Why Culturally Competent Care for Women of Color Matters

JOEL BERVELL: Hey everyone. Welcome back to this special series of conversations on The Dose. In these episodes, we’ll be exploring issues in women’s health as a whole. But we’ll be moving beyond maternal and reproductive care to explore other dimensions of women’s health care. That’s things like access to primary care and preventative services, mental health support, clinical trial diversity, and so much more.

Unfortunately, in the U.S., primary health care systems still don’t effectively meet women’s needs as they age and transition through stages of life. These issues are some that I find deeply personal. I’ve watched firsthand as several women in my own family struggled to access equitable health care. Shortcomings in our health care system prevented them from receiving the care they deserved. And when I entered medical school, I noticed firsthand how little we learn about women and gender differences in our classes.

These next conversations are some that I wish would have been included in my medical school curriculum. And I’ll be inviting a very special guest to host one of these episodes, too: my sister, Dr. Rachel Bervell. She’ll host next week’s episode about support for new moms.

Alright. But today we have with us Ashlee Wisdom. Ashlee is a public health innovator. As a founder and CEO of Health in Her HUE, she’s created a digital platform that connects to women of color to culturally competent and sensitive health care providers, and community support. That includes virtual care squads, a directory of providers, and more. So that all people can access the quality care they need and deserve. Ashlee’s work, and her work towards her master’s degree in public health, was driven by the truth that Black women and women of color experience the worst health outcomes of any group in the United States.

That’s regardless of income. And as we’ll discuss, that happens not because of anything women are doing, it’s about what is done to them, and denied to them by the systems we have in place. Those gaps and failures prompted Ashlee to look for innovative answers. And what she didn’t find, she invented. It’s my great pleasure and honor to kick off this miniseries about women’s health by having this conversation with Ashlee Wisdom.

Thank you so much for being here, Ashlee.

ASHLEY WISDOM: Thank you for having me on the show, Joel. Great to be here.

JOEL BERVELL: Yeah, I’m so excited to see you again. Your work is focused on connecting Black women and women of color to culturally sensitive health care providers. Statistically speaking, that can be a challenge. So let’s get into it. What is the gap you were looking to fill, and is that even possible statistically?

ASHLEY WISDOM: Yeah, so when I pitch or present, I often call out the delta between the number of Black people that exist within the United States, and the number of Black practicing physicians within the United States. And so, Black people represent 13 percent of the U.S. population, and only about 5 percent to 6 percent of practicing U.S. physicians identify as Black. And so, that makes it really difficult for Black patients to connect with Black doctors if that’s their preference.

Oftentimes, that actually is. And so, while technology isn’t the panacea, I definitely see technology as being a tool that can help bridge the access between Black patients and Black doctors until we get our physician workforce to the point where it’s as diverse to meet the needs of a diverse patient population.

JOEL BERVELL: Absolutely. I love that. And one of the things I always say is we need a diverse provider population, because the population of the United States is diverse. But as you suggested, it doesn’t reflect that. And as a medical student, I see that every single day — in my classes, in the communities I’m in, even on social media. The comments that people leave saying, “I wish I could find a Black doctor. I wish I could find a Latino/Latina doctor that could be able to help me out.”

And over this conversation, we’ll talk a lot about what’s changing, and what you’re specifically trying to change. I want to make sure that this conversation is in the context of existing systems of health care. So things like mental health care. How are mainstream providers facing new demands for specialized care for Black women, or not facing those new demands?

ASHLEY WISDOM: Yeah, I think that there is more, now that . . . there’s always been the stigma with mental health. I think just kind of generally, and then specifically within the Black community that I think is finally . . . we’re finally seeing a breakthrough where people are talking about mental health issues. It’s more normalized. I kind of credit that a lot to social media, and people having access to therapists who are being very vocal about mental health issues on social media. And also conversations in pop culture.

And so, because of that, I think there is now an increased demand for Black women seeking out mental health support, which is really great. But what’s unfortunate is that there just aren’t enough therapists, diverse therapists, for every, let’s say, Black woman that wants to see a Black therapist or Black female therapist if that’s who they feel more comfortable speaking to.

And so, I always make the caveat that while Health in Her HUE is really trying to reduce the friction and barriers to Black patients connecting with Black health care providers, we’re not advocating for a segregated health care system, nor are we saying that the onus should only be on Black therapists or Black physicians to provide culturally responsive or culturally affirming health care that all health care providers have the capacity to do so.

And so, I think now mental health providers are feeling extra pressure to figure out how to be a more affirming health care provider or mental health provider to Black women. And that means taking into account their lived experiences, understanding the impact that racism, sexism, and all the different ways in which women, Black women, can be marginalized. That’s factored into the way that they’re providing therapy and mental health services to them.

JOEL BERVELL: I love that you are talking about that everyone needs to be on this. It’s not just up to specifically Black physicians. Because as we know, there’s not enough of us. And also, that’s difficult to put the onus on everyone for that. Is there adequate training for that cultural competency right now?

ASHLEY WISDOM: I would say no, not really. I think the medical establishment is starting to feel that pressure because there just aren’t enough doctors of color, health care providers of color. It’s like, “Okay, well, we do have an existing provider, a physician workforce. How do we make sure that they are equipped to provide quality, competent, and affirming care to a current diverse patient population?”

