Good morning, everyone. Well, I just first want to acknowledge Dr. James for inviting me to come and join you today. I'm really excited to be here. I consider you my people. Anyone who's interested in health equity, and I want to thank Madonna for getting me here, just her managing me and getting me here. So I titled my talk today, as we're talking about cultural competency in psychiatry is a path to equitable mental health care. And so as we're having this conversation today around cultural competency, know our end goal is equitable mental health care. Let me see here. So I'm just going to quickly, I'm going to go through this. These are my disclosures. This is a little bit of our agenda today. We're going to do some terminology, just to make sure all rooted in definitions. We'll talk about disparities. We're going to do a little bit of historical review and talk about some of the current day harms, some alignment. So I often, as I'm speaking, no matter where it is, so sometimes health equity doesn't translate with people in all audiences, right, in all segments of society. But what does translate is making a business case for health equity. And so I'm always interested, highly interested in health equity measurement. So we're going to talk about some alignments, kind of from the federal, the quality aspects of this, provider training, strategies for systemic change, and I'll conclude after that. So I just want to start by just grounding us first, initially, in definitions. Because there's a lot of things you're hearing around cultural respect, cultural humility, cultural competency. So there's a lot of these terms. But as we talk about cultural competency, a term that was really coined back in the late 80s, Cross and others defined cultural competencies as a set of congruent behaviors, attitudes, and policies that come together in a system or agency among professionals and enable systems and professionals to work effectively in cross-cultural situations. My own organization, the National Medical Association, we defined cultural competency. You also look at the Centers for Medicare and Medicaid Services. And this is important because we know that under Administrator Brooks-LaSure and under President Biden's administration, if you look at it, President Biden and almost every federal agency tasked them around equity, right? And so we know that this last year we saw a lot of finalized rule sets tied to payment and reimbursement around culturally competent care. And they define it as being able to deliver services that meet each individual's social, cultural, and linguistic needs, thereby reducing inequities in healthcare to ultimately reduce disparities. And this is also important because it's coming from CMS. So it's not just the audience of the provider, right? The actual clinician, but payers, hospitals, when you think about the entire ecosystem, right, have to respond to this. Again, the shift, the shift in language. I think any of you, and I've always argued, that none of us can take a one- or two-hour course and be culturally competent. It just can't happen. And even if you take a course every year, it still doesn't mean you're culturally competent. And so that's that shift in the evolving language to more of cultural humility, right? And I'll show a slide that kind of shows the difference here. I share with you this document created by the American Medical Association and the American Association for Medical Colleges. It's a guide to language, narrative, and concept. So when you're in your spaces and places, you want to make sure you're using culturally appropriate language also. That's a reference. And then cultural respect. We expect everyone, you heard the story, the story she just told, I was a third-year medical student, you know, we're just going on, at that time, medical school, the first two years, didactic, second two years, of course, are clinical. And I remember it was on my internal medicine rotation. I remember bedside rounds, right, the whole group at the bedside, and that older gentleman from the VA had no idea what the attending was talking about, talking around him and at him, but not respectfully to him. So again, this comparison between cultural competency and cultural humility. And so from a competency aspect, you could be trained on norms and practice about particular cultures, I know enough about you to treat you, but with cultural humility, you're continually asking to learn. You're engaging that patient. So as we talk about the patient-centered care, right, and you're emphasizing adaptability, self-awareness of your own limitations in managing and treating me, and also it's lifelong, and a reflection on biases. I'm going to quickly talk about mental health disparities. Again, I'm the immediate past president of the National Medical Association. We were formed in 1895, and really it was during a time when, of course, African-American physicians and others, women, could not be admitted into the American Medical Association. So we were born out of a need, right, because the need is, at the time, as you know, doctors, you couldn't get hospital privileges or any of that if you were not a member of the AMA, right, and so black physicians were excluded. So we were formed in 1895, and the reason and our main mission is to eliminate healthcare disparities. And