Robert Rohrbaugh: Bringing Antiracist Tools to Clinical Practice

Harlan Krumholz: Welcome to Health & Veritas. I’m Harlan Krumholz.

Howard Forman: And I’m Howie Forman. We’re physicians and professors at Yale University. We’re trying to get closer to the truth about health and healthcare. We’re excited to welcome Dean and physician psychiatrist Robert Rohrbaugh today. But first, we always like to check in on current hot topics in health and healthcare. So what do you got today, Harlan?

Harlan Krumholz: Well, I’m going to talk to you about an article I saw, but just before I get to that, I want to give you a quote, a sort of description of what somebody said. And I’m going to ask if you know who said this or what does this sound like? So this is someone who’s commenting on public hospitals and says that really hospitals, these essentially safety net hospitals—wasn’t referred to at the time this person was saying this—should “reduce the number of people whom it must care for at the expense of the taxpayer,” a “robust sterilization program and limits on immigration of the ‘defective’ would serve that goal.”

And there was a search for the real “final solution to the immigration problem” that rests on “the assertion of poverty and disease were proof” that “the alien is a public health problem just as he is a social problem.” And that these individuals, who were also “lawbreakers,” were people that we needed to root out, essentially, and it included people from “southern Europe.” But for the Chinese, “the exclusion of the yellow race from the United States is not a matter of prejudice, but one of self-preservation.” I know you actually do know this.

Howard Forman: I know. But I will tell you when I came across this, I too, my first impulse was that I see this every day in the most hateful corners of social media. This is a vile anti-immigrant, eugenic-oriented individual. That’s how I interpret that.

Harlan Krumholz: We hear Trump talking about vermin and talking about immigration.

Howard Forman: It’s very similar to that.

Harlan Krumholz: But this is of course even stronger. So this turns out to be something that in 1923, Dr. William Mayo, you’ve heard of this guy, William Mayo.

Howard Forman: William Mayo is one of the founding brothers as part of the Mayo family for the Mayo Clinic. One of the most important—

Harlan Krumholz: It’s the moniker of the Mayo Clinic is the Mayo brothers. And so this is in 1923, and I think it’s just... It was you who had actually pointed me to this, so that was just sort of a convention that I did to sort get into this topic, but “‘Ridding the Race of His Defective Blood’—Eugenics in the Journal.” It’s a perspective piece in TheNew England Journal of Medicine saying what role have the medical profession in general? And TheNew England Journal of Medicine in particular, which was The Boston Medical and Surgical Journal at that time, in 1923—it was named something different—became renamed, in 1928, TheNew England Journal of Medicine. What complicity did the Journal have in promoting ideas that we now find repulsive?

Howard Forman: And actually, and it’s why I wanted, I brought this up to you yesterday and I said, I would love you to talk about this. And we’re fortunate to be able to have sort of what the New England Journal is going to come out with the night before our podcast comes up, so this is not any great secret at this point, but when I went to look at the reference to this original paper in 1923, I at first was like, “Is this real?” I mean, this is, 101 years ago is not that long ago. I know maybe some of our listeners think that’s a really long time, but as you go up in age, you start realizing 101 years—not a long time ago. And yet, this is a horrible essay. This is an essay that it is almost impossible for me to imagine that anyone could ever have been proud of. And yet, this is a speech.

Harlan Krumholz: Really it’s only 35 years before I’m born. This issue, this perspective piece is also talking about how Francis Galton, who coined the term eugenics in 1883, ends up endowing a university chair for eugenics in London. I mean, Mayo, this is reprehensible. I mean, I wonder how Mayo is, Mayo Clinic is actually reflecting on this, but it is by far and away not unique. And then you end up seeing, flash forward to World War II and what goes on in Nazi Germany and the sterilization and elimination of Jews and others that were considered undesirables and defectives, almost emerges directly from this body of work that’s saying, what kind of eugenics sterilization can we adopt within medicine? It’s a mainstream idea within—

Howard Forman: Oh my God. There are comments in there that basically ascribe to people in, I think England, the fact that they enjoy living in the lower class. Like this is built into their nature that they want to be in the lower class. There are so many things in here that are wrong. And what worries me about it is like we are at a time right now where some of the lines in this essay, if you just change the word alien to immigrant, the essay reads like it could be written today. There are parts of it where people feel really strongly, a very strong anti-immigrant impulse in this country.

