FEMALE SPEAKER: Welcome to Mayo Clinic COVID-19 Expert Insights and Strategies. The following activity is supported in part by an independent medical education grant from Pfizer Inc and is in accordance with ACCME guidelines.

IVAN PORTER: Hello. I'd like to welcome you to this program from the COVID-19 Expert Lecture Series. Today, I've got three excellent panelists, along with myself, they're going to discuss some health disparities information related to COVID-19. Today, we will have the pleasures of hearing from a hematology oncologist.

Dr. Gerardo Colon will speak with someone from neurology. Family medicine and palliative care, Dr. Mashia Robinson. And we'll also speak with someone in dermatology, Dr. Olayemi Sokumbi.

Today we'll focus on the medical subspecialties perspective of health care disparities with COVID-19. To start, I'll want to tell you that I have no financial disclosures. And I'll go over our learning objectives.

We want to be able to describe health disparities and outcomes from COVID-19 in patients from minority groups. We want to discuss some of the comorbidities that have been linked to hospitalizations for COVID-19. We'd also like to describe some health care disparities seen in our different specialties.

And finally, we'll talk a little bit about how COVID-19 has exposed new health care disparities in certain medical fields. To start, I'd like to give a little bit of background information. Currently, on the screen you're looking at census data from 2010 to 2019, what they call the vintage year 2019. Remember that.

And we're looking at people that are self-reporting race. We're going to focus on a lot of people that have self-reported one race. Also things to notate would be that Hispanics may be from any race. So they are included in all of the race categories.

But if we look at the data from the census, we know that there are about 330 million Americans, 328 some odd million that were reported at that time. That's a 6% increase from the prior census.

So we're due for another census this year in 2020. I think you'll see the importance of an accurate census count and then also accurate reporting within the disease process of COVID-19. Note here 13% of the population were reported African-American. Note that, white alone, non-Hispanic population of 60%.

And let's look at some COVID-19 case and outcome data. So if we look at earlier this week, looking at cases reported based off of race and ethnicity, knowing that isn't always reported, but from what we do know, you can look and see that this white non-Hispanic group accounts for 40% of these cases. So 60% of the population, 40% of the cases.

If you look at your Black non-Hispanic group, African-American, 13% of the population, but 30% of cases that are seen. And then, also, if we just think about our Hispanic population down here at the bottom, we've got 19% of the population, but 30% of cases. If I go a little bit further, let's talk about some of the outcomes, the worse outcomes, death, also broken down by race and ethnicity.

Interesting is that the white alone non-Hispanic group, the largest group affected, 60% of our total population, 40% of the cases, half of the deaths, 50% or so of deaths. If we look at are African-American non-Hispanic group, again, 13% of the population, 19% of the cases, but 21% of deaths. So definitely disparate outcomes that we see.

And, again, if we couple that to the Hispanic reporting down below, you see 19% of the census data, 30% of the cases, and a little bit less, 16.7% of the deaths that we see from COVID-19. Very difficult to wrap our heads around some of the reasons why these disparities exist, very complicated, multilayered. We'll try to talk about some of those today.

As we think about COVID-19 cases and hospitalizations and those deaths that we just spoke of, we know that there are factors that put everyone at risk. And those include crowded situations, being in close contact with other people, being in small enclosed spaces, and also how long people are actually exposed. And so what we have to think about, as we think about disparities, is where people have to live, where people have to work, what work they're doing.

So if we think about our essential workers or frontline workers, infrastructure, critical infrastructure workers, if these groups are disproportionately represented by races or ethnicities, clearly they're going to be more likely to be impacted. And I think that does bear out in the data. Knowing what we know, we can certainly think about actions to reduce the risk of contracting COVID-19, but there are, again, some occupations that simply don't allow us to be able to follow the known recommendations.

If we think about the risk factors for COVID-19 hospitalization itself, we know that medical conditions underlying medical conditions play a huge role. I know we've heard that looking at differences between known comorbidities, such as asthma with a 1 and 1/2%-- well, excuse me, a 1 and 1/2 time increased risk of hospitalization, all the way up to having multiple of these processes, much more increasing the risk of hospitalization related to COVID-19. Another important point is that the race and ethnicity point, added to all of these, increased one's risk that much more.

