This pandemic has lifted the veil of the disparities that already existed globally, especially when it comes to medicine. What is worse, not only has it revealed these problems, it has also exacerbated the marginalization of many communities. In this episode, Alaina Rajagopal sits down with Dr. Victor Cisneros, an attending physician and Graduate Medical Education (GME) Director of Diversity, Equity, and Inclusion at Eisenhower Health. Dr. Cisneros discusses his upbringing as a Mexican immigrant and how this has affected his perspectives on diversity in medicine. He sheds light on the disparities in medicine and how the pandemic has highlighted under-resourced populations and regions. Tune in to hear more about what you can do in your community to help alleviate some of these issues and make an impact on society.
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Disparities In Medicine: Exploring Underlying Issues On Equity And Inclusion With Dr. Victor Cisnero
We're talking to Dr. Victor Cisneros. He was born in Guadalajara, Mexico but was raised in Anaheim, California. He received his Bachelor's degree in Biotechnology and a minor in Chemistry and his Medical degree and Master’s of Public Health and Board Certification in Public Health at the University of California Irvine School of Medicine. He was part of the Program in Medical Education for Latino Community or PRIME-LC, a dual degree program that focuses on increasing physician leaders who are culturally sensitive and linguistically competent to address the specific needs of California's Latinx population.
After medical school, he completed his Emergency Medicine Residency training at UC Irvine, where he was one of the Chief residents. During residency, he also served as At-Large Director and Board Member for AAEM and liaison to the Diversity and Inclusion Committee and International Subcommittee.
He also served as the Vice-Chair for the Social Emergency Medicine ACEP-EMRA committee. He completed a research fellowship in Population Health and Social Emergency Medicine. He serves as an attending physician and Graduate Medical Education Director of Diversity Equity and Inclusion at Eisenhower Health. Welcome, Dr. Cisneros.
Dr. R, it's my pleasure. What an intro. It’s such a pleasure to be a part of your show.
Tell me a bit about how you got into medicine. Do you remember when you first wanted to be a doctor?
I do. This is my second career. Initially, I was a Bioengineer. I went to Cal Poly Pomona, where I majored in Biotechnology, and I worked as a validation engineer at a pharmaceutical company in Southern California, Rancho Cucamonga. I didn't have much guidance or anybody to guide me through medicine. I had volunteered in the Emergency Department as an undergrad part of this volunteer project. I always loved it.
I loved the emergency department, and I saw that there was a lack of Latinx physicians and people who were versed in the Spanish language and the community. At the back of my mind, I always had a little bit of curiosity about becoming a doctor but I never had guidance or anything. When I was an engineer, I realized that the pay was great. I went into engineer for the wrong reasons. I graduated high school and my mentors were like, “You're good at Math and Science, so you should be an engineer.” I
'm like, “That sounds like an amazing idea.” I ended up pursuing that path, not knowing exactly what it meant. It's a great, amazing, cool, very rewarding career but it wasn't for me. While I was working there, I realized that I wasn't fulfilled and there was something more than crunching numbers in a cubicle. I missed that human interaction. Looking and pondering back, and thinking about what my father taught me growing up was like, “Always follow your dream. Never follow the money because you only live once. If you're not living your dream, you should change it.”
I had this epiphany one time when I was sitting at my desk and I was like, “This is not where I see myself in the next ten years.” I didn't have anybody to reach out to. What does anybody do when they may have any questions, they google it so I googled how to become a doctor. I said, “How to become a doctor after you have your Bachelor's degree.”
A bunch of Post BACC programs came up and two of them were UCLA and UCI. Being a local kid from Orange County, I decided to apply to those two local programs. I got into UCI and the rest is history. I did a Post BACC where I did a year of classes and shadowing and the MCAD and all the bells and whistles that we all know take to go into medicine. That was where my journey started back in the day.
Never follow the money. Always follow your dream because you only live once. So if you're not living your dream, you should definitely change it.
You became a UCI Lifer after that.
Until that, I had a change in the path.
When did you decide to go into Emergency Medicine specifically?
It was around that time too that I mentioned I had volunteered in the emergency department at a local Emergency Department Trauma Center. I was like a “candy-striper” cleaning, gurneys, and stacking medications. I love the emergency department. When I went into med school, I kept an open mind about the process and different specialties because you really don't know what specialty you want. It’s not until you’re 3rd or 4th year.
