Various sources have published findings highlighting significant disparity in health outcomes between white patients and patients of color. Maternal mortality and morbidity continue to occur at unacceptably high rates in the United States, and rates are significantly higher among communities of color. Even when adjustments are taken into consideration for confounding factors, such as socioeconomic status, health outcomes for black patients are still worse than those for white patients.
Mortality and morbidity conferences, which are departmental reviews of cases with less-than-ideal outcomes, have long been a part of medical education in nearly every specialty. They first took place in 1904 with the evaluation of surgeon competence.
Given the central role that morbidity and mortality conferences play in medical education and quality improvement, they serve as a natural stage for the examination of systematic inequities in health care. There has been an increasing desire to incorporate an equity component into these conferences. Despite the desire and drive, there is little published guidance around best practices.
“Everyone is talking about health care disparities within obstetrics and gynecology; people are very motivated to address it, but very few know how,” said Keith Reisinger-Kindle, D.O., OB/GYN faculty at BSOM and OB/GYN physician with Wright State Physicians (WSP).
This realization, and an intense interest in addressing social injustice and its effects on health care and patient outcomes, inspired Reisinger-Kindle to create a model to incorporate equity into morbidity and mortality conferences.
After unofficially discussing this issue and sharing best-practice health equity activities among colleagues for nearly a decade, Reisinger-Kindle officially organized a group in 2021. Included in this group was fellow WSP OB/GYN physician David Dhanraj, M.D., BSOM chair of OB/GYN and newly appointed associate dean for clinical affairs. Other members represented various leading health care organizations, including Massachusetts General Hospital, Brigham and Women’s Hospital, Tufts Medical Center, and University of Massachusetts Memorial Medical Center.
The group began what would be a six-month process that started with documenting and comparing examples of what each organization does to promote health equity during morbidity and mortality conferences.
BSOM OB/GYN organizes health-equity-specific morbidity and mortality conferences quarterly, in addition to regularly scheduled morbidity and mortality conferences. Residents, medical students, faculty, nursing staff, and social workers attend. Following a discussion of case details and didactics, the format becomes primarily interactive, with small group breakouts and activities, such as social identity wheel mapping, privilege walks, and analytical dialogue sessions.
Cases at BSOM are chosen by faculty trained in anti-racism education, social justice dialogue facilitation, and social identity-based conflict resolution, and alternate between obstetrics and gynecology cases, to allow for sufficient depth of case and topic analysis. Previous topics have included: Introduction to Language and Concepts: Examining Racism Beyond Implicit Bias, How Racism Impacts Housing Inequities and Worsens Health Outcomes, and Language Matters: How “Microaggressions” Result in “Macro” Inequities.
Tufts Medical Center OB/GYN department holds quarterly health equity rounds during grand rounds. Department faculty, nursing staff, residents, and medical students attend. Other departments are invited based on the topic. Sessions begin with a reflection and take place within a “brave space,” a space where participants can be open and honest, without judgement or fear of punishment. Interactive surveys allow those in attendance to be polled anonymously.
HEqR (health equity rounds) are a key component of the health equity program at Harvard Medical School’s combined OB/GYN residency program at Massachusetts General Hospital and Brigham and Women’s Hospital. Cases are selected by residents, with approval from department quality, diversity, equity, and inclusion leadership, from suggestions provided by clinical staff, or via the anonymous “(In)Equity Inbox.”
At the University of Massachusetts Memorial Medical Center, health equity analysis has been built into the OB/GYN monthly departmental morbidity and mortality conferences. Before presenting a case, residents are given guidance from the department’s director of diversity, equity, and inclusion on identifying opportunities to advance health equity from details within the case.
A review of the activities of each organization resulted in a list of 10 recommendations, “tips and tricks” as Reisinger-Kindle refers to them, or a framework to use for building a mortality and morbidity conference format that incorporates principles of health equity. This list, with additional supporting documentation, was submitted to The American College of Obstetrics and Gynecologists in 2021 and published in the journal Obstetrics & Gynecology that December.
“Institutions do things differently, but using the main premise behind the tips and tricks will help them reach a similar goal,” added Reisinger-Kindle.
One of the group’s recommendations involves permitting active patient participation by inviting patients to physically be present at the conference, or directly sharing their words and feelings. “Hearing from patients directly prevents bias and gives them an opportunity to call us out when we’re wrong,” said Reisinger-Kindle.
For Reisinger-Kindle, and the entire group, the hope is that sharing defined goals for successful implementation will allow other institutions to apply health equity analyses into their educational conferences, to continue to address inequities in care as a community and a profession.
Reisinger-Kindle added, “We need to be learning from the bad outcomes, of course to prevent them, but also with a new perspective that centers on bias to create better outcomes. My biggest fear [is that] we keep talking about it, but things never get any better.”
Reisinger-Kindle, who is formally trained as a social justice and anti-racism facilitator and educator, initiated anti-racism dialogue training for the OB/GYN residents in 2019, soon after joining BSOM as an OB/GYN professor and associate director of the OB/GYN residency program. Since that time, the program has rapidly grown, more facilitators are being trained, and offerings are being made available to more BSOM faculty, staff, and students.—Lisa Coffey