So we've got to think about, not only these comorbid diseases as risk factors, but also the ethnicity and race of the patients that we're treating in and of themselves as a cause if we're going to think about ways to mitigate these risks. All of this data is available on a CDC website, publicly available. I welcome you to go and look and see the up-to-date information that's available.

Now I'd like to introduce the first of our panelists, professor of medicine for the Mayo Clinic Alix School of medicine, also vice dean, a consultant in hematology and oncology, and chair of the Mayo Clinic School of Medicine Education Subcommittee, Dr. Colon.

FEMALE SPEAKER: Thank you, Dr. Colon for joining us today on our panel on health care disparities and COVID, the medical subspecialty perspective. We're going to start off with our first question, which is, what are some of the health disparities seen in oncology?

GERARDO COLON-OTERO: Thank you, Dr. Donaldson. So that's a great question. But cancer disparities had been recognized since the 1970s. It was the first time that there was data about cancer incidence and cancer mortality in different races and ethnicities. And it was actually cancer was one of the first specialties were one of the first areas where the disparities were noted, once that data became available.

So ever since then, we've been aware of these disparities, the most striking disparities that were noted back in the 1970s. And that was a report published in Cancer that was reporting on the changes from 1950 to 1967 once that data was available. And the report was that there was a 20% increase in mortality from cancers among African-Americans compared to whites. And that really started the whole area of concern about these disparities.

And actually, a significant part of those disparities that were described back then related to smoking and lung cancer, that for some reason there was a significant increase in smoking among African-Americans accounting for that particular increase. But since then cancer disparities have persisted, not just among African-Americans, but also among Native Americans and Hispanics and for multiple different cancers.

Although, the magnitude of the disparities have decreased somewhat, but they still persist. And there are disparities in multiple cancers. There are multiple factors that contribute to those disparities.

Socioeconomic status is one of them that relates to lesser access to health care. That's a big contributing factor. So for example, on breast cancer, even though African-Americans and Hispanics have a lower incidence of breast cancer compared to whites in our country, when you look at the younger age group, the women who are less than 40 years old, actually African-Americans, have a higher prevalence of breast cancer and a much higher mortality.

And when you look at it at all ages, African-Americans, even though they have a slightly lower incidence of breast cancer, they have a significantly higher mortality from breast cancer. And Hispanics have a lower prevalence of breast cancer and a lower mortality compared to whites. But, again, when you look at the younger patient population, age 40 or less, even though their incidence is a little lower, their mortality is higher equivalent to that of whites.

So it's something that we see among African-Americans, Hispanics, and also Native Americans is that the cancer occurs at a younger age and has a worse prognosis. And there is an increased number of patients who have the more aggressive breast cancers. And breast cancer would be what we call the triple negative breast cancer. Which are the cancers that don't express estrogen receptors, nor progesterone receptors, and don't have amplification of HER2.

So there are probably some environmental reasons. And there is probably a genetic component that explains why we're seeing the cancers at a younger age. And we're seeing an excess number of the more aggressive breast cancers.

The environmental component could be related to the lower access, also related to the stress associated with low socioeconomic status and prejudice, which may contribute in some way to that, and also the genetic factors that explain the younger the woman is, the higher the incidence of genetic component to their disease. Although, the prevalence of the genetic component doesn't seem to be different between African-Americans, Hispanics, and whites, but there may be some other genetic components that we haven't recognized yet. So that's an example.

For example, also in prostate cancer, African-Americans have a higher incidence and a higher mortality from prostate cancer than whites. Hispanics have a higher prevalence of gastric cancer. And different areas among the Hispanic population have a higher prevalence of gastric cancer compared to other areas of the Hispanics population.

And then you also have the smoking-related tumors, which there the prevalence depends on the prevalence of cigarette smoking. And then you have the HPV-dependent tumors, where access plays a huge role, particularly, for example, in cervical cancer. So if women don't have access to PAP smears, or they are not having HPV vaccination, then they have a much higher prevalence. And that's seen in the Hispanic and the African-American populations.

FEMALE SPEAKER: Yeah. That's great information. And transitioning to the impact of COVID on your practice, what have you guys found an oncology world as it regards to access to in COVID or just any conditions associated with COVID and oncology?

GERARDO COLON-OTERO: No. I mean, COVID has affected all of us in all areas of medicine, in oncology, in particular, because of the potential devastating effects of a COVID infection on a cancer patient who is undergoing chemotherapy and the concerns that if the patient gets COVID right after chemotherapy, their outcome may be worse. So there have been registries of cancer patients who get COVID, national and international registries, that have been created. And data is coming out regarding the risks of dying from COVID if you have cancer.