And I think honestly, most people are in favor of immigration reform, figuring out how do we safely allow people to be able to enter this country in numbers that we can absorb, at a rate we can absorb. But this is an anti-immigrant screed. This talks about the 3% number that the United States had adopted around that time, which was really used to keep a lot of immigrant groups out of this country, including Eastern Europeans, the Italians, the Irish, and others, and absolutely keeping the Chinese out of this country.

Harlan Krumholz: And let me just be really quick. I want to just read two short parts to this so listeners can get a real sense of this. So “Eugenicists identified a need to restrict certain immigrants,” just as you’re saying, “particularly eastern European Jews and southern Europeans such as Italians.” But here’s the thing that really shocked me: “The Journal concurred with the eugenic remedy: restricting the entry of too many,” quote, “‘undervitalized and undermoralized aliens now crowding into the country.’” And he goes on—this is an article I really recommend people to read—that “Although the Journal published a few articles by writers who questioned the utility of sterilization of populations such as the “insane” in 1913, its editors”—the editors of what is now The New England Journal of Medicine—“issued an early and full-throated endorsement of eugenic surgery, concluding that ‘if the lay mind is ripe for such drastic measures we see no reason for scientists to object.’” And I’m just wondering how is it that the Journal weighs in on this political issue making it a scientific issue, saying, of course we want to be able to—

Howard Forman: Because I think it was very mainstream. And I think for our listeners to reflect on, I think what we’re highlighting is that some of the most abhorrent things, some of the things that we agree today are abhorrent, were not considered abhorrent at that time. And it worries me, and it makes me always remind myself and try to be humble that I hope that there is not a time in the future where things that I have felt passionate about turn out to be similarly despicable. But it is worth reading. We will—

Harlan Krumholz: It’s just wild. I’ll give you one more. So the Journal observed that because World War I broke out, they were objecting to the fact that, he said “students of eugenics” are “aghast that no dwarfs, no cripples, no mental defectives, no old men’ were accepted” into the armies. So we’re “‘killing off our able-bodied men’ rather than those who shouldn’t or couldn’t reproduce” and that—

Howard Forman: It’s painful, it’s very painful. No, I really hope that, I mean, we’ll come back to this hopefully in the future. But I do hope that among our listeners, you actually go read these articles that we’ll post on the website, because I think they’re very important.

Harlan Krumholz: Anyway, it’s just important. I know we’re going to talk with Robert Rohrbaugh also about his focus on antiracist language in medicine so forth. But yeah, this is an important moment to reflect on this piece. Let’s go to our guest.

Howard Forman: Dr. Robert Rohrbaugh is the Associate Dean for Global Health Education and the Deputy Dean for Professionalism and Leadership at the Yale School of Medicine, as well as a professor of psychiatry. He was the founding director of the Yale School of Medicine’s Office of International Medical Student Education in 2008. And in 2015, he co-founded the Bellagio Global Health Education Initiative, which encourages the collaboration of global health education leaders coming from high-, middle-, and low-income countries. Earlier in his career at Yale, Dr. Rohrbaugh worked for Connecticut’s VA in numerous leadership positions, developing the Psychiatry Primary Care Clinic and serving as clinical director of the mental health service line. During his tenure, Dr. Rohrbaugh received his BA from Franklin and Marshall College in Pennsylvania and his MD from Yale, where he then went on to complete his residency and NIMH fellowship in clinical research and a fellowship in general psychiatry as well.

