Thread by @DrJenChen4kids, Looking forward to #AAP2020 #Peds21 on Advancing Child Health Equity with @RheaBoydMD [...]

Looking forward to #AAP2020 #Peds21 on Advancing Child Health Equity with @RheaBoydMD @DrTiffJohnson @JyothiMarbin @MariaTrent5

"Every generation has to make a dent in the wall of injustice" - Dr. Mary Frances Berry, PhD

For further reading on Dr. Berry's work: https://africana.sas.upenn.edu/people/mary-frances-berry

Levels of racism (really any -ism)
- Institutional (structural), eg Jim Crow, Indian Removal Act, Mexican Repatriation, internment of Japanese Americans
- personally mediated
- internalized

Kids who witness bullying/discriminatory behavior against others may have trauma too, but they can also make a difference for the victim (so it's important to talk to all kids about bullying) https://www.stopbullying.gov/resources/research-resources/bystanders-are-essential

Bystanders are Essential to Bullying Prevention and Intervention

A bystander has the potential to make a positive difference in a bullying situation, particularly for the youth who is being bullied.

https://www.stopbullying.gov/resources/research-resources/bystanders-are-essential

Raising Resister strategy (Dr. Janie Ward, The Skin We're In)
- Read it (caution that specific situation might not always be racism)
- Name it
- Oppose it
- Replace it

https://www.simmons.edu/academics/faculty/janie-ward

Will need to work at multiple levels to prevent and mitigate effects of racism: pediatric practices, schools, communities, etc.
- COVID 19 has uncovered/exacerbated flaws in US public health policy and SDOH (as Dr. Fauci also said earlier)

Thanks @MariaTrent5! #AAP2020

Now on to @DrTiffJohnson "A is for Anti-Racist"
Doesn't just affect BIPOC: "Racism saps the strength through the whole society through the waste of human resources" @CamaraJones
https://www.msm.edu/about_us/FacultyDirectory/CommunityHealthPreventiveMedicine/CamaraJones/index.php

Many examples of overt racism and explicit bias, sadly...including starting in medical school (which is probably not surprising to most of #MedTwitter)

https://www.pnas.org/content/113/16/4296

Implicit bias comes out more when we have other high cognitive load (eg after a busy ED shift), also has association with burnout symptoms
@DrTiffJohnson's 2016 study: https://doi.org/10.1111/acem.12901

@dyrbye's 2019 study https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2739043

Also had residents take "kid IAT" before/after shifts showing bias effect similar to adults, so it doesn't just help to have a cute kid instead of an adult in the photo

https://pubmed.ncbi.nlm.nih.gov/27620844/

Comparison of Physician Implicit Racial Bias Toward Adults Versus Children - PubMed

This is the first study demonstrating that resident physicians have implicit racial bias against black children, similar to levels of bias against black adults. Bias in our study did not vary by...

https://pubmed.ncbi.nlm.nih.gov/27620844/

How can #tweetiatricians be anti-racist in clinical practice?
- Read (and process) AAP statement: https://pediatrics.aappublications.org/content/144/2/e20191765
- train staff in clinically competent care
- assess pts for SDOH/stressors
- give anticipatory guidance on racism and discrimination

The Impact of Racism on Child and Adolescent Health

The American Academy of Pediatrics is committed to addressing the factors that affect child and adolescent health with a focus on issues that may leave some children more vulnerable than others....

https://pediatrics.aappublications.org/content/144/2/e20191765

Re: anticipatory guidance; don't want to foster mistrust, also some strategies work better for teens
https://www.aappublications.org/content/36/8/11

Need to confront personal biases too, eg taking others' perspectives, focusing on common identities, individuation, using counter-stereotypical examples

Helping families navigate race issues should be ongoing conversation

As pediatricians, we have committed our lives to assuring the well-being of all children. We have taken a stand against health hazards such as childhood poverty and gun violence. However, when it...

https://www.aappublications.org/content/36/8/11

For all the #MedEd ppl, a study of 3547 students showing factors that help reduce bias, especially positive contact with Black faculty! https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636581/

Medical School Experiences Associated with Change in Implicit Racial Bias Among 3547 Students: A...

Physician implicit (unconscious, automatic) bias has been shown to contribute to racial disparities in medical care. The impact of medical education on implicit racial bias is unknown.To examine the...

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4636581/

Things to consider:
- What policies may inadvertently perpetuate care inequities, eg late policy?
- What organizational culture aspects may negatively affect relationships w pts/family eg hospital policing?
- What can we do to improve equity? (should be integral part of QI)

Decolonizing the medical curriculum
- community grand rounds
- disparities journal clubs
- city tour with community liaison
- training on trauma-informed care
- addressing hidden curriculum
- #MedEd portal has anti-racism collection
https://www.mededportal.org/anti-racism

On to @JyothiMarbin discussing workforce diversity
- more innovative, more creative, better at problem-solving
- better patient care, educational experience for students
- fundamentally just the right thing to do!

We know systemic racism skews resources, including housing (redlining) and schools (see Brown vs Board of Ed) -> gaps in wealth equity

For those who don't know what redlining is, highly recommend The Color of Law https://www.epi.org/publication/the-color-of-law-a-forgotten-history-of-how-our-government-segregated-america/

The Color of Law: A Forgotten History of How Our Government Segregated America

Order the book You can order the book on Amazon.com, Barnes & Noble, or from IndieBound.org, including your local bookseller. In The Color of Law (published by Liveright in May 2017), Richard...

https://www.epi.org/publication/the-color-of-law-a-forgotten-history-of-how-our-government-segregated-america/

The system was set up to perpetuate white supremacy, so we need to disrupt "business as usual" -> radical inclusion
- prioritize diversity
- eliminate vague hiring assessment eg "fit"
- diversity among leadership matters (consider term limits for higher-up positions)

Not all of us can take a group trip (especially nowadays w COVID) but another idea is race based affinity groups: space to process and reflect by self-ID racial group
- now offering quarterly for all residents/fellows at UCSF

Break time, will probably need a new thread for @RheaBoydMD

Thanks @drjoanjeung for moderating and also shoutout to whoever is doing the #AAP2020 closed-captioning in real time! #AccessibilityMatters

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