Welcome to the Augs FPMRS webinar series. I'm Dr. Laika Hota, moderator for today's webinar. Today's webinar is The Nature and Impact of Racial Disparities in Urogynecology, presented by Dr. Neha Sudol. Dr. Sudol will present for 45 minutes. The last 15 minutes of the webinar will be dedicated to question and answers. Dr. Neha Sudol is an early career urogynecologist at Kaiser in Northern California. Her areas of interest include translational research, technology and medicine, and prioritizing diversity, equity, and inclusion for her patients, colleagues, and community. Before we begin, I'd like to review some housekeeping items. This webinar is being recorded and live streamed. Please use the Q&A feature of the Zoom webinar to ask any of the speakers questions. Use the chat feature if you have any tech issues, and the Augs staff will be monitoring the chat and will be able to assist. Thank you. Dr. Sudol? All right. Well, thank you guys so much for having me. I will just kind of get right into this talk. I have no disclosures that start with the objectives. So, the objectives for these 45 minutes are the following. I would like to define race and racism in the context of healthcare disparities. I want to review the evidence-based literature on racial disparities in urogynecology, and then spend some time focusing on discussing some concepts for moving the needle on some of these really important issues. I also have some disclaimers that I think are important for me to get out there right out the gate. The first is that I'm not an expert, but I am engaged and I desire change, and I think that's why all of us in this room are here today. So, I'm the one giving the talk. I am in no way more of an expert than anyone else in the room. We're all here together. We're intending to listen, learn, and just try to do better. And so, from that perspective, I really hope that at the end of this talk, there is some degree of conversation and input because, again, we are just all here together as a team. My second disclaimer is that there are no perfect or adequate terms. So, one of my objectives is to define some terms and get us on the same page, but the reality is every term that we use has pros, cons, and controversy. And so, we're just kind of working with what we have, and this could even be a brainstorming session of thinking about what terms could be used in future, but there is no such thing as perfect. The last disclaimer that I have is that this talk is not comprehensive, and while that probably seems obvious because this is only an hour talk, what I mean by that is that I'm unable to address issues relating to every race and every ethnicity within the time allotted. I say this, and I put this as a disclaimer because this topic is very important. It's complicated. It's complex. It's sensitive as well, and so my intention is not to offend or suggest that one issue is more important than the other. It's just simply my goal to provide clear examples of healthcare disparities so that we can be united in sort of a grassroots kind of movement, if you will, so that we can all get on board about effecting change moving forward. So, with regard to some terms and definitions, the point of kind of getting us on the same page here is that many of the concepts that relate to healthcare disparities are intuitive, but interestingly, there's really no consensus on these definitions, so it's so important for us to try to get on the same page, even if it's just for this hour, because if we don't agree on the definitions, it's very difficult to really interpret their influence, and you'll kind of see that in the literature when I talk about the review of the literature. Getting right into it, let's talk about race and unracism. So, race is something, it's a term, and we throw out that statement, it's a social construct, and the reason why we say that is because it really only came into society probably around the 16th century. We kind of created this term. We made this definition, and there's five different races that are sort of used traditionally. That's white, Black, Asian, Native American, and Hawaiian Pacific Islander, and basically the definition that we created is that it's this grouping of humans based on certain traits, whether that be morphologic, genetic, or behavioral. Because we create these boundaries and these groups, it in turn leads to this concept of racism, whereby race is the fundamental determinant of human traits, whatever they are, and then it inherently leads to this concept of superiority of a particular race, superiority of one race over others, or a few races over one. And that's where the concept of race and racism really kind of comes from and how it's defined. With regard to ethnicity, this is very different than race, because race focuses more on physical and biogenetic traits, but ethnicity is really concerned with the group, culture, or identity. So, ethnicity is a word for something you acquire, it's based on what you acquire from your family or from a group that you share culture, traditions, familial bonds, that kind of thing. But when you think about race and ethnicity at the same time, what happens is the end result is that people may have race similarity, but ethnic dissimilarity, or vice versa. So, let's talk a little bit about some specific examples here. Let's talk about underrepresented minorities, or the acronym BIPOC. The term underrepresented minority has a couple problems, and as I said in one of the preambles, there's pros, cons, and controversies. And here's kind of the issue that has arisen with underrepresented