So first of all, I want to welcome you to the podcast. I’ve been really fortunate to know you since I arrived at Yale. We’ve been acquainted with one another, but I really didn’t learn a lot about you until during the pandemic and even more so during the last couple of years when you took on this new deputy dean role and really have taken a big role in both professionalism as well as faculty development at Yale. And I want to just start off because our listeners may not understand how much medical schools have evolved over decades, but they have; they mostly were scientists and researchers who might practice clinical medicine as well. But primarily it was about research, and now we have a very varied clinical faculty, research faculty, and so on. And so I just want to give an opportunity to you to talk about how professional and faculty development has evolved during your time here and particularly in your new role.

Robert Rohrbaugh: Well, thanks, Howie, and thanks Harlan for this opportunity. It’s really great to be with you today. It’s a really good question. In terms of our faculty mentorship programs, we are a very large faculty and as you suggest, we’ve really been increasing on the clinical side particularly. And so how to provide mentorship to those varied individuals all the way from basic scientists to people that are working in clinical settings. Nancy Brown, when she came, really wanted to make this an area of focus in terms of developing our faculty.

And so one of the first things that she’s prioritized in this area has been the development of an annual questionnaire, the faculty development annual questionnaire that allows faculty to be able to tell us about the things that they’re doing, tell us about their plans, what things are meaningful to them, where they’d like to be in five years, a little bit about their mentorship and whether it’s adequate or not, and to be able to have that conversation with their leaders. Obviously we can’t do that centrally, to provide mentorship for everyone, but our role is to ensure that those on our faculty do have mentorship and are progressing in their careers in this FDAC process. The faculty development annual questionnaire is one that I think has been very well received by faculty and even by the leaders who are implementing that process.

Harlan Krumholz: You do that so well, and it is an important, I think, feature of Yale right now that there is an intense focus on this development. One thing I wanted to—we’re going to probably bounce around. You’ve done so many things in your career, and there’s lots of things I think that we’d like to get into. Around the development of faculty and students, one of the issues that’s come up in the last decade for sure is a focus on what are we doing that we sort of assumed was the right way to do things, but may have inadvertently or even overtly characterized certain groups of patients in ways that maybe weren’t necessarily the best ways. And so there’s been an emergence of this idea about how do you become an antiracist? How do we actually become active participants in moving the field back? And Howie and I are of course very interested in, we discussed on this program actually an article coming out in The New England Journal of Medicine perspective piece that’s sort of talking about some of these issues.

You have also published something in The New England Journal of Medicine along with other colleagues about antiracist documentation practices. And I found that piece to be sort of fascinating because we were taught in ways that we never thought to question what the right thing to do is. So you present an example in this Medicine and Society piece in The New England Journal of Medicine that—an example, where you say, for example, the history of the present illness, somebody documents Rashid is a 57-year-old Black woman with a history of hypertension, systemic lupus, erythematosis, and obesity presenting to the emergency department with chest pain for the third time in two weeks. And then you have a little more to this example after that. And that kind of explanation of a patient would be standard teaching for people to say something like that. But you guys unpack this in ways that actually I think bring light to the fact that it has certain assumptions built in to the way that we do that.

Robert Rohrbaugh: Our thesis in writing that article and others that we’ve written is trying to look at very common practical things that we do as physicians and interrogate them to see where they might be bringing bias into our work. And our thesis in that article is that by bringing the race of the individual into the first identifying part of the patient’s story, that we’re already activating potential implicit bias in the people that are listening to that story or reading that first line about that patient and about their interactions with the healthcare system. And so even that very first sentence that we’ve all been taught how to do has a potential to introduce bias.

And so our thesis is that because race is a social construct, that race isn’t something that should be in the writeup of the patient but should be in the social history because race is a social construct. And so we want to make sure that we’re noting the race because it has potential important connections to the patient’s healthcare delivery and our own implicit biases. But do it in the social history, don’t do it at the beginning where you’re having a tendency to introduce implicit bias.

