to male doctors. But after explaining the situation to her family, particularly her eldest son, he was able to work with her.

“In the future,” said Dr. Samaniego, now a clinical assistant professor of neurology at the University of Iowa, he might ask one of his female colleagues to step in so that he did not have to inconvenience his patient or disrespect her culture.

At a time when the country and patient populations are becoming increasingly diverse — racially, ethnically, and culturally — that kind of awareness and sensitivity needs to be incorporated into medical training and daily medical practice, said neurologists who spoke to Neurology Today about a diversity training certificate and a Diversity Leadership program at the AAN.

In interviews with Neurology Today, they said it was often hard to find mentors to discuss these issues. Moreover, they said, it's challenging to keep the issue on the front burner as part of regular medical practice, particularly when people do not always agree what issues are the most important.

“Issues with diversity come in all sizes and flavors and every person has a different degree of understanding,” said Yazmin Odia, MD, MS, lead physician of medical neuro-oncology at Miami Cancer Institute Baptist Health. “The problems are different and inherent to the environment you are in.”

Dr. Odia participated in the 2016 AAN Diversity Leadership Training Program. The nine-month program accepts 10 participants who meet for a three-day intensive workshop, and then decide on a group project for the year to be presented at the AAN annual meeting. They also receive one-on-one coaching two or three times a month on different challenges they're facing and how to be a skillful leader whether in the lab or in the academic world.

The project aims to define a problem and try to solve it, Dr. Odia said. For example, how do you “increase underrepresented communities going into neurology? The cause and the key solutions must be looked at at the strategic level.”

DIVERSITY AWARENESS

Altaf Saadi, MD, was one of four neurology residents who helped create a diversity and inclusion certificate at Harvard Medical School. For the program, she organized a monthly lecture series on equity, diversity and inclusion (EDI) issues, including lectures on unconscious bias, caring for the Boston homeless population and patients with limited English proficiency, and physician advocacy. The program, which was first described in in the September 19 issue of Neurology, drew faculty and staff from across departments at Harvard, she said.

Dr. Saadi had also written an article with her mentor and other collaborators about disparities in neurologic health care access among black, Hispanic, uninsured and low-income patients, which was published June 13 in Neurology and presented at the 2017 AAN annual meeting.

“I feel very strongly that there is no one-size-fits all diversity, inclusion, and equity training program that would be effective,” said Dr. Saadi. “Programs have to be tailored to their communities, including patients and hospital staff, and their messaging around diversity must target the specific concerns and issues common among the underrepresented groups in their communities.”

Dr. Saadi said that it's important for departments to define what diversity means to them and to set concrete goals to meet them, and use as metrics for growth. For example, one goal could be to have a certain percentage of female/minority faculty and/or grand rounds speakers.

The program motivated Dr. Saadi to focus her post-residency fellowship on diversity issues as part of the National Clinical Scholars Program at UCLA. Her fellowship projects include development of medical education curricula around diversity issues, as well as continuing to explore health disparities within neurology and medicine more broadly.

THE ‘HIDDEN CURRICULUM’

Anna Bank, MD, who participated in the Harvard program and is now a fellow in clinical neurophysiology and epilepsy at Columbia University Medical Center, said that even at an institution like Harvard, it was clear that women and minorities weren't well represented among the faculty, particularly among full professors and department leaders.

“Within medicine, they often talk about the ‘hidden curriculum’ — how particularly in your third year, you learn from your colleagues and your supervisors how doctors interact with each other and with patients,” she said. “In that same ‘hidden curriculum,’ comes awareness of diversity issues — or lack thereof.”

“Whether it's the morning report or in conference, where women are outnumbered by more senior people who are men, you see the challenges in getting women to speak up and be heard,” Dr. Bank said. “It's good to have this kind of training in unconscious bias, and not let people talk over you or interrupt you, or to be sure that you're hearing from voices that aren't necessarily heard.”

Neurologists interviewed for this article said one challenge is that they often hear that diversity issues are not particularly relevant to neurology, or that the field is doing fine as is. The second is making sure there are enough mentors for students or residents to turn to when having sometimes touchy conversations.

“I wasn't sure who I could turn to, who I would feel comfortable having these conversations with about these issues,” said Dr. Saadi. “I certainly had conversations with people who I thought would be supportive and who were not.”

Becoming a coach to others is one of the goals of the AAN Diversity Leadership Program, said Dr. Samaniego, who participated in the program in 2016. He said the program encourages neurologists from different backgrounds to achieve personal and professional leadership roles. He had one-to-one discussions with a coach and an AAN leader on how to improve his leadership and his listening skills, for example.

Awareness is a two-way street, Dr. Samaniego said. Patients need to acknowledge that their doctors may not be familiar with their culture and background. Dr. Samaniego said diversity training would particularly be useful for foreign doctors to introduce people of different backgrounds and discuss communication with patients and other physicians who may be different.

“When I came here, I was surprised that patients were so involved [in their care decisions],” Dr. Samaniego said. “They didn't just want to hear the test results, they really wanted to look at the images and understand what was happening,” he said.

Hope L. O'Brien, MD, FAAN, associate professor of pediatrics in the division of neurology at University of Cincinnati College of Medicine and co-director of the young adult headache program, participated in the 2017 AAN Diversity Leadership Program.

“Once you're out of residency, whether in private practice or academics, you're trying to figure a lot of other things out, whether it's dealing with electronic medical records or other logistics,” Dr. O'Brien said, adding that support is key to career development and growth.

Dr. O'Brien is the only black neurologist out of approximately 80 faculty members within the child and adult program at the University of Cincinnati, so she said she's very aware of the lack of representation of women and minorities, and how it affects patients.

“I will go in the room and, if there's an African-American patient, their eyes light up and they're very excited to see somebody who looks like them,” she said.

“These kind of diversity initiatives need to start as early as possible in education, and we need to bang on the doors of hospital administrators to recognize the need,” she said. “We're in a huge health crisis and this would only help us in ways to improve that.”

Although medical schools are improving their diversity focus, said Dr. Odia, the medical world needs to see cultural competency not just as a moral stance, but a medical one. The stroke data show that minority patients lack early screening and preventative medicine and often have worse outcomes.

“It will improve outcomes and improve compliance, which are our goals right alongside managing diabetes and reducing stroke risk,” said Dr. Odia.

LINK UP FOR MORE INFORMATION:

• Bank AM, Saadi A, McKee KE, et al. Opinion and Special Articles: Creation of a diversity and inclusion certificate program for neurology residents http://n.neurology.org/content/89/12/e146. Neurology 2017; Epub 2017 Sep 19.
    • Saadi A, Himmelstein DU, Woolhandler S, Mejia NA. Racial disparities in neurologic health care access and utilization in the United States http://n.neurology.org/content/early/2017/05/17/WNL.0000000000004025. Neurology 2017: 88(24):2268–2275.
    • AAN Diversity Leadership Program: https://www.aan.com/membership/diversity-leadership.