minorities. The term under is a prefix that is defined as not enough, or not done well, or below. So, there's a problem right there, because people who may be grouped into this underrepresented minority don't self-identify this way, because of that prefix. I think all of us would agree, you wouldn't want to identify that way. So, that's one issue with it. Another issue is that a term like this tends to conflate groups that are different simply because of low participation. So, underrepresented minority refers to racial and ethnic groups that have low participation groups in some sort of field, whether that's information technology, or medicine in our case. And so, a lot of times that happens to be Black, Hispanic, maybe Asian, maybe Native American, Hawaiian, Pacific Islander. And so, all of a sudden, these groups that are not necessarily similar are conflated, and for that reason, there's a problem there. And then finally, the third issue with it is that you have to address the elephant in the room, which is the overrepresented minority, which tends to be white race. And if there's an underrepresented, that means that there's an overrepresented group. And that overrepresented group tends to be the one who possesses the power to influence who the underrepresented minorities are. So, those are some of the problems with that terminology. In turn, the term BIPOC, or Black, Indigenous, and People of Color, has sort of come into our common terminology over the last maybe 10 years, kind of evolved around 2012, 2013 on Twitter. And, you know, again, pros, cons, and controversy, but the term BIPOC has some pro in that it's more of an objective term. It doesn't have a prefix like under. It's just kind of listing off different groups. A con, though, is that you're still conflating groups that may not necessarily be similar. Similarly, let's talk about Hispanic and Latino, Latina, Latinx terminology. This is another example. So, these are terms related to ethnicity. Hispanic has traditionally meant someone who is from a Spanish-speaking country. So, the intention is that this term brings people together who speak the same language. And while that could, that tends to be, you know, the idea of it is to be inclusive, what happens in that situation is that you're still excluding certain people. So, for example, if you think about Spanish-speaking countries, you think about, you know, the Latin American countries below the United States, but it's going to exclude countries like, for example, Brazil, which is primarily Portuguese-speaking. Alternatively, the term Latina or Latinx means it's grouping people together who are from Latin America, which, again, could be very, very inclusive, but it could also be almost too inclusive because it's including over 20 different countries that clearly have different cultural, different cultural, like, lifestyles, different traditions, and different issues and different problems. So, you know, ethnicity, again, is an imperfect situation. And then, furthermore, where it really breaks down is that while someone might identify as their ethnicity being Latin American or Hispanic, it doesn't necessarily help with identifying their race because their race could be a variation of different mixed races, or it could be something that they don't even really identify with that in that very specific group of five available races. And a lot of times what you'll see is someone who marks Hispanic or Latinx is also going to mark other, so it kind of makes things very complicated. So, as you can see, terms and definitions are complicated because, really, as it goes with language, even terms that have been created with the best of intentions can morph in meaning. But let's at least try to apply those terms and try to understand them in the context of healthcare disparity. So, this table is really nice and important, I think, for us as urogynecologists to help us understand and kind of go back to the title of this talk of what the impact and nature of healthcare disparities are in our field of urogynecology and why it matters so much for us. So, you know, basically what this census table shows up is that the thought is that 2030 is going to be a turning point for us in our U.S. census, and that turning point is going to be the following. All the baby boomers are going to be over the age of 65 by the year 2030. And what will happen will be a couple things. One, immigration rather than birth will be the thing that causes a natural increase in population growth, which will then lead to a net international growth. And because of that, what they anticipate is after 2030, the population of people who have more than two races that they identify with will be the fastest growing population followed by Asian populations. So, with a rise in the aging population, we anticipate that the number of U.S. women with symptomatic prolapse is going to increase over that time, and that's the demand for pelvic floor disorder care is going to increase as well, which is very important for us to understand. The aging population is growing, the racial kind of landscape is changing, and the needs that our patients are going to need our services to a higher degree, and so we really need to understand both age and the race landscape changing in the context of our community. And for that reason, I would say, and, you know, this is coming from citations, but I 100% agree with this, but understanding health care disparities will inform policy and treatment recommendations for our population. And quite frankly, it's critical in achieving social justice, equity, economic