Howard Forman: Can I pivot again to—at the beginning of the pandemic, everybody was aware of how many physicians, surgeons, internists, pediatricians, everybody got activated to work on the floors. It was an overwhelming experience. A lot of our trainees and our faculty were involved in that. And there’s been a lot written, including stuff that you’ve written, about sort of the stress and the aftereffects of that. But I’m curious to know, because I think the public may not know this, how involved the Psychiatry Department at Yale became in supporting those healthcare providers across the board because it was a story that was never really told. I was aware of it only from side conversations. I’m curious if you can tell us a little about how the Psychiatry Department became part of this whole process in a way that I think nobody’s really talked much about.

Robert Rohrbaugh: The pandemic was kind of consistent with an ongoing disaster. So psychiatry departments often get involved in responding to disaster situations. And in some ways the pandemic was kind of an ongoing disaster. And so it was natural for us to want to be involved and to activate our faculty to respond. And I think we responded at a number of different levels. One was at the community level. So we really tried to help the community to process what was going on and particularly their emotional responses to what was going on. So we had probably 20 to 25 faculty that volunteered to do this kind of virtual work with community members. So we would say we’re going to have a time at five o’clock in the afternoon for anyone who wants to get on and talk about what’s happening. Some of those were podcasts that were about specific issues, like how do you be a nurse work all day and then go home and how do you manage the worry that you’re bringing COVID home to your family, and how do you manage having to sleep in the basement because you’re afraid that if you have contact with your family that they might become infected. So we worked at the community level. We tried to work at the team level, so these were teams that were really stressed trying to take care of these patients, and so we had huddles in which again, people were able to come and express their feelings about what was going on. We worked at the leadership level. So one of the roles I had was, and Howie, that you also took on, was coaching for the individuals who were so stressed and working so hard and finding it so challenging to lead during this pandemic.

So then we also had a website where you could take a stress survey to find out—everyone was stressed, but were you stressed more than others? And if you were, you could ask to have an individual consultation. And so this was a really wonderful part of the response that our voluntary faculty, we have a very large voluntary faculty in the city of New Haven. These are individuals who are mostly in private practice but who volunteer their time to teach and many of them volunteered hours of their time to work with our healthcare workers who were so terribly stressed by the experience that they were going through. So we tried to work at various levels of the organization to provide care.

Howard Forman: You’ve been involved at the intersection of primary care and psychiatry. And specifically for me at least, as we get to more population health measures and being able to deliver care to larger populations, you can’t always have a psychiatrist there for every patient, nor would every patient want that necessarily. What do we do to make sure that the primary care workforce, including nurse practitioners and other providers, not just physicians, are properly prepared to be able to face what does seem, when we look at the pediatric population, an emerging population that has an unusually high degree of anxiety, depression, and other mental health disorders including substance use disorders. How do we empower our primary care workforce and what can the psychiatry profession do to help that?

Robert Rohrbaugh: Yeah, the answer to this, how it used to be that we needed to provide training, we needed to make sure that psychiatrists and other mental health professionals were present in primary care settings. I think those are still important issues, but more and more, I have to say, I think virtual technologies are taking on some of this. So for people that have mild to moderate symptoms of anxiety and depression, and those are the folks that are mainly in primary care, the data’s really good for virtual interventions. And so I’m more and more thinking that that group, that very large group of individuals, that might be met by virtual.

Howard Forman: And can you say just a little bit more about what you mean by virtual? Because I take that to include nonhuman interventions using digital technologies.

Robert Rohrbaugh: So, exactly. So there are really good programs now where you essentially use a cognitive behavioral therapy intervention, but it’s done through the computer. So you might be doing worksheets on how to get to sleep at night, and it’s going through the checklist of all the things that you should be doing, turn down the temperature of your room, don’t take caffeine, all the things that someone in primary care might have said, but you’re working it through virtually on the computer. Those sorts of interventions have been shown to be very effective.

