Finding Comfort in the Familiar: A look at how diversity improves the care experience
Written By Niki Kapsambelis, Featured in the 2021 Spring Magee Magazine
When medical students begin their rotations at UPMC Magee-Womens Hospital, one of the first people they meet is Sarah Napoe, MD.
It’s a purposeful meeting for Dr. Napoe, who serves as the Obstetrics and Gynecology Department’s new ombudsperson for diversity. She wants to ensure thatstudents know she is there to help them experience a positive and welcoming environment. But moreimportantly, she is fulfilling a promise she made to her mentor when she herself was in medical school.
“If we can make our institution a welcoming place, hopefully students will consider staying with us,” Dr. Napoe explains. A resident’s workload is high, and the road to becoming a physician is long. When you don’t see many people who look like you, or someone implies that the only reason you are in a highly competitive profession is because you received special consideration based on your race, depression and burnout can quickly follow, she adds.
But there is also a deeper motivation behind her mission.
A question of trust
Black women — and their children — in the United States face a staggering racial disparity in health outcomes: they are three to four times more likely than white women to die from childbirth, regardless of education or socioeconomic status. And disparities extend to breast, colorectal and cervical cancer screenings, Napoe adds. In a national study published in the American Journal of Public Health, Black women were two to three times more likely to die from five common causes of maternal death and injury than white women with the same conditions.
Locally, a 2019 report published by the City of Pittsburgh’s Gender Equity Commission found that fetal deaths are twice as likely among Pittsburgh’s Black women compared to white women, a key indicator of maternal health. Likewise, Black women are three times more likely to deliver babies with low birth weight.
While many factors contribute to these disparities, patient experience is the heart of the matter, according to Alexander Olawaiye, MD, the Obstetrics and Gynecology Department’s vice chair of diversity and inclusion. No matter how fair and professional a health care provider is, the patient’s perception of inequity can create mistrust toward the health system, leading that person to delay seeking treatment, fail to fully comply with a treatment plan or decline to report new symptoms.
“When people don’t have that trust, they basically shrink back into their cocoons of fear and anxiety,” Dr. Olawaiye says.
He witnessed the phenomenon within his own family: his uncle, who holds a master’s degree in economics and has worked in companies around the world, developed throat cancer and was suspicious of his oncologist, who is a white physician. Dr. Olawaiye spent hours on the phone convincing him that his treatment was not an experiment; today, the uncle has been in remission for two years, but not everyone has a trusted family member to talk them into truly partnering with their care team.
“That’s the core of the problem. If we get past the issue of trust, we will do so much better,” he says.
Toward more robust inquiry
Clinical care isn’t the only area that benefits from cultivating diversity. Research — the kind that ultimately drives better patient outcomes — produces more robust, relevant results when the people who conduct and participate in studies are as diverse as the population, notes Mary Ackenbom, MD, a urogynecologist who also is an investigator with Magee-Womens Research Institute (MWRI).
Generally speaking, the Black community has endured a history of negative experiences — such as the infamous Tuskeegee Syphilis Experiment — that has led to a deep mistrust of medical research, Dr. Ackenbom notes. That apprehension, combined with the inherent complexity of research goals and the difficulty of communicating their value, can make enrolling Black participants challenging — which contributes to the disparities.
“It’s this vicious cycle,” she says. “We see this mistrust, so we aren’t able to enroll as many people from different backgrounds and populations, and we’re limited in our findings, and ultimately we aren’t able to improve upon outcomes.”
In her own field, Dr. Ackenbom noticed that patients opting for elective urogynecology surgery are not diverse, leading her to pursue a new line of research that explores why.
“I think it’s very telling, and very important, to get a sense of what barriers are out there so we can figure out potential interventions that might overcome those barriers for these women,” she says.
Currently, Dr. Ackenbom is beginning to study barriers to urogynecologic care in underrepresented minority women around the region.
In her clinical practice, which includes patients from both rural and urban areas across western Pennsylvania, she has heard some patients remark on her race.