prosperity, and frankly, overall health of our nation. So, we are all acutely aware that over the last two years specifically, there's been an increased degree of attention on racism and how it impacts health care outcomes. Specifically, joint statements like this one that I think many of us have read and seen have been helpful to some degree because they're helping to unite all of us in different organizations and even individually to think a little bit more critically about how to take action. So, it's reminding us that racism, not necessarily race, is the issue that requires immediate attention. So, reading directly from the collective, recognizing that race is a social construct, not biologically based, is important to understanding that racism, not race, impacts health care. So, moving a little bit away from definitions now that we kind of have, you know, that sort of foundation for the rest of our talk, I want to talk a little bit about the review of the literature. You know, I want to give us a little bit more of a bird's eye view. So, you know, I hope I don't disappoint in the fact that I'm not going to go into the nitty gritty details of what the disparities are because, you know, when I was building this talk, I realized that, you know, research in this area is rapidly evolving. And I think all of us here in this room and all of us as, you know, clinical clinician researchers or clinicians are comfortable looking and finding data that we need for our clinical practice and things like that. But I think it's important for us to kind of have a bird's eye view out there so that we can talk and be a little bit constructive about what we can do moving forward, what has gone well, what we can do better, and what we can change completely. Just as an aside, you know, I recently relocated from Southern California to Northern California. I have to say I'm missing Southern California a little bit these days. So this is a picture of Newport Beach Harbor for those of you who are familiar with the California coastline. Northern California is still very beautiful, but this is my old home just a couple of weeks ago. So I thought I'd throw that in there. So speaking of Southern California, my group when I was there at UC Irvine, some amazing medical students that we worked with, as well as our fellows at UC Irvine, together we worked on a project to kind of assess the publication trends in urogynecologic disparity research. Basically, what we did is we performed a systematic review of sociodemographic disparities among U.S. women with chronic disorders, specifically looking at different databases from 1975 to 2020. And we were looking at multiple different sociodemographic disparities, including race and ethnicity, language, socioeconomic status, educational level, insurance, peer-to-peer, and marital status. Basically, the way we designed the study is that within the databases, what we were trying to do was we wanted to extract all studies that were focused on pelvic floor disorders, but also that addressed at least one of the sociodemographic factors in their primary or secondary outcomes. And our objectives were to characterize this literature to four disparity pertinences, including prevalence, treatment-specific knowledge, treatment obtained, and outcomes. We also wanted to quantify the number of publications within each sociodemographic factor and the pelvic floor disorder that was studied. And then finally, we just wanted to see what the trend was over time of the research that's being published on these topics. And this is what we found. So, just looking, this is just the raw data. This is not percentages in these, in these, in these diagrams. But if we looked at those themes that I mentioned, those four themes, what we found is the most common theme that was reported in the literature was with regard to disease prevalence. The least common theme that was reported was with regard to treatment-specific knowledge in orange. So, disease prevalence was most commonly reported, but knowledge about the conditions of pelvic floor disorders and the treatments that were available among patients was the least reported and the least studied. With regard to the sociodemographic factors that were studied, as you may recall on the previous slide, we were looking at many different sociodemographic factors. But what we found in our research was that really only three of the factors were consistently addressed. And those three factors at the highest rate were race and ethnicity, with socioeconomic, as an educational level, being second, being kind of tied for second. But race and ethnicity was the sociodemographic factor that was addressed most commonly. And then finally, for our third objective, we were just trying to see what the trend was over time. Were there more studies being published over time? Were there less studies? What was the robustness of the literature? And what we found was that it did appear that the amount of research on these topics of health care disparities seemed to be increasing over time, which was really great to see. Additionally, we noticed that there were increased randomized control trials and increased cohort studies over time. That being said, the number of studies overall each year were quite low. My caveat to this is that our study was from 1975 to 2020. And I will say that in this last year of 2021, we're not even done with this year yet. There have been a significant number of publications, which is just so amazing to see. And so I don't want to take away from that with this chart. And I just want to highlight