so I'm going to bring up this report I always like to talk about. This is Secretary, this report was written by Secretary Heckler who was HHS Secretary, and back in 1983, she composed her health report, and she proudly went before Congress to share that Americans are living longer. Infant mortality was on a continual decline, and the overall health of Americans had shown almost uniform improvement. She is standing before Congress, but she says, but there's a continuing concerning disparity in the death and illness experienced by blacks and other minority populations as compared with our nation's population as a whole. It was from that report to Congress at the time, right, that they then proceeded to develop the Black and Minority Health Report, and so she put together a task force, and we know that those disparities have existed ever since federal record keeping began. Not a new problem. And so as I think about what that report talked about, maternal mortality disparities, infant mortality disparities, liver disease, hypertension, death and destruction of minority populations, this is current headlines, and I'm like, wow, it's really the same things they were discussing then. We're still dealing with that today, right? Many of the same causes in that report in 1983. So I'm going to run through some disparities with you. Just some key points here. When we think about mental health disparities and what are the implications of that, of course there are racial and ethnic disparities. African Americans and Hispanics consistently utilize mental health services at lower rates than our white counterparts, despite similar prevalence rates or even lower of mental health disorders. Asian Americans continue to describe inadequacies in abilities to achieve culturally competent care. Native Americans, we know, have higher rates of substance use disorders and suicide, major depressive disorders, prevalence higher among African Americans compared to non-Hispanic whites. Overdose rates, one of the things I was tracking over this last year, black men nearly seven times higher rates than older white men in overdose death rates. Black adults, highest rates of mental health related emergency department visits, longer wait times, less likely to be admitted or transferred than Hispanic or whites. And we know oftentimes black patients are oftentimes not diagnosed readily. I'll talk a little bit more about that. Socioeconomic disparities. We know lower income and education levels consistently are associated with higher rates of depression and or anxiety. Access, significantly limited for those with public health insurance or without health insurance compared to those with private health insurance. And I'll speak to that. I've been in private practice, I don't know, over 20 years, right? And even me in downtown Dallas at times with a commercially insured patient can have challenges, can have challenges getting to a mental health care provider. So think about that from the public health sector and those without insurance coverage. Unemployment status is strongly associated with mental health outcomes. Unemployment correlates with higher rates of mental health disorders. Gender and sexual orientation, another factor as it relates to disparity. Women, higher rates of anxiety and depression, we've known that for a long time. Men have higher rates of substance use disorders. Men are, women may attempt suicide more, it's just that men may be more successful at it. LGBTQ plus individuals report higher rates of mental health disorders, suicide attempts, barriers to accessing care in a culturally accessible and competent manner as compared to cisgender or heterosexual individuals. And of course, transgender individuals face some really unique challenges including higher rates of depression, anxiety, suicide, often exacerbated by the discrimination that they face in the environments where they reside. Some of my work also in Dallas, I'm the medical director for a community-based organization. We primarily manage HIV disparities. It's in South Dallas, which is a medically underserved area. We have a transgender clinic. We have, we are meeting these, so it could be sex workers. We have a broad swath. Most of our clientele is uninsured, so this is stuff I'm seeing day for day. Geographic disparities, I just want to call out because rural areas consistently show lower availability of mental health providers and specialized services sometimes that they need compared to urban areas. And residents of rural areas also have higher rates of untreated mental health disorders and longer wait times, of course, to access care. Urban areas, particularly in the inner city, have higher rates of severe mental illness and, of course, comorbid substance use disorders are more common. And so as we think about factors that contribute to these disparities, I'm looking at the factors, many of them are tied to cultural competency correlations, right? And so rather that structural racism and discrimination, socioeconomic barriers, whether it's lacking insurance or I even talk about oftentimes people have insurance, they're still insurance poor, right? They can't afford the coinsurance, the deductibles or the co-pays or the out-of-pocket costs. Cultural stigma, cultural stigma, that's still a thing. We're not past it. Lack of culturally