This month, Sanjay Basu, Head of Clinical at Waymark, spoke with Dr. Manisha Sharma, a Waymark advisor. Dr. Sharma shared her experience building a community-based care model in Memphis, how rhetoric and labels can reinforce structural racism in medicine, and how to bring humanity back into healthcare.
Sanjay: Thank you so much for joining me. You published the results of a care management program for people receiving Medicaid benefits in Memphis, Tennessee, which produced impressive improvements in people’s health by integrating multidisciplinary care teams with primary care practices. Could you tell us more about what prompted this program?
Manisha: Thanks Sanjay, happy to be here. What we saw in Memphis was that the stories on the ground and the challenges people were experiencing didn't match the way we think medicine should be delivered. There's so much research that shows that the social drivers of health result in inequitable access and quality of care. We realized that the Camden Coalition had a really amazing COACH model that could apply in Memphis to meet people where they’re at.
In traditional medicine, we often ask “what's the matter with people?” Instead, we should be asking: “what matters to people?” With this framing, we realized that for many folks in Memphis, their current health situation was being defined by their experiences in the carceral system. For example, I had a patient who was in prison on minor drug charges, and he was prescribed antipsychotic medications even though he wasn't psychotic. I asked why he was on these medications and he said “I don't know. That's what they gave me.” You start to realize that there are so many stories like that.
I collaborated with my partners in justice to design and apply the COACH model for those people for whom the system has been not helpful, and think through how to broaden primary care to wrap around them and their clinics. We need to understand what matters to patients, and that requires understanding what happened to them in the past to lead to their present state of their medical care.
Sanjay: Thank you for that. You've done a lot of work on health equity, and particularly highlighted how we can change our rhetoric around equity. Could you speak to what efforts you find most meaningful and effective in this regard?
Manisha: I think the work that both Dr. Camara Jones and Dr. Aletha Maybank have done is particularly meaningful. That work is intended to have us stop and understand how the structures of racism have been codified as normal within our system of medicine, and to recognize medicine and health as two very different things. The goal is to get people to pause and understand how narratives that have been labeled “normal” actually reflect structural and institutional racism. We also need to get people to understand how these narratives are unhelpful in our medical work.
For instance, in medicine, we use terminology like “frequent flyers” or “high utilizers”. These labels imply that people are abusing the system. When we start to realize how those narratives actually end up blaming and shaming people, we can start to shift the narrative to treating people as human beings and not as labels.
I have a good friend, Dr. Stella Safo, who says: “we see the bodily impact of bad and good systems and policies in our exam rooms.” What we've been able to do is find ways to help people articulate the issues they’re facing at hand. It’s about being proactive and measuring what matters to people and what happened to them. We're shifting the narrative, and I think that's been very powerful. The next step is: how do you operationalize that in a systematic way? How do you scale it?
We've been trained in a blame-and-shame manner where medicine is very disease-forward versus people-forward. Changing that is what I'm excited about.
Sanjay: To that point, you worked in physician engagement to bring forth new models of primary care. Can you describe the challenges you experienced there?
Manisha: I was part of Iora Health with Dr. Rushika Fernandopulle, who was really inspiring. He talked a lot about bringing humanity back into healthcare delivery, which means that you have to address people as human beings and not as a disease or a transaction. We used to ask ourselves, “What is the persona of the physician we'd like to build into the system?” I think we've been indoctrinated to think our degrees,our specialties, and our experience are what we lead with, versus the humanity of who we are.
We defined the challenge as“what does it mean to deliver on humanity?” When you start to think about how patients and people of our community distrust the healthcare system, it’s usually based on conflicts between a patient and their providers. We’ve taught providers that it's okay to have a power differential, and it's okay to blame and shame our patients. We realized that we did not want to have those physicians in the mix, and the way we would prevent that is to try to find candidates with a high degree of humility. We’d include questions in our interview process like: “Tell me about a time that you failed at having a patient take your recommendations and what did you do about it?” We always talk a lot about our successes, but humility is based on the things that didn't go so well and how we navigate through them.
Sanjay: And in bringing those physicians into new models, what do you look forward to most in the realm of primary care practice innovation?
Manisha: What I look forward to is bringing humanity back into healthcare. I also look forward to making both our primary care delivery and payment systems more people-centered. In primary care, we get to know: “How are patients getting to work? Do they have enough food to eat? Are their kids taken care of?”
To give you an example: I saw a young woman who was listed as needing a physical exam. When she arrived at her appointment, she came to me and was depressed and sad. She had visited her pediatrician with her baby, who told her that “her baby has the devil in her,” because the baby was crying. Her children were subsequently taken away from her because she had postpartum psychosis and depression. The baby actually had a colic. Now she had two other children that were older, never had an issue, but because this woman was black, poor, and had a 10th grade education, and all of her other children were taken away from her, she was sad and depressed. For me, as a primary care physician, that was the etiology of her depression. My goal for treating her depression was to help her get her children back, which we did after one year. I remember going to court and being able to explain that her children should have never been taken away from her. What should have happened is to give her the support she needed to help her succeed.
I'll never forget another patient who really brought this home to me. She was a 57-year old woman scheduled for another physical exam. When I met her, she looked much older than 57-years old. She looked like she was in her seventies, if not eighties. She was tired. She said she just needed help to sleep. Now this is supposed to be a physical exam, right? And the things in primary care that we're supposed to be doing during the physical exam are listening to her heart, ordering her vaccinations and her labs and her mammogram, the usual deal.
But why wasn't she sleeping? She told me that her son was shot in the head two weeks ago and killed. So that 's on my schedule as a physical exam, and what matters to her is she just needs to sleep for a moment. This is the reality of primary care. The system doesn't allow us the time to listen. The system is saying we have to do a bunch of other stuff that doesn’t matter to people, like, like order vaccinations or labs, just to check some boxes. As providers, we need to take the time to listen to what actually matters to patients instead of running through a checklist. The system needs to make time and space for this. Those are the things that I think about in primary care innovation and where we have opportunity.
Sanjay: Thank you so much for sharing those stories, and thank you for all of these insights. Most of all, thank you for being an advisor to Waymark!
Manisha Sharma, MD is a Waymark advisor and currently serves as a Senior Medical Director at Blue Shield of California and a Co-Founder of Civic Health Alliance, which advances health through civic engagement in care settings and communities. Previously, she served as Director of Primary Care and Community Health for CareMore Health, and as a Co-Director of Physician Engagement for Iora Health, an integrative primary care and technology company.