some of the beautiful research that's been done this year. So if we just kind of take a sampling, just to kind of like get a taste of what is out there currently in the literature, again, just that bird's eye view, you know, we'll go sort of in chronological order. You know, in 2008, Nygaard et al. published the prevalence of symptomatic pelvic floor disorders in U.S. women, a publication that a lot of us cite a lot of times when writing up our manuscripts. And so what was interesting here was that, you know, the study was looking at weighted prevalence of different pelvic floor disorders. And it was concluded that race and ethnicity was not significantly associated with having at least one pelvic floor disorder. However, parity, BMI, and income were. But I just put up this slide because I think we may argue that groupings of the race and ethnicity here may be a little bit limited and that disparities or lack thereof may not be accurately revealed here, because as we talked about with terms and definitions, there are so many iterations of how we can define ourselves that when you put us in boxes, which kind of sometimes feels like it has to happen in a study. But when we do that, I think there's a chance and it's more than likely that we're essentially missing disparities or lack thereof and the data does not always tell the real story. There were other studies that have been published on prevalence of pelvic floor disorders by race and ethnicity. As I mentioned, that tends to be what's published most often, prevalence data. With regard to stress incontinence and mixed incontinence, Hispanic women seem to have an increased rate of these disorders compared to non-Hispanic white women. Symptomatic prolapse seems to be more common in white, non-Hispanic, and Hispanic compared to black women. And the degree of broader with regard to these issues seems to be more significant in white versus, or reported to a higher degree would be the better way to say it, for white compared to black women. With regard to treatment obtained, so based on the prevalence data showing that Hispanic and white women tend to be the ones who are apparently experiencing these at a higher prevalence based on what the data is reporting. There have been studies looking specifically at comparing Hispanic white versus non-Hispanic white women. And some studies have shown that Hispanic patients are less likely to initiate conservative treatment like pelvic floor physical therapy compared to their non-Hispanic counterparts. Additionally, Spanish speakers are less likely to be offered or undergo surgery. And if they do get offered surgery, it seems like the rates of obliterated procedures compared to apical support procedures are higher in the Spanish-speaking population. I just want to pause here, and I kind of, you know, did this intentionally, but, you know, these are studies that could easily be looked at as, oh, they're studying the same population because it's talking about Hispanic populations. But I use the terminology verbatim from these studies because in the first study, they're talking about Hispanic women. In the second and third studies, they're talking about Spanish speakers. And one thing that's really important is that someone can check a box and say that they're of Hispanic ethnicity, but it doesn't necessarily mean that they're a Spanish speaker. It means that they are from a Spanish-speaking country. So, those two populations could be very different, and they likely are very different. So, the population in the first bullet point and the population in the second bullet point are two different populations, but could easily be thought to be the same. So, when we think about healthcare disparities, are we by mistake grouping people together, or are we really intentionally separating groups and understanding kind of the individuality of these different groups in the best way possible? And I bring this up, and I'm saying it out loud. It's sort of like my internal analog, because this is what I think about for myself. And, you know, again, I'm not an expert, but I'm constantly always trying to learn, and I find that whenever I'm reading a research paper, I want to take that research paper and apply it to my clinical practice or say, okay, like, I understand what this is saying. In this conclusion, I'm going to pull out, and I'm going to use it in clinical practice. But I think that's really, really hard to do with healthcare disparities, because we're not necessarily able to get like a final answer and just quickly apply it. It really requires sort of individualization, and I'll talk a little bit more about that when I talk about finding the needle. And sort of to talk about research a little bit more, I will say that for me personally, when I think about research design and studies that I might look for when I'm trying to understand healthcare disparities in our field or in healthcare in general or just in general, I actually find that focus group research is extremely helpful for me to understand. It helps me kind of understand my bias, understand kind of my anecdotal experience with what patients might be saying in a more private and comfortable and safe setting compared to maybe when they're with me. And so I thought this study was really interesting. It was a focus group. It was focus group research out of three different institutions, University of New Mexico, Cedars, Sinai, and Los Angeles, which is a private hospital, and all of you in LA, which is a public hospital. And they basically had about 58 women, Spanish-speaking patients as well as English-speaking