competent care providers, I cannot tell you how often and for some reason when it comes to psychiatry, it's probably even more important to patients than I would say any other specialty in medicine, that they can have someone who understands. They tell me, so Dr. Lawson, I don't have to do so much explaining about why I approach things in this manner. Language barriers, this is huge and this is big and we have to be respectful, right, of people in their native languages. Limited mental health literacy and awareness, I'm highly interested around health literacy broadly but certainly mental health illness. Many minoritized communities, we are overcoming stigma and what's tied to that and so literacy is highly important. And so just think about if you are at the intersection of multiple of these identities, the barriers one could face, right, whether it be your race, your socioeconomic status, where you live, your zip code, compounds the challenges and reinforces the need for culturally competent approaches. I'm going to take us through a little bit of a historical review because this is not new and this is not because we're in an age of wokeness, right, so I'm often challenged around being woke but this, I always come back to disparities and I come back to historical precedence. And so we'll talk about Dr. France Fonin's work in the 50s and 60s around colonialism and mental health and his work emphasized the need for culturally sensitive mental health approaches especially for post-colonial societies, not new. Moynihan Report, Dr. Moynihan examined socioeconomic conditions that affect black families and underscored the need for addressing social determinants of health as it impacts mental health, racism, and economic inequality. The DSM, we all know that for a long time it was criticized for not embedding in the cultural biases there within from a diagnostic perspective and so this led to some of the revisions and the framework, the development of frameworks for culturally informed diagnosis. Dr. Pierce in the 70s who was a psychiatrist who introduced the concept of microaggressions, right, and his work brought attention to the impact of racism in mental health. And then also influence our modern framework and approaches around culturally, cultural competence in psychiatry. Of course the landmark report in 2001 of the Surgeon General, Surgeon General Dr. Satcher, this report was the first landmark, this was the first report that talked about race, ethnicity disparities in mental health as it relates to access and health outcomes. Thank you to Dr. Satcher for doing that and he advocated for culturally competent mental health care and research to eliminate these health disparities. We move forward to 2003, the Harlem Project. This was a community-based mental health initiative to address disparities in psychiatry and psychiatric care and incorporate culturally tailored interventions for black and Latino populations, demonstrated the effectiveness of culturally specific models to improve health outcomes. And then the Cultural Formulation Review by DSM-5 in 2013, again beginning that, again following the shift toward incorporating cultural humility into psychiatric assessment and treatment. And of course we all recognize the impact of the historical traumas, whether it be the transatlantic slave trade, whether it be the Native American genocide, whether it be the Japanese internment camps and those intergenerational effects on mental health. Misdiagnosis. If we do not incorporate culturally competent practices into our behavioral health care frameworks, you run into what happened in the 60s almost into the 80s, whereby black men were misdiagnosed with schizophrenia. And so in 1974, many black men, the rates of diagnosis of schizophrenia increased after the Civil Rights Movement, conflating political issues with mental illness. And it takes me back to remembrance of the slaves being diagnosed with drapedomania. If you were a slave who wanted to escape, you had a mental health disorder. You see the similarities. The indigenous populations and historical trauma, as you think about PTSD from the forced boarding schools, cultural erasers, the Latino community, language barriers. Even most recently, the woman who called 911 because she saw a La Tigra in her neighborhood. They thought she was talking about the animal. She was talking about the gangs. Again, lack of cultural competency ended her up with a thought she was delusional. The dismissal of black women's mental health concerns. It continues to be bubbled to the top for black women. Again, in 2016, a study highlighted where black women presenting with symptoms of depression were more likely to receive a diagnosis of a personality disorder than white women with identical symptoms. We've continued to hear this from black women. You may be aware of the CDC Hear Her campaign. Black women continue to say that their concerns are dismissed. Asian-American youth and suicide rates. 