And the data is not conclusive. Cancer patients have a higher prevalence of comorbidities that had been associated with higher mortality from COVID, like hypertension, heart disease, and obesity. So it isn't clear whether those comorbidities are the reason why there had been an increased mortality seen in cancer patients or whether it is related to the cancer disease per se. Some of the data from those large registries suggest that perhaps lung cancer patients, in particular, may be at higher risk.

And hematological malignancy patients may be at higher risk, but it isn't totally clear. It seems like if the patients had had chemotherapy within a short time of getting COVID, they may be at higher risk of having a worst outcome, but even that, the data there is not conclusive. as well. The data is confusing, because many times, for example, if a patient has a metastatic lung cancer, who is undergoing treatment and gets COVID and develops respiratory problems, many times the fact that they have metastatic cancer plays a significant role in their decisions to undergo further aggressive management of their COVID disease.

And that is noted in some of the scientific reports that have been published, since the COVID pandemic where, for example, in one of the reports it stated that only 20% of the patients with cancer who died of COVID were receiving respiratory support. So that to me tells me that many times the decision is made not to proceed with more aggressive treatment because of the metastatic cancer. So it may not be that they had a higher mortality from the cancer. It's just that the decision was made not to proceed with aggressive management.

So it's a confusing aspect, but it definitely has had an impact for us, because of the concerns, which are right concerns about whether the patients who receive chemo have a higher mortality from COVID. We have been very proactively testing all of our patients before each cycle of chemotherapy. And if they test positive and if it is in their best interest not to receive chemotherapy try to withhold the chemotherapy until the COVID infection clears and then resuming the chemotherapy, at that point.

So that's sort of how we have approached it. Thank god in our practice where we are, we have not had an overwhelming COVID infection situation. So it hasn't been-- it hasn't had a huge impact on our practice at this time.

FEMALE SPEAKER: That's great. Are there any other safety precautions you're taking within the institution or within your clinic for those patients who may be COVID positive or just, in general, trying to make sure that the patients very negative in coming to see you are protected?

GERARDO COLON-OTERO: Yes. We have been limiting the number of the family members who can come with the patient for their chemo or can be with them in the room to one at the most. We test every patient who comes into the building for fevers. And we asked them if they had had any symptoms that suggests active COVID infection. And if so, we don't allow them to come to the building.

We've tried to minimize the staff who is in the building, trying to have to staff that is not essential to be in the building to serve us from home, rather than coming out. We screen all the staff before they come in the building for symptoms of COVID. We also have mandatory masking and social distancing of the local staff, and among the patients, and the practice. And we are constantly sterilizing and cleaning our facilities to try and minimize spreading of the disease. So those are some of the measures that we have established here throughout the Mayo Clinic, too, not just in our practice of oncology.

FEMALE SPEAKER: Certainly there's lots of cancer patients and just patients in general who are very concerned about their risk factors and outside of the hospital in regards to COVID. Are there any recommendations are given to patients when they're not in hospital getting treatment in order to protect themself?

GERARDO COLON-OTERO: Yes. We have stressed to them the importance of social distancing and masking and try to avoid contact with anybody who has any symptoms, try to minimize contact with other individuals, try to avoid indoor space where there's a lot of there's crowds. And those are some, and then to report to us any symptoms. We try to stress to the patients that our facilities are probably a safe place for them to come and to have their care that they need. So it's very important, because there's significant concern that patients are not coming to receive the treatment that they need and that that's going to have a very negative impact on their survivorship of their cancer. So we try to stress that to the patients to not delay the care that they need in view of the COVID pandemic.

FEMALE SPEAKER: Great. Any final parting thoughts about health care disparities or what you guys have been dealing with from oncology that you want to share with our viewers?

GERARDO COLON-OTERO: Yeah. No, I think the COVID pandemic has uncovered the huge disparities that exist in health care in our country. And to a great extent that's due to our health care system and how it is designed and established. And hopefully, action will be taken to address these disparities.

It's definitely needed. It is not something new. It's something that has been existing for a long time and is historically, for centuries, pandemics had always affected the lower socioeconomic status individuals. And unfortunately, it has not led to action to solve those problems, but we've made some progress.