patients. They could be Hispanic. They might not be, or I think their ethnic identifier was with regard to Latina, so they could actually report which country they were from as well. And the nice thing about focus group research is it actually sort of creates themes. When the statistical analysis is run, it kind of collects all the data that the subjects are talking about and creates themes of what's kind of persistently reported. And the themes that came out were the following. For Spanish-speaking patients, there was increased fear of cancer with regard to their urogynecologic condition. There were also discrepancy in treatment options in the sense that they often felt that there was almost like a delay in achieving the care that maybe they felt that they deserved or they needed. There was resistance to offered treatments, a lot of times getting conservative non-surgical treatment first, and then some resistance to that because maybe some of them felt like they didn't understand or it was painful or scary. And then finally, patients preferred a Spanish-speaking doctor, and they actually lost confidence in their doctor who used the interpreter and even felt that sometimes the interpreter was really not giving them the information correctly. They could kind of tell that there was a disconnect between the interpreter, the physician, and the patient. With regard to treatment outcomes, some research from Dr. Brown just this year, most of the slide comes from her publication. Black women experience higher rates of total abdominal hysterectomy. This has been kind of validated in MIGS research as well, that the likelihood of a Black woman receiving a minimally invasive hysterectomy approach is lower than white counterparts. They're at higher risk for postoperative complications, specifically higher rates of complications after copal plexi compared to white, Hispanic, and other populations. And what was really great in this study was that they were looking at potential other contributing factors, which included not only race and ethnicity, but also hospital type, income by zip code, broad hysterectomy, things like that. And then finally, just to highlight one more study just coming out of this year, Dr. Brandon and her group at NYU, they looked a bit more granularly at our treatment recommendations to our colleagues. So, this study was looking specifically at the guidelines from ACOG and Oslo's practice bulletin on pelvic organ prolapse and looking at the citations of where those studies are derived from. And what they found was that most of the studies that these practice guidelines are based on study white populations, while Black, Hispanic, and Asian populations represent less than 7% of those studies. So, the guidelines that are being put into this document are really not inclusive of all different classes. And so, there's definitely a lot of work to be done here. Something that I thought was really interesting that they reported was something called a representation quotient. So, early on in the talk, they talked about underrepresented minority versus the overrepresented minority. And this representation quotient talked about that in the sense that what they found was that when they did the calculation, white women were 36% overrepresented in the literature that contributed to the ACOG practice bulletin, while Black and Hispanic and Asian women were underrepresented by as much as 50% in some cases compared to what their population is on the U.S. Census Bureau. So, ultimately, kind of as we think about the definitions and then we think about the review of the literature and what's out there, and then we kind of process, well, what's the impact of these differences on our healthcare for our patients? What we know for sure is that they don't necessarily reflect innate differences, but they do reflect deeply rooted American racism and discrimination that seems to advantage some and disadvantage others. And in the worst of cases, this is what happens. It leads to diagnostic delay or inaccuracy, which was seen in that focus group that those patients perceived that they were aware that there felt like there was some sort of delay or inaccuracy in their care. And it limits treatment options and access to an already vulnerable population. So, how do we move the needle on this? Which, frankly, feels less like a needle and more like a boulder, but if we're going to stick to buzzwords, we'll keep moving the needle. I think, first, it's important to recognize the limitations to progress. Ultimately, there's bias and selection, study design and analysis. As I showed in the circular diagram of what kind of studies are reported, a lot of studies focus on prevalence data, and that limits primary prevention. If we're reporting so much on prevalence, we can't really focus on change and prevention mechanisms. It also perpetuates the idea of a biologically determined difference rather than a social construct. And then with regard to pathophysiology, it's possible that we're overestimating the genetic impact of all of this, right? Because we're not necessarily grouping people in the way that they maybe self-identify. But it's also important to be positive and see that we need to recognize progress. So, here's an example of recognizing the progress that we have made. Specifically, if we think about then, we think about how Marion Sims was highlighted in the urogynecologic and the gynecologic community as the father of modern gynecology who developed these surgical techniques to successfully close vulva vaginal fistulas. But the reality was that he was conducting