Harlan Krumholz: Thank you so much.

Howard Forman: Yeah, we’re so grateful for you to join the podcast and to have you as a colleague here, you’ve been a great contributor to Yale, and I appreciate you a lot.

Harlan Krumholz: Thanks. Wonderful to have you. Great to talk to you.

Robert Rohrbaugh: I appreciate it.

Harlan Krumholz: Well, Howie, that was a great interview, but now I want to get to the part that despite our amazing guests and other topics is my favorite part, which is near what’s on your mind this week.

Howard Forman: So this is to me really fascinating, and it’s very much evolving right now. But if you’re a private practice physician or an executive involved in delivering healthcare, you’re already aware of a cyber-attack on a company called Change Healthcare, which is a subsidiary of UnitedHealthcare Group, the largest private health insurer in our country, if not the world, but others may be seeing the random headlines and may not know about this. I’m just going to briefly unpack this for you. Change Healthcare is a clearinghouse for healthcare billing, basically including physician practices, hospitals, pharmacies, and so on. They apparently clear $1.5 trillion in charges each year. It’s not the same as collections, but that is still an enormous amount of money. They dominate this space. Seventeen months ago, they were formed through the acquisition and merger of the original Change company with the Optum subsidiary of United Healthcare Group.

And at that time, before that time, the Department of Justice, U.S. Department of Justice argued that they would have 94% of the market for these services in the court’s jurisdiction and a very high percentage of others. Even after divestiture of some assets, they would still be very dominant. To cut the story short, the Department of Justice lost this argument in federal court. The merger was allowed to move forward. Fast forward to two weeks ago, February 21st, when Change Healthcare undergoes a cyber-attack and is forced to take most systems offline, this has the immediate effect of stalling their services and most importantly, stalling payments to their clients. This may not seem like it’s a big deal, but when your biggest source of cash basically stops, small and large practices alike suffer. And as one example I can give you, there’s a Philadelphia physician and practice owner who saw her collections drop by more than 92% this past week.

So if you have to make payroll and don’t have deep pockets elsewhere, it’s a big problem. Our recent guest, Farzad Mostashari, has been quoted as saying that as many as 25% of all physician practices are in severe financial distress due to this event. His company, Aledade, which we spoke about just a few weeks ago, has already extended $100 million to their own physician practices to sustain them. The federal government has offered very modest help. And UnitedHealth Group has also offered very, very modest help. But this seems like a greater concern than is widely being appreciated. And one final note, Change Healthcare is the successor company to Healtheon, which is one of the earliest healthcare dotcom darlings. It became WebMD and then Mdeon and then eventually merged with a different company called Change to arrive in the current spot. And I just think this is one of these very complicated things that’s happening really quickly, but it is a crisis out there right now. And I’m not sure that we’re going to quickly respond enough. We may see some permanent harm from this.

Harlan Krumholz: There’s so many different angles on this story. There’s the issue about a state actor who’s attacking a critical infrastructure of the United States. I mean, is it even an act of war that someone has come in and found this sort of very central aspect of our healthcare system and being able to unravel it through this hack? Another aspect of it is how hard it is to actually fix the hack. It wasn’t like we found this and in a half hour an IT team can fix it. They’re saying weeks like they’re trying to figure out what to do. It’s a problem like that.

Howard Forman: I think, by the way, that they may have made, we don’t know this for sure, but there’s a random $22 million bitcoin payment that was made somewhere that people are suspicious was actually a ransomware payment made by UnitedHealth Group about this.

Harlan Krumholz: So that’s another fascinating aspect of it. And another one is, how did we get to this place in this country where we have such a critical piece of our old healthcare infrastructure concentrated within UnitedHealthcare? It happens to be a very vulnerable entry point to be able to disrupt the entire healthcare system. And by the way, there’s a certain brilliance to that, which is to say, if I wanted to disrupt healthcare in the country, what would I do? And for someone to even realize that, hack Change Healthcare, and all of a sudden you can cause massive disruption across the entire country.