And hopefully, with the increased awareness within our society, this will bring very much needed change so that we can eliminate this disparities that, I think, personally-- and I'm speaking just for myself-- I believe health care is a human right. And it's something that every human should have access to. And it shouldn't be dependent on whether they have a job or not or whether they lost a job or whether they can afford health insurance or not. And I think it's a moral obligation for health systems, particularly non-for-profit health system to proactively address these health care disparities that exist in our country.

FEMALE SPEAKER: Great. Thank you that was really valuable information. And I'm sure everyone will get a lot out of it. I appreciate your time and your participation.

GERARDO COLON-OTERO: Thank you, Dr. Donaldson. Have a good day.

IVAN PORTER: Thank you very much for that perspective, Dr. Colon. Now I'd like to move to another specialty. With us today, we also have the director of clinical practice for dermatology here at Mayo Clinic in Florida, Dr. Olayemi Sokumbi.

She's an associate professor of dermatology. She's also an associate program director for the Dermatology Residency Program. She's co-chair of the Mayo Clinic Alix School of Medicine Diversity and Inclusion Council. Dr. Sokumbi.

OLAYEMI SOKUMBI: Thank you so much, Dr. Porter, for the opportunity to speak and talk about the disparities as we deal with this COVID-19 pandemic as it pertains to my specialty in dermatology. Now dermatology, as you all know, is the study of the skin. And the skin being the largest organ in the body, it's also, of course, the specialty that we use for this political and social construct that we call race.

So the term meaning the skin type will determine one's race is based on what the skin looks like, typically what we call our Fitzpatrick skin types. I mentioned this as an introduction, because when we look at the United States and we look at what we expect in the future with race, by the year 2050, we estimate that about half of the United States population will actually be considered skin of color. That means there will be more darker skin types than we have the lighter skin types.

The reason why that's particularly important is when we look at health disparities, as it relates to dermatology, just in general, we cannot have this conversation before without considering what we have in terms of dermatology workforce. As Dr. Porter mentioned, we have about 13% to 14% of the United States population is considered African-American black skin types. However, when we look at our dermatology workforce, about 2% to 3% of dermatologists are skin-color dermatologist.

When we look at our Hispanic population, with 16% Hispanics, we have only about 4% represented in dermatology. This huge disparity when we look at the field, in general, has significant effects when we think about how we approach our patients of color, has significant effect as we think about research opportunities, and therapeutic options for patients who have skin of color, who are seen by dermatologists. More concerning is recently we've been looking at survey data. And we have about 47% to 50% of dermatologists graduating from training programs within the United States, stating that they do not have comfort level, or they do not feel prepared to take care of patients of color, because they were not trained adequately representing all skin types.

This is problematic when we think about skin cancers or we think about inflammatory dermatosis. I'll use melanoma as an example. Melanoma is the most deadly skin cancer. About a 100,000 Americans or so will have a new diagnosis of melanoma in the year 2020. About 7,000 folks patients will die of the diagnosis from their melanoma.

Now if you look at race in melanoma, melanoma is actually a disease more commonly seen in Caucasian skin. So the lighter skin types, in fact, are about 20 times more likely compared to dark skin types. If we looked at the numbers, about 20 to 30 per 100,000 in terms of incidence of melanoma in Caucasian skin versus about 1 per 100,000 in Black skin.

Despite these disparate incidence of melanoma, if you had melanoma as a Black person, you're more likely to die of melanoma than Caucasian person. That's problematic. When we look at the five year survival for melanoma, it's about 92% in a Caucasian and about 74% in African-Americans. This lets us know that even though the diagnosis is 20 times more common or more likely in a Caucasian skin, if you're black and you have melanoma, you're more likely to die of your melanoma than someone of a lighter skin tone.

And I think that when we look at the data, you try to break it down. They've looked at things like, is it an access to care problem? Certainly that plays a role, when you look at the numbers of dermatologists and access to dermatology issues with, of course, low socioeconomic status and access to insurance. All of these play a role in the late diagnoses of patients of color with melanoma.

However, if you were to control for insurance and also actually control for a stage of diagnoses, the definitive treatment for melanoma is a surgical modality. However, we've done studies showing that the time to definitive surgery comparing a Caucasian patient to a patient of color, the lag time is problematic. So not only are we dealing with the disparity in terms of late diagnosis, dealing with disparity access to care, we have to figure out when they do get the diagnosis, why are they getting treatments later?