In your first two years, you can be in a cave somewhere in the middle of nowhere, studying medicine and it's pretty much the same. In your 3rd and 4th year of medical school, you get a little bit of flavor seasoning of each specialty. The broad spectrum of medicine that emergency offers and the fact that it's probably my humble opinion, the closest thing that it mirrors to public health. In the back of my mind, I've always had a little bit of curiosity about public health medicine and disparities gave my upbringing and things that I've faced growing up.
Going through it, I figured, “I want to know a little bit of everything.” When you envision at least myself growing up, I didn't have healthcare, I would go to the medical department to get care. When I envisioned a physician, he was an ER doc, someone who knew a little bit of everything that you can ask questions and might not be a specialist at any certain specialty. At least in my humble opinion, the resuscitation specialist. The first fifteen minutes of every specialty.
In the back of my hand, I knew that's where I belonged and probably the ones that were more attuned to what's going on in the community because we see the whole piece of the pie. If you're pediatric, if you're an OB-GYN, you're going to see women's health issues. Internal medicine, adults, maybe ICU. We see a little bit of everything. We see from the traumas to the vaginal bleeders, the belly pains, and the pediatric patient that comes in. I learned that early on during my third year, and then took a year off to my Master's in Public Health. It re-solidified that.
Often in emergency medicine, it's the people who went through rotations and were like, “I liked everything.” Speaking of public health, you also have a Master’s in Public Health or an MPH. How do you think that becoming a specialist in public health has informed your clinical practice?
The way the medical school is structured, it's four years of this compacted amount of knowledge. They say it's like drinking water from a fire hydrant. It does feel like it sometimes when you're going through it. It's so compacted that we have to take away certain things out of the curriculum. For example, our limited exposure in most med schools for Biostatistics, even Public Health or Disparities is very limited. Maybe one lecture here and there in the four years.
Getting a Master's in Public Health allowed me that year to dive in not just into the literature but the biostats and learning how to speak the language. A lot of times people go into Public Health and you have a Master's, you don't have that clinician side of it and that exposure of how the hospital runs. If you're an MD, you might be very well versed on how the clinics and how the hospital runs.
Maybe lacking a little bit of a common language that public health practitioners use or maybe the stats, the bio or how to interpret the literature. It gives you these little extra tools in the toolbox to speak the same language and cross the bridge between both specialties, per se. It's been an amazing extra tool in my toolbox for what I've been doing.
It does give you additional education that makes interpreting the literature a little bit easier. That's one of the most challenging things that we do as physicians are breaking down the literature and recognizing when it's time to change practice based on that or when more studies are probably needed before changing our practice. You have spent a lot of time learning about and understanding disparities in the medical system. Were there any personal experiences that prompted your passion for this topic? You touched on it a little bit earlier.
I'm an immigrant kid from Guadalajara, Mexico, who came here when I was two years old. Family of immigrants. I've lived these disparities on a personal basis. I know what it is to be hungry. I know what it is to lack a roof on top of my head. I know what it is to be homeless for a little. There are parts of my childhood that I know what it is to not have a house.
Living in a garage or doing my homework in the back of a car because we didn't have a place. Definitely, my early experiences growing up in these conditions sparked that interest and that fire that grew as I learned more about these disparities and how important. Not only did I live at myself but at the same time studying them as ever increased my passion for it and that fire that was growing in there.
That's such a powerful story and has probably given you so much more compassion, empathy and the ability to relate to a lot of what our patients go through in the emergency department. The ER is the only place people can get medical care. I love what you're bringing to the specialty.
I was one of those kids that didn't have a primary care doctor that would go to the nearest emergency department because I was sick and my parents didn't know the language or didn't know how to maneuver the system, or even knew that we qualified for some pediatric healthcare at the time. If you're not versed with the language or this is not your mainland where you grew up, it's hard navigating the system.
It's hard enough as a physician yourself. There’s a different part when you're versed. Imagine when you're not, and you're coming into unknown territory. No known language, unknown culture. It's very difficult. I'm very empathetic and understanding, and I can relate to many of our patients that we face and encounter in the emergency department on a daily basis.
We passed a sobering milestone of 700,000 deaths in the United States due to COVID-19. This pandemic in particular has emphasized a lot of the disparities in our medical system. Black, Hispanic, and Indigenous communities in particular, especially in rural areas have been disproportionately affected. With your public health hat on, why do you think this is?
You alluded and hit the nail on the head. It's not that COVID is some new magical virus that targeting specific ethnic backgrounds or DNAs. It's literally what this virus has done that has lifted the veil of the disparities that already existed. The underbelly that most people maybe weren't aware of or the public wasn't aware of but already existed, which is these communities and different ethnicities that have always been marginalized.
