(soothing piano music) <v ->Let me just start by</v> bringing up a subject you talked about, Dr. Altin, which is the risk of amputation related to income or socioeconomic status. We've all thought, perhaps, that it's just socioeconomics, you know, more patients less likely to get, you know, care, and so higher amputation rates, but you showed, you know, still higher rates of amputation, even for those who were making, you know, much more money. Any thoughts as to why that disparity still exists, and how we can overcome it? <v ->I think this issue of implicit bias is really prevalent</v> in every aspect of the care we give to patients, and that's why it is important to have a diverse workforce. There's a patient for every doctor and a doctor for every patient. You know, there are some patients that I can click with from the moment I see them in the waiting room and they smile at me and I smile at them. It's not necessarily to do with race or gender or anything, I mean, I work in a VA, they're all guys, and then there's certain patients that you don't click with. And so that, sort of, initial patient-doctor interaction can either change or morph as you continue to know each other, but then when implicit bias is never really addressed by the provider, then you can't improve, right? And we need to be improving ourselves. And we need training sessions, but mostly you need to make sure that you're doing the right thing for every patient because it's the right thing for every patient, not because of what you think about what they might do with what you ask them to do, right? For example, you know, when we're referring patients to optimal medical therapy or supervised exercise therapy, you don't refer the patients who you think might go, you refer everyone. And then they can decline, but you have to sit there and talk to them and explain, "This is why exercise helps." And you have to have that 10-minute conversation, even if you think they might not listen. Because I've actually been surprised that the patients in the wheelchair who can get around with a cane, are like, "I'll try the treadmill." But if I said, "Well, you have a cane and they pushed you here in a wheelchair a city block, you're probably not gonna get on the treadmill." And they do and they get better! So there's a lot of ways that we interject our bias into the care of patients. Some of it is on how they look, as far as what demographic they fall into, but some of it is on the other things that we think they're not gonna follow or comply. So the point of your question about socioeconomic status or salary is that that's not enough. Right? There are a lot of other ways in which we interact with our patients where our bias'll show. <v ->Thank you, Dr. Altin.</v> Quick question. You all pointed out, and we've all pointed out that African Americans have higher amputation rate and we've also mentioned that many of them have not had any arterial study prior to the amputation. We also talked about the ARCH bill sitting in Congress. Do you think this is enough to improve this numbers, or is there anything else that we should be doing to reverse this presentation? <v ->Yeah, I'm not an expert on this</v> by any stretch of the imagination. I see a lot of patients, and I hear a lot of stories, and so, from that I can just say that there are historical inequities that are nearly impossible to fix in a 20-minute visit. And there are historical inequities that no congressional bill will solve. But at year three, at year five, or year seven, of caring for someone compassionately and fairly, it is possible that despite differences in appearances and approaches, that their trust grows. But that is not something that we should presume that we get, as physicians, at the first encounter. It is something that we have to earn. And the problem with these peripheral talks and these peripheral procedures, it's like a one-time care episode, but these patients are so critically and chronically ill that to be a good provider at PAD care, you become their interns. And you need to know everything about them, because they're going to come when you're on call with a study. They're going to get a CTA and you'll find pancreatic cancer. I mean, you are their physician. And they're some of the sickest people who've fallen through every gap in healthcare that exists. So I think the answer is there's no single solution, we just have to be really good, good doctors, who also do procedures from time to time. But the majority of the work is done in the clinic, month to month and follow up to follow up. 'Cause it's a chronic disease; it's not fixed with an SFA balloon. <v ->Thanks again, Dr. Rymer.</v> I wanted to really congratulate you and your group with what you've been able to do at Duke. It's really a model for so many other institutions to follow. 'Cause, I mean, I clearly remember, you know, interviewing and, you know, trying to, you know, become an expert in cardiology, and just feeling overwhelmed when I'd go to some of these institutions, thinking, you know, that's just not for me. How do you roll this out to other institutions? How do we get this, you know, information out to many, again, who believe this, but just don't know how to implement it. <v ->Yeah, I think that's a great question.</v> You know, I think for us, it was, and I think it requires institutions to step back and really take an evaluation of how things look when trainees are coming into their residency day. I recall, at Duke, for instance, we had this hallway, it was of key researchers at the Duke Clinical Research Institute. It was a perfectly white hallway, and it had only pictures of white men, down the hallway, who have accomplished many great things and deserve to be recognized, but I can remember on the surveys kinda coming in, people would say, "That was the first look I had at Duke when I was coming into your training fellowship, and I didn't see anybody that looked like me." So you have to think about how you are perceived. And then there has to be a real buy-in from the divisional leadership, from the department chair, that this is really important. And sometimes changing those perceptions, particularly amongst the more senior faculty, is tough, but it's necessary. And having people really believe that having a workforce that looks like the population of patients we care for is important, is key. I don't think rolling it out is actually all that hard, it's just about intentionality. It's about getting the trainees to come during the day, meet with people, with other women, with women trainees, meeting with diverse populations of the faculty, if it's underrepresented minority trainees, and getting them to interact with those folks, and letting them know there's going to be a supportive environment when they come to your institution. And so what we've seen as a result of those changes, it's not just within our cardiology fellowship. For the first time ever, we now have a woman trainee that's coming up the pipeline for each of the years down the road in our interventional program. And we now have significantly more diverse representation. So I think it's all about intentionality, it's all about taking a step back and, sort of, looking at your own biases and seeing how they're contributing to both how you pick your trainees, but also how you take care of your patients. <v ->Well, I want to thank our speakers,</v> my co-moderator for a fantastic session. Thank you for joining us this morning. Enjoy the meeting. (soothing piano music) (audience applauds)

amputation risk

income

implicit bias

diverse workforce

compassionate care