All of these are problems that currently plague this specialty. When we look at inflammatory dermatosis, particularly I like to use a disease that commonly affects Black women, a condition that I'm interested in referred to as hidradenitis suppurativa. It's a condition that deals with inflammatory boils, nodules, abscesses occurring in the inguinal areas, in the axilla.

And we know all of the risk factors. It's more common, at least, three times more common in a Black person than in a Caucasian person. However, when we look at treatment options, we look at the clinical trials and how we've decided on our standard of care for this particular problem. All of our trials were done in Caucasian skin. And once again, we see that lack of representation, which lets us know when we're taking care of patients, how do we know that we're treating our skin of color patients appropriately when we didn't even try the treatments in these patients?

When we look at emerging data with some of our complicated dermatologists, like psoriasis, atopic dermatitis, the data stays the same thing. Emerging treatments, new treatments are not often offered to skin of color. And they're are not usually getting the standard of care.

So I tie in my point about the workforce, because I think that the lack of representation in our workforce spirals down to whereby we're not looking at these diseases. We're not studying the diseases that are current skin of color patients. And, of course, when you look at the disparities, we don't have enough access. And all of this just comes up to a big issue that has become the forefront in dermatology.

Now when we think about the COVID-19 pandemic and how it's affected our dermatology practice recently, just like most medical specialties, we've had to reevaluate what we consider urgent. A difficult dilemma actually, because dermatology is known for a lot of morbid conditions, not necessarily increased mortality of the conditions. So here we are deciding what's urgent and really triaging.

And what we find is sometimes these chronic dermatosis, such as this hidradenitis suppurativa, they get put in the non-urgent category. And so we have this lag time, where patients are suffering and do not have access to care for these problems. And, of course, we have to think about safety issues.

We've incorporated teledermatology, as most folks have had to do. And an important component in that is considering, is this going to become a new social determinants of health? Because to have a good teledermatology visit, you need, of course, great internet access, and you need access to technology. And when we look at the data in terms of folks who can afford these, we know that they're definitely not the patients from low socioeconomic status. And so that further expands the disparity as we care for dermatological conditions during this pandemic.

Now we have patients who have inflammatory dermatosis that we tend to treat with immunosuppressive medications. These medications modify the immune system, sometimes suppress the immune system. And when you're dealing with an infection, such as COVID-19, of course, physicians now worry about discontinuing medication, initiating medications while we're dealing with a deadly pandemic.

Now for patients who have had chronic conditions, a lot of the patients, the data has shown that while it's OK to keep patients on the condition-- on the medication, I'm sorry, you have to have constant contact with your doctor, reevaluate and deciding whether it's OK to continue the immunosuppressive medication. And the recommendation has been released that if you do actually have a new dermatological condition, inflammatory condition that might require these immunosuppressive or immunomodulatory treatments, most dermatologists are holding off, waiting for things to calm down because of the risk of increasing or altering the immune system during the pandemic. Finally, when I think about the exposure of the disparities within dermatology, I think of in the early days when our colleagues in Europe were reporting dermatological findings in patients with COVID-19.

Everyone was reporting where what organs might be involved in COVID. And the literature from Spain, literature from Italy, we started getting data about cutaneous manifestations of COVID. Shortly here within the United States, we started reporting cutaneous manifestations of COVID-19. What was particularly important to us, there was a variety of clinical presentations that informed either actually severe disease.

There were presentations that actually represent a clue to early diagnosis. There were presentations that suggested a patient might do well. And so we were all yearning for publications and the scientific literature to help us learn about the manifestations so that we could be prepared to take care of our patients. And so the publication started being reported.

A paper that was released in May was significantly helpful in just highlighting the disparities in dermatology, because by the time we looked at over 130 or so images in our medical literature during the pandemic, none of the clinical images showed patients with Fitzpatrick skin types, five and six. So that would be a skin color such as mine. That's considered a skin color that does not burn. That's how we determine the Fitzpatrick skin types.

And so I-- when those of us, who are skin of color dermatologists, take a look in the literature and we're in a process of trying to educate our colleagues about skin of color, it becomes problematic, where there is nothing in the literature showing you what you're looking for, which prevents you from teaching your residents, prevents us from educating our future learners about dermatosis choices. Specifically, when they looked at the data of all of the photos that way were in the literature about cutaneous manifestations of COVID, 92% of the images represented Caucasian skin. So our so-called Fitzpatrick's skin types 1, 2, 3, those are skin types that typically burn, we had 6% representing Fitzpatrick skin type 4. So that would be a lighter brown hue, but a color that might still burn.