The Hispanic, African American communities, Latinx communities, a lot of the rural communities don't have equitable healthcare. It's not just about access, it’s about equitable healthcare. There's a lot of disparities that have already been there that this virus exacerbated like food, security, housing and a lot of marginalization. It's not something new.
When you start to look at how systemic this is, you can look at the higher risk of underlying conditions like hypertension, diabetes, obesity because of the concept of food deserts where there isn't healthy food available. People are eating more processed and worse-for-you food. A lot of the hospitals are under-resourced. If people are in rural areas, they lack access to hospitals. There are so many issues that already exist in the medical system. The pandemic has highlighted a lot of that.
This pandemic has lifted the veil on the underlying issues and disparities that a lot of people would maybe turn a blind eye to or weren't necessarily aware of.
We trained in Orange County. Orange County tends to be an affluent county in California. Most people don't know that 1 out of 4 kids goes hungry every night. This is before the pandemic or was going home, it was suffering food insecurity. This is a county that gets overshadowed by the South of the county, which tends to be very affluent. A lot of times you can't even imagine what's going on in Riverside County, San Bernardino County, which is even more.
These are kids that at least we're being guaranteed a meal at school. They would go to school and their parents are like, “At least they're going to be guaranteed a meal at school.” Now, you have a pandemic that hits. Kids don't go to school, parents that are already struggling to live paycheck by paycheck or relying on this food source from school, their kids are not even guaranteed this meal. Think about how that exacerbated already the disparity that was existing with this.
For example, for this pediatric population, I’m not talking about adults. Most people are not even thinking of what's going on now. The fact that this virus has targeted the Latinx population, the biggest producer of our produce, the farmworkers that are working in our fields, picking our tomatoes, strawberries or oranges in the valley. It's mainly Latinx Spanish-speaking immigrants. These are the community that are being hitting hard.
The economical after-effects that we're going to see are going to be huge. Nobody's going to go pick strawberries and oranges in the middle of nowhere for under-par working conditions and possibly not even fair pay. If you look at it a lot of different ways, this pandemic has lifted the veil to the underlying issues that a lot of people would maybe turn a blind eye or weren't necessarily aware of. A lot of us that are studying this and have been studying this have known these issues were there.
The CDC reports that Hispanic, Indigenous and Black people are at least twice as likely to die from COVID-19 compared to non-Hispanic White people. However, I should also note that White people account for a higher number of deaths because they're the largest demographic group in the United States. You touched on it a little bit with jobs. Why have these groups been more vulnerable to COVID-19?
They're the ones that probably suffer more comorbidities, diabetes, hypertension and hyperlipidemia. They're the communities that have less access to care. If they do, is it equitable care? As we know, in some insurances, it's hard to see your PCP. You might have some government insurance but it might take you 3 or 4 months. We've experienced this as ER docs, where you see a lot of underserved patient populations.
Getting them to see their primary care doctor is sometimes impossible, and you're relying on these community clinics. Is it really equitable care versus someone who might have PPO insurance could easily get their diabetes medications managed versus the guy who might run out of their Metformin and go into decay? You have these underlying medical conditions already, such as obesity, diabetes, hyperlipidemia, and then you add the stressor of COVID or an infection, yet you don't have the access to equitable care. They're going to be way more affected than someone that is not going through all these issues.
Also, potentially, lack of ability to social distance. A lot of these populations have jobs that you can't work remotely. You have to show up in person. That can also contribute to a lot of the increased spread in these groups.
A lot of these communities live in one-bedroom apartments, in close counters, not because they choose to but because that's all they could afford. You talked about our homeless population, all of a sudden, housing was a huge thing and these foundations were coming in for housing for the homeless population because they realized that it was a huge issue. Prior to this, let's be honest, housing issues have existed all over the US but what did this virus do? It highlighted the underbelly of what was going on.
Another statistic from one of the papers we were talking about was the Rural Policy Research Institute at the University of Iowa published data showing that 1 in 434 Rural Americans has died from COVID-19 compared to 1 in 513 people who've died in more urban areas. It's such an interesting statistic. In rural areas, you expect that it's a little easier to social distance. Many of the factors we've already discussed and probably a few we haven't also influenced this, do you have any thoughts on this?
It comes all down to the social determinants of health, in my opinion. Some of these rural areas have problems with access and care. You're not going to drive to go to the nearest hospital or their nearest clinic when you're out in the middle of nowhere. If you get a virus you're probably going to pass away in your house or you're probably not going to go. You might be able to social distance but if you're hypoxic, there might not be a good EMS system that can get to your house on time if you're struggling. It's multifactorial. It all comes down to the social determinants of health, which is a big umbrella of multiple factors that affect us in public health.