experimental surgeries on women who didn't have an option for consent. These were slaves, and only three of many women were actually named in his journal, Bessie, Lucy, and Anarka. And because of his work, the community had rewarded him as a president of AMA. He had a speculum named after him. But over time, we have changed, and this is our now. Now, we honor Bessie, we honor Lucy, and we honor Anarka. We call them the mothers of modern gynecology. We recognize that their experiences should raise awareness about racism in medicine. Some of our colleagues have replaced the name of the simspeculum as the Lucy speculum. Our simplexure in the urogynecologic in our society has been retired. Some of his statues have been taken down, symbols of hate have been replaced with beautiful statues to support and to honor these mothers of modern gynecology. And even more so, we even have days that are intentionally there so that we can acknowledge the pieces that these women endured and their contribution to science and how we have gained so much from them. So, here's an example of how we have done well, how we have changed, we've made progress. Areas that we probably still have a little bit more work to do, or a lot more work to do, is with regard to ethnicity. You know, these populations are the second fastest growing racial or ethnic group in the United States, and we absolutely need to understand how these individual selves identify. For two reasons. One, we need to be able to support their clinical needs better. That's our intention for every single one of our patients. We walk in the door and we want to be able to support them clinically. We want to be able to make them feel better. And I think that understanding people's race and ethnicity and how that plays into that whole person is really important. We also need to better describe them in research. And I think another thing that we need to do is seek a better understanding of race and ethnicity. Understand what it means when we say it's a social, not a biological construct, because we created these terms. Assess cultural literacy and bias, that's internal, that's on our own, we should be doing that. And then slowly, you know, we can make that a bigger thing. But again, I sort of mentioned, again, I'm a learner. I'm not an expert. And for me personally, focus group research is really helpful in helping me to understand my own biases, but also make me feel like maybe I'm gaining a little bit more cultural literacy, because I can understand, I can be a fight on the wall to those patients in those focus groups to sort of understand that's what they felt and that's what they were experiencing. And then I can apply it to my own health literacy and kind of check my own biases through their experiences. And then also consider the multifactorial way that people identify. You know, for those people who do cost-effective analyses, I don't, but I'm always impressed by the decision analysis trees, and I almost wonder if race and ethnicity should have some sort of breakdown like that, where, you know, we can kind of think through all the different ways, the multifactorial ways, the pathways that play into what we have traditionally called race and ethnicity, but there's so much more to that. So in addition to race and ethnicity, we have to think about someone's country of origin, what their generational status is. Someone who's a fifth generation identifying and marking and checking a box of Hispanic is very different than someone who's recently emigrated from a Spanish-speaking country. And then what's the language spoken at home, right? I think about that slide where we talked about Hispanics, and we all speak about Spanish-speaking patients. Those are two different populations. So what else is out there that's important for us to consider when we study and we understand these populations that walk into our door? And then, you know, ask why when we read the literature, or ask why when we see certain outcomes happening. Why is this happening to this population? Is it limited access? Is it disease burden and symptom severity? Is it health literacy? Is it virgin bias? Is it the patient's personal preference? Is it racism? Thinking about all of that and asking why and just considering considering the possibilities so that we can kind of think about how to do better. And then, you know, finally, kind of shifting a little bit away from the patient population, but to our community as surgeons and physicians, you know, there's definitely clear data. We know that biomedical faculty that resemble the population improves health care. So if there's an underrepresentation in our own community, that's going to be a challenge for serving our patients. So we have to kind of look internally to see how we can be a little bit more equitable in that way. And the benefits of being more resemblant of the population are the following. Minority medical scholars tend to study problems that impact their own community, which is really good because they understand at the granular level what's going on, and they deserve to be able to study that and bring in those pieces that are so important. Additionally, racial congruence may play a role in recruitment of specific communities. And then finally, minority faculty serve as amazing role models, mentors, and advocates for students in the educational process. And this is a big component of microaggressions, because a lot of times when someone is in an environment, whether that's a workplace environment or not, but if they're in a workplace environment, they don't see a lot of people