And then none at all in the medical literature, demonstrating these skin types that we need to learn, these skin types that might represent early clues, these skin types that may represent significant outcomes or poor outcomes. There are no photos for us to learn from. Even more worrisome is when you look at or think about the data that Dr. Porter presented or the data that we're all aware of, that you have 13% of our population being African-American. We have this disparate number of patients with COVID-19. So about 30%.

So disproportionate to the population itself. And so we know we have patients who have COVID-19. We know we have patients who have cutaneous manifestations of COVID-19, but there were none to be found for us to teach our learners, for us to learn and to prepare ourselves to take care of these patients.

We discovered that the pernio-like or what we refer to as chilled-latent dermatology-type presentation, can be an early clue to diagnosis. And you have to think about the disparity of the folks, the 47% dermatologists who said they're not comfortable. They're not prepared. They don't feel comfortable taking care of dark skin types. Isn't it possible that they've missed this diagnosis that could have been an early clue, that could have been picked up early, that could lead to a better outcome than the delayed presentations that might have occurred?

Similarly, when we looked at a condition, the same condition hidradenitis suppurativa, and we looked at the comorbidities associated with that, is hypertension, diabetes, cardiovascular risk factors, smoking, some of the things Dr. Porter talked about when he was referring to the risk factors for COVID. So now we have a significant overlap between the risk factors of COVID and the risk factors of hidradenitis suppurativa. And the black patients, the black female patients, are the ones most likely to have this condition.

So now the idea being, is there even an increased risk in these patients for COVID-19? Because they certainly share all the comorbidities of COVID-19. And on top of that, they are an immunomodulatory medications.

We suppress their immune systems to help them deal with this awful disease. All of these things expose the disparities that occur in our specialties and our need to really change the way we look at things to make sure that we have curriculum preparing our trainees to take care of patients of color and, of course, to allow the growth of this specialty so that we have more physicians of color in this specialty so that we're prepared to care for our patients.

IVAN PORTER: Thank you for that perspective Dr. Sokumbi. We will come back together to discuss a few more points following our next panelist. I'd like to present Dr. Mashia Robinson.

Dr. Robinson is jointly appointed in neurology and in family medicine. She is the medical director for palliative care at Mayo Clinic in Florida. Dr. Robinson.

MASHIA ROBINSON: Thank you, Dr. Porter. So when we think about palliative medicine, we think about really a specialty that aims to recognize prevent and alleviate suffering of all forms for people that have a serious or advanced medical condition. And we try to really improve quality of life for people at any age and at any stage, independent of whether the goal is curative, or to provide care as people are undergoing therapy for, perhaps, terminal conditions.

So the Center to Advance Palliative Care suggests that about 94% of hospitals that have 300 beds or more have a palliative medicine team. About 72% of hospitals that have, at least, 50 beds or more have a palliative medicine team. But what we know is that about 60% of hospitals that are public in nature or the safety net hospitals have a palliative medicine team.

And so there is already some disparity with regard to access to palliative care, particularly for minority populations. There are also more specific disparities when we think about access to pain medications. In minority communities, some pharmacies are less likely to carry some of the opioids that patients require. And, therefore, they're less likely to be able to get the pain management that they need.

We think about disparities in communication. The data suggests that particularly Hispanic and African-American patients are less likely to have the same degree of empathy shown during physician and patient communication as Caucasian patients. We think about the disparity in the provision of preference, concordant care. So even when wishes are known, minority patients are less likely to get the kind of care that they were hoping for.

When we think about palliative care, in general, a large role for a palliative care physician and providers think about advance care planning as well. And, although, we know advance care planning occurs less frequently, in general, than it should in the United States, there is certainly a notable difference in the completion of advance care planning in minority communities, African-American and Hispanic versus Caucasian. And I think there are a number of barriers and considerations that we have to look at when we think about the reasons behind this.

The first would be cultural issues. In particular, minority culture, it can be challenging to accept the need for palliative care discussions about end-of-life care and hospice care. We think about faith and religion. If God's going to take care of it, then why do we need to plan this?