2020 report noted Asian-American students who showed signs of depression or suicidal ideation were not referred for the appropriate psychiatric care due to cultural stereotypes, that they are model minorities, right? They don't have problems. Recently, you may have seen it in the news, four-top singer, this is in Michigan, lawsuit, he was put in a restraint jacket. He told the nurse, right, I'm a, you know, celebrity, I was this, this. She thought, again, he was delusional. Ended him in a straight jacket. In the psychiatric unit. Lawsuit ongoing now. So, training. I want to just speak really quickly to this. So, again, if nothing else, understand the dire need for ongoing training. Self-reflection, bias recognition, continued education on what are cultural norms. Listening. If nothing else, what I continually hear from patients in the community, I need providers to listen to me. Patient-centered communication. I know we're all in a rush. We all want them to get to the point. We all want them to get to the relevant and what matters. But active listening is so important. And then developing the skill set to engage in difficult conversations. There are several tools that are out now. Leveraging technology. Interpreters. This is big, right? That continues to be a dissatisfier for the translation community, right? Perhaps sometimes we rely on family members and others to translate. But it continues to be a high-rated dissatisfier by a community that we don't have the proper translation and interpretive services that are needed. Ongoing policy development. And organizational commitments to inclusive practices. Challenges, of course. Time. We're all tasked. Time, how do we do this? Resource limitations. I'll talk a little bit more about that. Resistance, right? Limitations. Even with knowledge, providers may unintentionally rely on their own biases or the stereotypes they've already developed. And then I also have concern that cultural competency or cultural humility training is incomplete without implicit bias. In the political environment we live in now. And so I really want to just quickly give you the difference between implicit bias and cultural competency. And so implicit bias, an example would be recognizing bias in pain management decisions. We've known that it's always been thought that black people can tolerate pain better than others. Cultural competency would be adapting to respect particular cultural practices of an individual. So there is a difference, right? I just wanted to quickly let you review that. Because since 2023 and this is from this past fall, 86 anti-DEI bills have been introduced in 28 states. 14 have final legislative approval and have become law. 15 have been tabled, failed to pass or vetoed. And so I imagine some of this will bubble up to the top. I've been tracking a lot of this around the nation. The reason this is important because some of these bills have embedded into them that it's illegal to provide implicit bias training. I myself live in a state, the state of Texas, it is illegal to provide implicit bias training. So we've got to figure out how to evolve and that's why it's going to be so important to begin to embed these principles in other methods. And so, opportunities. I think there is, there are opportunities. For the first time since the census began, more than half of the nation's population aged 16 and younger now identify as a racial or ethnic minority. Right? So think about what that's going to mean for the future, for the young doctors that we're training now and other clinical providers. This is going to mean something. The growth in telepsychiatry and digital tools for training. Opportunity is making sure that we are incorporating anti-bias, culturally competent mechanisms within these software tools. CMS incentives for reducing disparities. I'll talk a little bit more about that. So I often, again, I talk about this because I'm always trying to make a business case. This isn't just us doing this for the goodness of, this isn't altruism. Right? For me, this is life or death. It is that serious, and I take it that serious. But, there are incentives. We'll talk a little bit about that because hopefully you're aware of what those look like. And then collaboration. I can't express to you the importance of collaboration. I'm sitting here with you all today, and as Dr. James was up here giving the introduction, I'm like, thinking of ways to collaborate. I'm putting this on the record. Let's think about our colleagues. I've been up the past two nights talking with the doctors in Los Angeles. Thinking about, you know, I'm hearing their message. I mean, we're trying to take care of elderly parents and the supports that they're going to need. I just got a call from the Haitian Medical Association. With the uprisings there, the mental health of the clinical community there under duress. These are things we can collaborate on to help our colleagues and our other sisters and brothers. Sorry, I'm going to get back on schedule here. So, and then lastly, I really want to talk about reimagining resident and provider training. So, you heard her just say, I'm just leaving Philadelphia working on the advisory commission around licensing. So we've been working on several commissions in Texas, for instance, when the laws passed around abortion care, right? We found that there were resident physicians in these states who were having to cross state lines to get the training they need to complete their residency. And so we worked on, the commission worked on that. What do we do to protect these folks where they don't lose licensure? We're working on now international medical graduate licensing. But one of the things the