“When I do have a minority patient, it’s often either they sought me out because I am Black, or they make a comment like, ‘I feel more comfortable now,’” she says. “Those comments always resonate with me. I get that — people with similarities are attracted to each other and feel more comfortable. That’s also a reason to strive to increase and embrace diversity: because it makes patients feel comfortable and cared for.”
Miguel Brieño-Enríquez, MD, PhD, an MWRI investigator who specializes in infertility research for women and men, notes that the diversity within his lab (two postdoctoral women who are Hispanic, a technician and student who are white, and himself as a gay Hispanic man) has been a valuable asset.
“The way we all approach the same question is really different — and that, for us, is gold. Because there is not a single answer or a single way to answer one question,” he says.
“I think both Magee hospital and Magee-Womens Research Institute are working hard to get this kind of diversity,” adds Dr. Brieño-Enríquez, who heads MWRI’s Diversity, Equity and Inclusion Committee. He notes that the institute is actively trying to connect new employees with others with whom they can relate.
A legacy of care
When Dr. Napoe studied medicine at the University of Pittsburgh, she took an elective that changed her life. It was taught by the late Morris Turner, MD, medical director for UPMC Magee-Womens outreach sites in Wilkinsburg and Monroeville, who was instrumental in eff orts to establish practices devoted to the needs of minority women.
“He really cared for them as individuals and was committed to bringing them care,” recalls Dr. Napoe. Dr. Turner once walked from his Point Breeze home to the hospital in Oakland to deliver a baby in a blizzard. He also was committed to ending disparities in health care.
Robert Edwards, MD, chair of the Department of Obstetrics and Gynecology at UPMC Magee-Womens, remembered Dr. Turner and his partners well. “They had a noticeable influence on the hospital, and this was a big part of my education,” says Dr. Edwards, who points out that a signifi cant number of attending physicians during the 1980s were minorities who were dedicated to helping underserved communities.
Those numbers began to decline in the 1990s, a trend that Dr. Edwards and other hospital leaders are working to reverse.
Gabriella Gosman, MD, the hospital’s vice president for medical affairs and vice chair for education, says the effort is continuous and multipronged. In addition to ongoing training for all employees, UPMC Magee-Womens is actively looking at all aspects of its hiring to create an atmosphere where minorities who are underrepresented in medicine will thrive.
That is where Dr. Napoe’s talk to incoming medical students comes in, and Dr. Olawaiye’s role also supports existing and prospective talent.
The efforts seem to be bearing fruit. For academic year 2021-22, three of the 10 applicants who matched for fellowships at the hospital are underrepresented minorities.
“We have so much work to do to begin to deserve that trust” among patients, Dr. Gosman notes. “When you think about hiring and having a diverse workforce, so patients see people who look like them, it’s not enough to build trust. But it is an essential part of moving toward that goal.”
Returning to the community
Before Dr. Napoe left to complete her residency and fellowship, Dr. Turner made her promise to return to Pittsburgh and help the patients to whom he had dedicated his career. He died suddenly from a cardiac arrest in 2014. Five years later, Dr. Napoe returned to fulfill her promise.
“One of the things that Magee and UPMC do really well is we don’t just sit in Oakland. We also do outreach work and treat patients wherever they are,” says Dr. Napoe, who cares for patients in Clarion, Erie, Bethel Park, and the McKeesport offices where she used to work with Dr. Turner.
Dr. Napoe notes that outreach efforts with Pitt extend not only to the School of Medicine, but also to all health sciences programs at the university. She also wants to see more outreach to the community.
“I think we need more community partnerships, so the community looks at us favorably and considers us as a place to work,” she says. Within the next five years, she’d like to see UPMC Magee-Womens increase its percentage of underrepresented minorities among residents and fellows: “If you train people, they get to know you well, and they know what they’re getting into.” Dr. Olawaiye agrees.
“The purpose of inclusion needs to be well defined and well balanced,” he says. “There’s an old adage: You shouldn’t only invite people to a party; you should give them an opportunity to dance.”
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