We think about the differences in the discussion about palliative care and hospice care. Physicians may be less likely to bring it up to patients in minority backgrounds. And then we think about the mistrust of the health care system.

Many people, particularly thinking about the African-American community, think about Tuskegee. But this predated Tuskegee, we think about people of slaves taking them to the operating room and operating without the use of anesthesia. We think about the grave diggers and pulling up bodies of African-Americans, while people were learning anatomy.

We think about what is still going on in the health care system. So it's not even just a history of mistrust, but even a current time of mistrust of the health care system. And then we also think about just general access to care. If you're less likely to be diagnosed early on and begin to get a diagnosis much later in the disease course, it can be more challenging to just have a diagnosis and then move to thinking about end-of-life care.

So those are just some of the considerations with regard to disparities that we see, particularly in palliative care. So maybe just a few considerations, particularly in the time of COVID, when we think about palliative medicine, we think about four essential things that the teams provide, that we help with symptom management. We help caregiver support. We help with goals of care. And we help with advance care planning.

When we think about symptom management, usually we're at the bedside, seeing our patients, being close to them, being able to evaluate and examine them. And during the time of COVID, because of a need to try to decrease exposure to the virus, we've been doing much of this virtually. And so some of the symptom management, while we can see on video, or Zoom calls, or in conversations on the phone, people can tell us what some of the symptoms are, it becomes a little bit more challenging to ensure that we are adequately capturing all of the symptoms that patients have.

And we think about caregiver support. We think about the necessary visitor restrictions in hospitals or in residential facilities. And therefore, we're trying to figure out how do we provide support to caregivers in a very unusual circumstance. And some of that includes being proactive in terms of calling family members.

That includes involving the interdisciplinary palliative care team. And so getting the social worker involved and providing some emotional support to caregivers, having the chaplain or spiritual advisors involved to provide some support for caregivers. And then having the clinicians also available to be able to give regular updates as well on their loved ones conditions.

We think about goals of care. And many people say, can you really do that virtually? Can you establish rapport? Can you have a connection with patients and their family members virtually?

And what we found was that, yes, we can. In fact, our procedure is the conversation. And some might say we're even uniquely tailored to a time such as COVID, because we're able to have those conversations with our patients and family members, whether that's in a virtual format or on the phone. But we have had to take some considerations in mind.

And so when family members are bringing their patients, particularly to the hospital and when they see them walk in with perhaps a little shortness of breath and being called a few days later, there's a discussion about intubation or perhaps withdrawal of life-sustaining measures. It can be challenging to have those conversations when loved ones have not seen their loved one and the patient in the hospital for a long period of time. And so we've had to figure out how do we bring people together using virtual technologies so they can at least try to see their loved one as we're trying to have these very challenging conversations.

And the last thing is advance care planning. And so we think about not only the patients who are directly impacted by COVID, but there are certain patients in the hospital as well that we're sitting down with and discussing what people's wishes and preferences are for end of life care. And we have to think about those patients and some of the indirect consequences of the needed procedural changes and institutional policies that have gone into place because of it, and really thinking about, how do we support these patients that are thinking about their wishes with other medical conditions that may lead to end of life care?

With regard to some of the safety precautions, as I mentioned, we are doing much more from a virtual standpoint in an effort to reduce exposure. And we're following CDC guidelines as part of palliative medicine, which is an umbrella term in terms of focusing on quality of life for people with serious advanced medical conditions. Hospice care is in that realm.

And so when we think about hospice care, we think about specific care for people who have a condition where life expectancy is six months or less if the condition progresses in its normal fashion. And so hospice teams are often going to people's houses. And so they've been following CDC guidelines about what PPE needs to be worn and also counseling, family members, and loved ones and caregivers about how to reduce exposure at a very critical time in people's lives, where touching, handholding, being at the bedside is often thought to be very important. And so there have been some necessary accommodations made for the hospice teams and palliative care teams going into the homes to guide during the time of COVID.

IVAN PORTER: Thank you for that perspective, Dr. Robinson. Now I'd like to ask a few follow-up questions if I could and also bring back Dr. Sokumbi. I find it interesting that a lot of the points that we've all spoken of kind of have a similar foundation.

So it crosses all specialties. And it even crosses the things we talk about it. It crosses disease diagnosis. It crosses into how we perceive the care that we receive. And I guess one of the first questions that I'd like to ask, Dr. Sokumbi, come back you mentioned race is a social construct and the damage that has done to your specialty. And I guess what I would ask is, do you feel that the data that is present right now, that is based off of this social construct that we've created, will bore out as more and more people will fit that mixed race definition?