AMA, for those who are not aware, the AMA is working on transforming medical education. Right? And so with data and technology now, the goalpost is precision medicine education. Right? So there's this whole thing we've been working on. So all of the, I struggle with this, they call us the marginalized medical association. So rather as a Hispanic medical association, AAPI, GLAMA, are gay and lesbian. And so all of us meet on a quarterly basis, right? And some of us have been engaged in this medical education transformation. But I also challenge that maybe we should also be thinking about the resident and other provider, right? Whether it's nursing, pharmacy, everyone should be having these exposures around cultural competency. And so yesterday as we were at the advisory commission, working on international trained physicians and international medical graduates, licensing alternatives, most countries, if you're training in healthcare, you are obligated to social service. Right? At least a year. Many countries around this world, the U.S. doesn't have that, right? So you could go to medical school at a beautiful academic center, you could go to residency at a beautiful academic center, and you could go into your private practice in a beautiful neighborhood and maybe never have to interface, right? With real community and real community challenges. And so I thought, how unique is that? Right? To think about if we were to tie medical education to ensure all providers were embraced to deal with and deal with all types of communities and populations. And so as it relates to quality, I first want to just make for the statement here, cultural competency is a quality measure. Cultural competency is a quality measure. So in 2003, the Institute of Medicine noted that racial and ethnic minorities tend to receive a lower quality of healthcare than non-minorities, even when access-related factors such as insurance status and income are controlled for. And so over 20 years ago, the U.S. Department of Health and Human Services, through the Office of Minority Health, released the Federal National Culturally and Linguistically Appropriate Service or CLAS. And CLAS standards are a set of 15 recommended action steps that should be taken by healthcare providers, systems, organizations, policy makers to advance health equity and improve quality. Because again, we want to eliminate disparities. And so federal efforts have also been integrated into the 2024 Physician Fee Schedule and coding. And this is important because oftentimes folks say, well, I don't have the time because I don't get paid for that work. Well now, you can get paid for that work. And so I'm in many rooms. I'm here in D.C. all the time. I am in the payer space. Z codes. Underutilized. This is an opportunity for the APA to share with membership using these Z codes to get reimbursed. There's now the standalone HCPCS code, G0136, to cover the administration of these standardized SDOH assessments. Because once you do those assessments, sometimes things are revealed to you about your patient that helps you manage them. And we've always done that. We didn't have a fancy term called SDOH, but I knew if a patient lived 100 miles from me and didn't have a car, I had to give them more insulin, right? I had to work around their particular circumstances. And so, but I bring this up because I'm in room after room after room. And they talk about clinicians aren't using the Z codes. Well, they're here. And they were what we wanted for a long time. And we should be aware of those. And utilizing those. Aligning with CMS. And the reason that's important, so while we know the CMS and Medicare and Medicaid, but also your private payers follow a lot of what CMS puts out. And so CMS health equity goals and quality metrics related to cultural care have been front and center over the past two to three years. Nothing is perfect. But I must say, in my entire career, I've seen more done than I've ever seen around this aspect, around culturally competency care. And so relevant measures are the patient satisfaction scores. But we know that patient satisfaction scores go up when patients say, I received culturally competent care. It matters to them. It matters with their adherence to therapy. It matters. Health equity and SDOH data, disparities in care. So you all may remember these certified behavioral health care community clinics. They have an obligation. They must provide culturally sensitive and competency within their frameworks. And then cultural humility training supports all of these metrics. So if you're doing the cultural humility training piece, you can get to the metrics. So oftentimes we're working in institutions that need these metrics. So it's not only you as a provider, right, for your quality bonus, your hospital, or whatever entity you're working in, FQHC, all of these. This boils down, again, to economics. But it's important that providers are informed so they understand the connection. Because at the end of the day, we're the ones doing the work. We're the ones at this point capturing the data and capturing the information that they need to meet these quality goals. Strategies for systemic change, embedding cultural humility in organizational policies and adoption of cultural humility frameworks. And this is important. You just heard me talk about