In many of these communities, there is a distrust of the medical system that goes back to unfair experimentation, for example, the Tuskegee Syphilis experiments. We could talk about the spread of smallpox to Native Americans. How has this mistrust affected vaccination rates in these communities?
It's huge. In my opinion, there are two types of people that are afraid of getting vaccinated. There is a population that's very politically driven based on political propaganda and myths that the virus is radio-controlled chips and that's one extreme population thing. You have the other patient population that tends to be more minorities. Almost Caucasian patients tend to be a 1.3 times higher rate to being vaccinated this is the CDC on October 4th, 2021 that showed some of this data.
My opinion is that it's their fear. A lot of the minorities have been marginalized and experimented by the government and don't trust the government. You mentioned two studies but you look at Latinos, the Bracero Program back in the 50s and 60s where they would spray them with pesticides and certain things. Another issue, which most people don't necessarily mention is documentation. A lot of Latinx populations that are undocumented are afraid to go get vaccinated because they're like, “I don't want to be deported.”
Many of these populations to the contrary of this some political-driven agenda. They don't want to be a strain on society. They want to come and work. They want to make some money for their family and better themselves. They want to be under the radar. They don't want to be in the highlight. For them, coming out to say, “I need the vaccine.” Even though they might want to believe it. They're afraid to like, “If I do this, could I get deported?”
It's important for us as physicians and public health practitioners to make awareness that we shouldn't be asking about status or documentation. People should be vaccinated. Vaccines should be free for everybody. It should be accessible. We should be educating our community and our patients, especially those immigrant patients that, “This is not going to affect your stay here in this country. We're not going to ask any questions.”
Unfortunately, we have certain states that sometimes you get pulled over and they ask you for documentation so imagine the fear. Why would they go to a testing center or a vaccination center where potentially there's going to be government officials that could ask them where they were born. The fear alone is also a big factor.
There was an article published in The Lancet in April of 2021. The authors touched on that topic specifically in the vaccination, in particular, should be available without regard to immigration status or anything like that. They also said that prioritizing community-centered engagement is important because different communities have different perceptions about why the vaccine may or may not be good or bad. You have to look at each community and figure out where those questions are, how to address those questions, and then help create a more trusting environment, particularly with communities that have been marginalized historically.
In the US, we have an abundance of vaccines available at this stage. However, there remains a great deal of vaccine hesitancy. Alternatively, in many under-resourced areas of the world, there is interest in vaccines but they may not be available or just becoming available now. Let's talk about the importance of vaccination in general, as a public health effort, beyond eradicating diseases like smallpox or polio. There are many other reasons that vaccinations are important for public health.
I'm not a vaccine expert by all means. Protecting ourselves and vaccinating ourselves, giving us herd immunity will eventually protect those that don't have a choice. Maybe some of the kids that can't get vaccinated because the vaccine is not available or may be immunocompromised patients. They potentially can't get vaccinated because they can't elicit an immune response or maybe whatever X or Y reason it might not be beneficial.
There is a subset of a population that we know that the vaccination might not be adequate in that aspect. I wanted to touch base particularly, and the thing that we can do as physicians and you touch based on that it's not a cookie-cutter solution. You hit the nail in the head again, you have to tailor the solution to every community. The African American community has a specific need, knowledge, and interest on how they see the vaccination. In the Latinx community, by all means, you can't have a Caucasian guy saying, “I'm going to go get vaccinated.”
Treating a community is way more impacting than treating one person at a time. And we have that moral responsibility.
You have to have someone in the community. For example, the idea of Promotoras and Promotores is coming in the community and speaking to small gatherings and talking about the importance of vaccination, what the vaccination is, educating the community, and dismissing some of these myths that it’s going to stay in your body forever and that's going to cause infertility. A lot of times they get their knowledge base from the media.
It’s Social media.
They're very polarized too depending on you have very polarized, Conservative media and Liberal like we have in the English speaking media. Unfortunately, these days, a lot of these reporters don't fact-check a lot of this stuff. Some of the things people propagate are necessarily not facts. People resonate and they hear that and then they create fear.
The importance of education specifically tailoring it to certain communities and needs. I know Latinx communities work more with local leaders and they listen to maybe, religious leaders or local leaders in their communities like Promotoras that's worked successfully in other ways and other stuff in public health. Trying to disseminate some of these myths is the third thing.