around them that look like them, that can be extremely difficult. And if that person is not well supported, there's no way that they're going to be able to support their patient population in the way that they intended to or the way that their patients deserve to. And finally, if you bear with me here, I am probably one of, probably would tell myself as someone who hates buzzwords, so I apologize for so many buzzwords, but this is my last slide. And I think I fought not putting this slide in, but I do think that these buzzwords are really important when we think about healthcare disparities, how we can change them in our community, and we can do at the individual level. Anytime we think about a problem and issues and how to make it better, we think about, okay, where can change be inserted? Is it the individual level? Is it at the departmental level? Is it at the institutional level? And I think for the purposes of this talk and just some things that I relate to and I'm most comfortable with is how we're able to affect change at the individual level. I mentioned at the beginning of the talk that I just kind of wanted us to come together and start building this grassroots movement to kind of make change. And in that way, I think it is really important to start making change within us for our patients and then kind of banding together and building from that. I think it's important for us to self-reflect, to inquire, ask questions, acknowledge when they're wrong. I think it's really hard to do that, but it actually feels really good sometimes because when you're open, when I'm trying to be a little bit more humble and open to the fact that I can be wrong, I actually learn so much and I don't forget. It's the same thing that if you do something wrong, then you tend to not do it again because you kind of remember that experience. And then when you learn something, educate others, advocate for yourself, advocate for your patients, advocate for your colleagues. You know, don't be an innocent bystander to an event. And then, you know, create a shared decision-making model with everyone around you, whether that's your colleagues and your patients or your staff. And I think in that way, we're going to make change happen at the individual level. So, you know, with that, I'm going to just kind of pause and just give, you know, say with gratitude, this is my why. My family supports me in amazing ways, but I really want us to be better for our kids and be better for our patients. And I'm definitely still learning and very much open to everyone's kind of comments and questions or thoughts. I'm just very curious about what other people think about this topic as well. So thanks so much for having me. I really appreciate the opportunity. Thank you, Dr. Siddall, for your presentation and your insight. We have 15 minutes for questions. Audience members, you may submit your questions in the Q&A section below. I will maybe kick us off with my own question of, I often think about how our LGBTQ population is very underrepresented and underserved in urogynecology. And I mean, what can we do to help improve our care for them and minimize their health inequities? I think that's a really good question. And again, I'm going to say this very honestly, that I'm not an expert. I'm a learner on this topic. I find that, you know, for me, one of the barriers is that there's a very broad spectrum of access. So some institutions have better access to LGBTQ versus other institutions. And then policies are different across the board. And so I think from that perspective, I wish that there was a little bit more standardization so that we all were able to be a little bit more inclusive in all of our clinics. I find that certain places I've worked, there's, you know, it's known that we're a supportive community and other places just, it's not that they're not a supportive community, but for some reason, the word hasn't gotten out or we don't have the infrastructure in some way. And so it just speaks to, you know, one of the studies I was looking at was talking about the differences between different institutions and how that plays into like a public institution versus a private institution where the institution is by their code and how that plays into the community that they serve. And so, you know, from that perspective, I wish there was just more uniformity because I think if we as physicians were a little bit more equipped and able to serve all, it would make it a lot easier, but I just find that it's not that way. I don't have a solution to that problem, but it just seems like it's not equitable. I don't know how to fix that right away, but to me, that seems like that's the issue. Thank you. So one question from the audience members, to what extent do you think differences in help seeking behaviors for pelvic floor disorders influences the disparities by race, ethnicity? Sorry, what, what you cut out with what kind of behavior? Oh, sorry. I'll just reread it. To what extent do you think differences in help seeking behaviors for pelvic floor disorders influences the disparities that seem by race or ethnicity? Alexis, can you clarify your question a little bit more so that I make sure I understand it correctly? Okay. Maybe while we're waiting for Dr. Griffin to clarify, we have another question here. One concern with further dividing our population groups is that it may make all of population-based studies much more difficult to evaluate because if all the groups have small numbers, conclusions are difficult to draw. How can we find real disparities if we are looking at 20 to 40 