Black women are three times more likely to die from a pregnancy-related cause than white women. Studies also show that Black and Hispanic women in labor are less likely than white patients to receive epidural analgesia. And few medical textbooks show skin diseases on darker skin tones, where they may present and be treated differently.
These are a few of the disparities in health care that Betelehem M. Asnake, MS MD, an anesthesiologist in the Department of Anesthesiology and Perioperative Medicine at UCLA Health, addresses in a new health equity curriculum she helped develop for anesthesiology residents.
Dr. Asnake was a fellow at the UCSF Center for Health Equity in Surgery and Anesthesia (CHESA) when she, along with two other medical students, developed the curriculum. She hopes the curriculum will fill long-standing gaps in medical education and equip residents with the tools they need to provide equitable health care for all patients.
“There’s a huge gap in terms of this kind of teaching,” Dr. Asnake says. “In fact, it is nonexistent. As physicians, we ought to learn about health disparities and specific disparities in our disciplines, because it affects the way we treat our patients.”
The curriculum launched at UCLA Department of Anesthesiology and Perioperative Medicine in October with the first module on Global Health Equity, Health Disparities and Social Determinants of Health. Subsequent modules include Cultural Humility and Structural Competency, Structural Racism, and Anesthesia Care in Resource-Constrained Areas.
All anesthesiology residents at UCLA Health now receive the curriculum as part of their training.
Dr. Asnake believes this training is charting new territory in medical education.
“I don’t know of any other anesthesiology program that has this curriculum except for UCSF where this was initially launched and implemented,” she says, adding that she and her UCSF colleagues created an open-access website so anyone can download the lectures and use them to teach their residents.
“The idea is to encourage other residency programs around the U.S. to follow suit,” she says.
An increasingly diverse population
Dr. Asnake notes the patient population is changing, and in 20 or 30 years, half of the U.S. population will be from different ethnicities.
“We’re going to have a more diverse population in this country, and it really makes sense to train physicians who are culturally and structurally competent over different cultures,” Dr. Asnake says.
Without this type of education, many residents find it difficult to have an open discussion on these topics, she adds.
“You hear on the news that maternal mortality is high among Black women or that COVID affects certain communities more than others, and you wonder why,” Dr. Asnake says. “Open discussion between residents and facilitators helps them process these things in their minds and understand that not all patients have the same tools to get better.”
"As physicians, we ought to learn about health disparities and specific disparities in our disciplines, because it affects the way we treat our patients."
Dr. Betelehem Asnake
Instead of being frustrated with a patient with diabetes not being able to control their blood sugar, the residents begin to realize there are dynamics in play such as education level, employment, where they live and whether they have access to healthy food options, she says.
“All those things matter to controlling diabetes, and understanding these things helps our residents to realize it’s about more than just medicine,” Dr. Asnake says.
All-encompassing
Belle Benanzea-Fontem, MD, participated in the first module of the new curriculum in October. As a first-year resident physician, she had been introduced to some of the issues within her specialty but was surprised to realize she had already experienced many of them early in her residency.
“Anesthesia is not a specialty where you think that equity comes into play often, but wherever patient care is involved you are bound to see the effects of health care disparities and principles of health equity," she says.
Dr. Benanzea-Fontem says the module was well thought out, and she appreciated the way in which the facilitator walked the small groups through various cases.
“I think what stands out most is that the curriculum doesn’t focus on just one kind of diversity — it was all-encompassing,” she says. “Hearing other peoples’ stories and experiences with these issues helps you maintain critical thinking, helps you to get away from thinking your days are routine, and makes you think of patient care as individualized.”
In addition to discussing disparities within the local community, October’s module gave the residents a glimpse of health disparities in other countries. As an example, Dr. Asnake points to the smaller health care workforce in many countries.
“Look at America,” she says. “The number of anesthesiologists per 100,000 people is 20 to 30, on average. But if you look at Ethiopia, where I’m from, the number of anesthesiologists per 100,000 is less than 0.1.
November’s module, Cultural Humility and Structural Competency, will focus on developing cultural humility in terms of understanding how each patient’s background and cultural norms are unique. The module also delves into the ways hospitals can provide equitable care for diverse populations — for instance, by offering interpreters or signage in various languages.
The Structural Racism module centers around stereotypes in medicine that stem from racial disparities and racism. One such lingering stereotype is that Black people have a higher pain tolerance when compared to white patients, says Dr. Asnake. That long-held misconception, she says, results in the pain of white patients being treated more appropriately than that of Black patients.
Residents also get an overview of nonmedical racism, including how certain communities are systematically held back when trying to purchase a home or obtain a loan.
The final module, Anesthesia Care in Resource-Constrained Areas, addresses how to safely anesthetize someone in a low-income, low-resource area — for example in Navajo Nation hospitals, Dr. Asnake says, where the setup might not be the same as at UCLA Health.
Filling the gap
Dr. Asnake is pleased that her department took the initiative to adopt the new curriculum when she presented it to them, and she says it’s been well-received. She credits the mentorship she has received at UCSF Center of Health Equity in Surgery and Anesthesiology, especially her fellowship director Michael Lipnick, MD, who provided oversight for the project and continues to be her mentor.
She sees this training as a first step to filling the gap in health equity education, not only for anesthesiologists but for all physicians.
“If we have more concentrated teaching about this, I think it will make more holistic physicians who are better informed,” Dr. Asnake says, “physicians with better knowledge who can serve their patients better overall.”
Learn more about the UCLA Department of Anesthesiology and Perioperative Medicine.
Jennifer Karmarkar is the author of this article.