And I wonder whether it’s a signal about what else they could do. But getting back to that concentration, like you said, I saw on The Washington Postthey said, processing 15 billion claims, like you said, $1.5 trillion a year for a company that most Americans have never even heard of. But how did that even happen? It gets in this position. And then again, like you said, antitrust, it navigated, so it became part of the biggest healthcare insurer. And one more facet of this too, which is that a lot of people don’t know this, but a lot of the money that’s made in healthcare around this is on the float. So there’s money that’s owed to the physicians—

Howard Forman: That’s being held.

Harlan Krumholz: If you can slow down the payment, then you get to hold and make money on that money until you have to pay it. So now you’ve got a major insurer who actually is in charge of the speed with which those transactions are occurring, and—

Howard Forman: It’s a mess.

Harlan Krumholz: It’s all under the same roof. So I think this is bad. And just to say there are some patients who are actually affected by this who are being billed full freight for their drugs, even though they have drug benefits because it can’t be linked back—

Howard Forman: They can’t process it. Exactly.

Harlan Krumholz: They can’t be processed correctly. So a lot of patients are even being put in positions where they’re being asked for money they don’t have. And so this is a mess all around. Hospitals, practices, and patients being affected. Again, people may not see this on the radar. Kind of goes by on the Change Healthcare hack, and you think, well, there’s lots of hacks, but this is a big deal, and we’re going to watch this story overcoming.

Howard Forman: Yeah. I’m wondering whether Judge Carl Nichols has second thoughts about his ruling about letting this go forward, but we’ll leave that for another day.

Harlan Krumholz: Well, that’s a question of whether or not would it have been different had it been outside of UnitedHealthcare? I don’t know.

Howard Forman: Yeah, good point.

Harlan Krumholz: But it is a concentration. It is an area if you wanted to make a direct hit and unravel the U.S. health care system, this was the place to go. And somebody, some state actor, they think actually did this.

Howard Forman: Yep.

Harlan Krumholz: You’ve been listening to Health & Veritas with Harlan Krumholz and Howie Forman.

Howard Forman: So how’d we do? To give us your feedback or to keep the conversation going you can find me on Threads. I’m at T-H-E number four M-A-N. That’s @the4man.

Harlan Krumholz: And I’m still working out my social media strategy, but I’m on X at H-M-K-Y-A-L-E, @HMKYale still. But I’m not using as much as I used to, but that’s where I am.

Howard Forman: Okay. And you can still email us at health.veritas@yale.edu, aside from Twitter or a podcast, I’m fortunate to be the faculty director of the healthcare track, founder of the MBA for Executives program at the Yale School of Management. Feel free to reach out via email for more information on our innovative programs or check out our website at som.yale.edu/emba. And if you like the podcast, or even if you don’t, please rate and review us on your podcast app. We always read your reviews, and it helps others find this. And by the way, Harlan, we have a really nice review that just came in this week that says, “Great podcast for updates in medicine, health policy and the business of healthcare. The discussions are lively and well-researched, highly recommend.” And I really appreciate that review from that listener. And there are several others as well.

Harlan Krumholz: I thought my mother wrote that, but actually this is from someone else.

Howard Forman: Someone else, yeah.

Harlan Krumholz: Well, that’s terrific. That’s just terrific. Health & Veritas is produced with the Yale School of Management and the Yale School of Public Health. Thanks to our researchers, Ines Gilles and Sophia Stumpf, and to our producer, Miranda Shafer. We’re so grateful. Thank you so much.

Howard Forman: Yes, we are.

Harlan Krumholz: Talk to you soon, Howie.

Howard Forman: Thanks very much, Harlan. Talk to you soon.