different groups versus three or four with those acknowledged limitations? I think that's, I think that's the million-dollar question. I think that's why the research that we have exists. And that's why, I mean, I think everything is always done with the best intentions because we're trying to form some conclusions so that we can treat our patients with the utmost care. I mean, I think that's exactly the intention. But what happens is that we're then in a way, while it seems like we have these broad groups, they're actually very narrow. And so, from that perspective, I think just simply at this point until we have a better definition and a better way for people to self-identify, I think it's important to just constantly recognize the limitations because we don't, it's not fully inclusive and it's not fully exclusive. So, I think it's a great point. And I think all the research that has been done with the U.S. Census Bureau type of race and ethnicity documentation is with the best of intentions, but we have to always be aware that there are limitations to that. And so, a disparity may just be a disparity. It might also just be a difference or a lack thereof. Thank you, Dr. Seidel. Maybe while we give the audience members just a couple more minutes to type in additional questions. One more from my end of things. We are in the middle of a pandemic. How do you feel like this pandemic may have affected these underrepresented or underserved minority populations during this time period, or has it? I think it's impacted everybody and it's impacted everyone in that, at where they were. And so, we were already, you know, under, populations who are not well represented were already at a certain level here, and they've been hit to a place that's brought them down to here. And so, I think from that perspective, we've all been hit, but now we're dealing with a bigger issue because there was already a vulnerable population that's even more vulnerable now. And so, specifically, I think in our field, I think all of us relate to the fact that when a patient comes to our office, they're often in tears saying, I've been bounced around and no one understood how I was feeling. And you're the first person that, you know, really gets it. And you're kind of addressing their issues after they've been bounced around. And so, that issue is going to be even bigger for our minority patients because they've been kind of, you know, everyone has delayed their care, but those patients already have an issue with delayed care and the COVID pandemic has just led to a further delay for them. So, frankly, I think to some degree, you know, it could be sort of catastrophic and our focus needs to be very much, you know, lasered into that space. Thank you. We have one more question here. And how do you think we could address the treatment-specific knowledge barriers in limiting health inequities? I'm sorry, you cut out again. Oh, I'm sorry. How do you think we could address the treatment-specific knowledge barriers in limiting health inequities? Yeah. You know, I think simple things are just making access to different, making access to all of our different educational tools and different languages, not just by language, but also cultural. So, a lot of times things are just immediately, like, translated to a different language, but they don't really consider the cultural aspects of it. So, I think one thing is making sure that the tools are accessible to everyone. That's a very, you know, simple idea. It's complex in execution. But, you know, if patients were able to access the same tools or were sort of exposed to the same knowledge and education, you know, pamphlets and things like that, or access to them, then I think that would help. That would be one step of many. Thank you. Maybe one more question. Do you think that there are other community partnerships that we as urogynecologists can develop to help improve health equity among our underserved marginalized populations? I think you asked about other groups that we could work with. Yes. So, other kind of, other partnerships, community-based partnerships that we might be able to, as urogynecologists, work with to really help improve our patient, underrepresented patient health equity. I think that is absolutely, probably the crux of it, actually working with community members to do that. You know, I think in different areas, whether that's, you know, actual, you know, actually within institutions, that sometimes there are, you know, equity groups within an institution that I think can be really helpful. And I know, you know, UC Irvine, when I was with them, that was actually something that was really helpful because we had sort of a task force within the department that was then working in an outreach way into the community. And I think that was actually really helpful in order to sort of bridge the gap between gynecology and then also what was going on in the community and kind of bringing them together and fostering that relationship. So, you know, I don't know from a national level where that would come, but I absolutely think, you know, within my previous institution community, I think that was really helpful. Great. Terrific. I think that was our last question. On behalf of AUGS, I'd like to thank Dr. Seadal and everyone for joining us today. Our next AUGS FPMRS webinar will be held on December 15th at 7 p.m. Please visit the AUGS website to sign up. And everyone have a good night.

racial disparities

urogynecology

race

racism

ethnicity

prevalence rates

treatment outcomes

diverse populations

healthcare disparities