that all of this DEI legislation, that this is getting blended in. In my mind, they're different, right? They're different. This isn't diversity. But again, this is life and death. So I'm looking at now, how do we embed these frameworks into value-based contracts, into insurance contracts with providers? There have to be other ways. It should be standardized. So I'm looking at all these creative options around how to do that. Partnering with communities. It is so important to be informed by the community that we're not in our offices developing plans and processes and protocols that don't embed what the community needs and won't, and what the community will do into them. Continuous professional development tied to the CMS compliance piece. Advocating for diverse leadership in psychiatry to reflect patient populations and provider and workforce diversity. One of the pillars of my presidency was around the healthcare workforce. Right? So things have happened over the past few years that we know will impact the healthcare workforce. And so as we think about what this looks like for us, again, that translation. I'm always translating into a business case, right? So I went before the Senate and it was really around workforce. Healthcare workforce. Advocating for the importance around diversity. Advocating for education. Advocating for protection of scholarships and funding to support what that looks like. And I'll never forget, Senator Bernie Sanders is the chair of the Senate HELP Committee. And if you look at even Senate HELP Committee legislation, they probably had close to 140 something bills over the last year. Many of them are tied to cultural competency. Much of the work is. So this is important and it is recognized. But I remember Senator Sanders opening up with his opening remarks. And he gives the number of percentages of minoritized physicians in the country. And Senator Bill Cassidy, Louisiana, he gives his. He's the ranking member on the committee. He gives his opening remarks. And he gives different numbers. And I'm like, well, where is he getting these numbers from? And he calls it out. He says, you may recognize my numbers and my data are different than Senator Sanders. And I'm like, yes, we recognize. Well, I use a different data source. Oh, you do? Okay. So he's given the numbers and I'm like, well, I just never heard these numbers. And I do this every day. But what I responded to that with was, despite what you tell me what the workforce is in the United States, what I can tell you is that these health disparities are irrefutable. Irrefutable. This is what we have in this country. And so I'll let you share your data. You share your data. But what I'm telling you is that these disparities exist and we must address them. And so with that I will say also the advocacy piece. And so I know the APA does that. And so really aligning with equity, quality, I continue to say they're tied hand in hand. You can't really achieve this without the other piece. And I think with that I'm going to close because the time perkeeper was waving the sign at me. So thank you. Applause. So Dr. James, do we have time for any questions or I will yield to your direction. If there are one to two questions for Dr. Lawson, please go to the microphone. Give your name and your affiliation and ask her the question. I know that was chock full of information. I was sitting back here taking pictures and writing notes myself. Here we go. Thank you so much. My name is Julia Frank. I'm emeritus at George Washington University Department of Psychiatry. I run a clinic for pregnant and postpartum women that takes Medicaid patients and so forth. But it occurs to me that there's a whole dimension of orthodoxy that is being left out, which has to do with religiosity. I hear this as a Jew and how Jews are folded into the white data, but orthodox Jews are very, very different in terms of how they relate to us than other kinds of Jews. I think about religious fundamentalists. I don't know how you can do this without being deeply offensive, but I do think it's something that should figure into the conversation. I absolutely agree with you. Mike Stone, I don't disagree with you at all. This past summer, the AMA invited all of the AAPI, GLAMA, all of these minoritized medical associations to the AMA meeting. It was the first time all the presidents came together in that matter. Of course, this issue that you bring up came up in the room also. I don't disagree with you. Not that I had time to explore that issue today, but as we talk about this, when I'm on the national stage, when I'm in my workplace, we definitely do incorporate that aspect because it's a quite important aspect. I can honestly say that being an OBGYN is definitely an important aspect to me. It's something I always have had to take into context. We do continue to work, done some work with some of the religious groups over the last year. I have personally, and I know there's more opportunities to do that also, so I couldn't agree with you more. You have my full support, and I'll help you work on anything you want to work on. Any other questions? Well, thank you. Thank you so much for having me.

cultural competency

equitable mental health care

healthcare disparities

implicit bias

mental health disparities

culturally competent care

systemic change