OLAYEMI SOKUMBI: I think so. I think that that's-- when you look at the data, even when you look at what some what folks are expecting in terms of 2025, I give the data for 2050 where we anticipate that half of the country will be considered a skin of color. And so what that means, this is the skin of color population would be projected to really become the majority. And the data already suggests that when we look at what we define a skin of color in dermatology, like I said, we use the Fitzpatrick skin types.

And they're based on whether or not a patient burns when they're out in the sun. And the predominant skin types have been the Fitzpatrick skin types 1 through 3, with skin types 4 introduced and some color, and then skin types 5 and skin type 6 being black skin. And because of what we're seeing in terms of interracial marriages, interracial racial procreation, I think that we're going to be going down the other spectrum, whereby the Fitzpatrick skin types 4, 5, and 6 will be the predominant color that will be seen. And that has significant impact when you have specialists within a field not trained to care for that skin type. So I think it will quickly become problematic for the ability for physicians within the United States to provide good dermatology care.

IVAN PORTER: Excellent point. Dr. Robinson, for you, I mean, the first thing you said was addressing quality of life and issues that patients are dealing with, not necessarily end of life issues, but just quality of life. And if we think about the impact this has had on certain populations and we think about the additional grief, we think about the additional social isolation that's-- excuse me, isolation, that's absolutely necessary, I mean, that's had to have made your job that much more difficult.

MASHIA ROBINSON: I think you're absolutely correct. This has been a very challenging time for many patients, particularly those living with serious and advanced medical conditions, some of whom already were feeling some sense of isolation, but they had caregivers, for instance, that were coming to the house to assist. They had other family members and friends who were coming to the house to assist.

And as you can imagine, many of those people and the additional assistance has decreased during the time of COVID. And so palliative and hospice care teams have tried to be as proactive as possible in reaching out to these patients and to the caregivers who are still present to ensure that we can provide support. And sometimes it's not about managing a specific symptom or prescribing a specific medication. But it's really just letting them know that somebody is thinking of them and caring about them. And so I think we've had to be somewhat more creative and proactive provide in this time of COVID.

IVAN PORTER: Very appreciative of the work that you do. Dr. Robinson, you also brought up reasons why it may be more difficult for you to provide care. You talked about cultural differences. You talked about issues with faith or religion, having the discussion itself, mistrust.

I think about the same reasons why there aren't more minorities that are in a lot of the clinical trials that we do. And you know, distrust definitely goes to the top of the list, but also just the cost itself, the cost of travel. You also have to add in health literacy. And so a question, Dr. Sokumbi, I guess, especially with your interest in education and being a part of the dermatology residency, with the lack of minority care providers, do you think that also plays a role in the lack of study inclusion, or do you think that this is more so just related to those baseline foundational factors that we spoke of before?

OLAYEMI SOKUMBI: No. I definitely think that it plays a huge role in studying inclusion. I use myself as an example here in our local area, here in Jacksonville. Within this catchment area, I represent the only black dermatologist within the area. And that's particularly-- the reason why it's important to mention that is because of the distrust, Dr. Robinson as mentioned, oftentimes I have patients who have been to other dermatologists, competent dermatologists even who are of a different race than they are.

But there is the perception that cultural competency that they are not able to get and build that rapport and that trust that they can get. Now I don't think-- I think that for a system within skin in dermatology, we need our patients to see all doctors of all skin types. The point is, though, that we need cultural competency, because when you can build that rapport and really have that diversity in the workforce, we'll do so much better with recruiting patients for clinical trials.

And so I find myself partnering with colleagues, even colleagues studying diseases that I'm not particularly interested in, but invested, because I know that those diseases, particularly affect skin of color patients. And because my presence there helps with that mistrust. Because the reasons why we're not getting these treatments for some of the inflammatory dermatosis is I talked to you about, Dr. Porter, is because we just don't have the data on how our skin of color patients respond to these treatments, even though they are the ones who bear the burden of the disease. And so I spend a lot of time educating them saying, we cannot find a solution or treatment if you don't participate in this, but that mistrust is there. And so it is particularly important that the workforce looks like the country, because the mistrust is only really widened or expands when really a person who looks like them is a rare breed within this specialty.