What do you think is the best way physicians can help engage some of these communities and promote greater trust?
Being active in social media and fighting fire with fire, we need to go out there and have a voice. A lot of us were good at our jobs and we try to be very passionate but we're afraid to be vocal about certain things. I'm not saying you have to be politicized or political but in social media just disseminating, “This is why.” Showing a picture of yourself getting vaccinated. Opening it up to questions. I know I've been doing that a lot on social media and trying to post facts.
I’m trying to go out there, maybe go into your local community, your local high school, your local gyms, your local community leaders. If you're a religious person going in your local church and saying, “If you need me to talk about vaccinations, I'm open to talking about this.” Not in any confrontational way and trying to convince people but presenting the facts and these are the facts as a physician. This is some education out there and being proactive. Our community deserves that.
As physicians, we're not just physicians one patient at a time but we're responsible for the community we serve around us. Treating a community is way more impacting than treating one person at a time. We have that moral responsibility. We all went with our Hippocratic Oath. Doing no harm doesn't necessarily mean doing the wrong thing.
Not being proactive when you're seeing myths and propaganda that is completely wrong, it's unfortunate that sometimes people don't believe in science now. Even though we have evidence of things that we've eradicated with vaccines. People don't believe that now because of social media and media. We have a moral responsibility to educating our communities and our patients. We should be leaders, educators, and community leaders, too.
You made so many great points. It's important to ask questions because often as physicians, we go into a room, we ask the questions that we want to be answered and figure out what we need for our diagnosis and we're like, “That's all I need.” We forget to ask the question like, “What do you think is going on? Why do you think this is a problem? Do you have any questions about vaccines? What is preventing you from getting a vaccine?”
Rather than saying, “Vaccines are great and this is why, and these are the facts.” There's a lot that we can do also to be a little more intuitive about what's going on with these communities and trying to figure out where the hesitancy is coming from or what questions they have that are preventing them from getting vaccinated or pursuing any health intervention. What do you think is one of the most important lessons that we can learn from the pandemic to take forward into the future and help improve medical relationships and community relationships?
There's so much that we can learn from this pandemic. I feel on so many different levels as to how our government works, how vaccines work, and how our community works. Even the power of social media outlets and not the negative effects that they can have. If I could summarize it, I would say that not every patient that we treat and that comes in is as simple as a diagnosis and treatment. Medicine is more complex.
This is where public health is really important. You can diagnose and treat someone but that's only sometimes putting a band-aid. If you diagnose someone's diabetes and you sprinkle some Metformin and insulin but did you get to the root of the cause of the problem? No. In my opinion, you're putting a band-aid on the bleed. The underlying issue is the person needs education and maybe diet, exercise. Maybe he doesn't have the ability to afford a gym or maybe can't walk to work because of the living conditions.
A lot of us live in nice communities and it's easy for us after dinner to go on nice walks with our family and kids. Some people don't have that. They live in urban areas where there might be a lot of crime and walking after dinner at night might not be safe. How can you tell your patients, “You should walk 30 minutes every night?” When they can't afford a treadmill, bike, gym or to go outside and walk because it might not be safe.
Diagnosing them with diabetes and give them medication, it’s important but it's not the underlying cause. What this pandemic has, again, lifted the veil is that we have a lot of public health work to do. We have thought of medicine as not one patient at a time but a macrocosm of the community and trying to address these social determinants of health that directly affecting our population's health both at the individual and community level.
In general, in medicine, we have become very focused on waiting until disease occurs and then treating that disease. You highlighted on focusing on ways that we can prevent disease before it ever happens and that starts at a community level and a much larger intervention than adding a medicine at the end of a visit. Any final thoughts or advice before we wrap this up?
This was an honor and a pleasure to be here. I hope you can invite me back. I look forward to reading more of your blog. As physicians, we need to explore other areas like this. Whatever it might be your niche or your passion, most of us has other niches and passions besides medicine. We need to explore these. I wanted to say congratulations on this. This is an amazing experience and you're doing an amazing job.
Dr. Cisneros, what is your Instagram? Do you have any other ways that our readers can follow or connect with you on social media?
You can follow me on Instagram, @Dr.VCisneros. COVID is the highlight but I try to post about disparities, equity, public health, and they can feel free to ask any questions or seek any advice.
Thank you so much.
That's it for this episode. Thank you for reading. If you like what you hear, please rate, subscribe or connect with us on Instagram @TheEmergencyDocs or on our website at www.TheEmergencyDocs.com. This episode was supported by the National Geographic Society's Emergency Fund for Journalists. Until next time.
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