And so, I know that there are different solutions or technology companies, digital health companies that are trying to fill that gap until medical schools and schools of social work can really provide that adequate training.

There’s a company that I really admire, Violet Health. It’s really supporting providers with becoming more culturally competent and making sure that that content that providers are engaging with is CME-accredited, so that they’re incentivized to engage with it. It’s been really great to see even innovative solutions coming to the market to support health care providers with becoming more equipped and more trained to provide that culturally competent or culturally affirming care.

JOEL BERVELL: Yeah, I think that’s so important. When I think to the medical school space, I think we’re trying to get to more of that cultural competency of understanding it, but sometimes it falls on flat ears when, even at my own medical school, I remember when I first came here, I was a part of the first cohort of Black students.

And so, if you don’t have students that are actually even representing different communities, peers learn from those around them. I know for a fact, I talk to my friends about this all the time. That I’ve taught them a lot of stuff about Black culture specifically, or even just what it’s like growing up Black that’s impacted my own access and my family’s access to health care.

If you don’t have people around you with that, it’s really difficult in order to actually start weaving that into your own practice. Because the beautiful thing about medicine is, it’s both art and science. But that art piece, because it’s objective, needs to be supplemented by people around you that you can learn from. I’m curious, so you’re a Black female entrepreneur in the health care space. You’re a rarity to be here. How do you make that business case for providing appropriate care and culturally competent care when we know it’s so necessary, but maybe other communities that haven’t seen it as necessary have never experienced it?

ASHLEY WISDOM: Yeah, I think what I’ve been tasked with in being a founder of a venture-backed company in the private sector is making the ethical imperative or making that case. But also really making the economic imperative. And so, for those folks who may not be moved morally to care about the needs of Black women and women of color, I have to now make sure that my story is meeting the audience that I am oftentimes speaking to. Which are sometimes investors, sometimes health plan executives, sometimes employer executives.

And really making that economic case of racial health disparities is costing you a lot of money. It’s costing you a lot of money to not care about the fact that Black women are not getting the quality care that they need and deserve. And so, you’re paying for, if you’re an employer, you’re paying for health insurance for your Black women employees. And if they’re engaging with a health care system that isn’t meeting their needs and they’re getting late diagnosis or misdiagnosis, you’re paying for that from an insurance claim standpoint, as well as a loss of work, a loss of productivity. Because you’re Black, women employees are probably going to have to take off more time to work because of their . . . managing different conditions or trying to seek out second opinions from different doctors because they’re not getting the care that they need. That’s really the work that I’ve taken on as a Black woman entrepreneur, is to really make that economic case as to why this problem is worth paying attention to, and not just paying attention to it, but really addressing it.

JOEL BERVELL: Yeah. Have you been able to quantify that in cost?

ASHLEY WISDOM: Yeah. I talk about the loss of productivity, and how much that’s costing our overall economic system. And that is costing 10 billion to the economy, the U.S. economy. 35 billion dollars in excess health care expenditures because of misdiagnoses or getting screenings, not getting screenings that are necessary, and then 200 billion dollars in premature deaths. Those are the three data points that I often call out to really make that case of why there’s an economic imperative to addressing this problem.

JOEL BERVELL: And those are huge numbers that are affecting everyone. How have the failures in the past kind of fueled meaningful and lasting innovation? If they have, or maybe they haven’t?

ASHLEY WISDOM: Yeah, I would say that those who are closest to the problem are definitely oftentimes more close to finding a solution to the problem. I actually gave a talk one time that I talked about how health care’s failures fuels innovation. Because when you’ve experienced that pain point, when you’ve experienced that problem, chances are you have an intrinsic motivation to try to solve it.

And that was the case for me. Working within a health care system, fortunately, I haven’t had any personal negative health care experiences. But working within an academic medical center, I saw firsthand how institutional racism worked within those systems. I remember how I was dealing with microaggressions, and how that started to take an impact, or that started to have an impact on my health. I was breaking out in chronic hives working within this particular department. That I was warned, “You should not work in that department if you’re a Black woman.” I needed to work there to satisfy my graduate school internship requirement.

And so, that experience really showed me how dealing with racism, and the bias, and the “microaggressions,” that we experience, they don’t always feel micro to me, so that’s why I said that. But dealing with those issues, they do take a toll on our body. I know that there’s the theory of “weathering” — Dr. Arline Geronimus. It talks about the racism and sexism that Black women, and discrimination that we experience, or Black people experience, over the course of their life starts to take a toll in their bodies.

So having that experience and seeing it in real time in my life kind of gave me the motivation. I was angry about the state of affairs for health care for Black women and didn’t see any solutions in the market that were really speaking to that or addressing those specific pain points.

I think that that’s oftentimes the case for most, especially Black entrepreneurs who are building in health care. They’ve experienced some type of pain points, some failure of the health care system, and set out to solve that problem, and then it led into a business opportunity.

JOEL BERVELL: Absolutely. I mean that’s the best business opportunities that are out there. The ones where you find the unmet needs that people have been asking for, and you bring your lived experience into fixing that. So thank you so much for what you’re doing. Right now you’re also working on a second opinion app. Can you explain a little bit what you’re doing there and why that’s needed?

ASHLEY WISDOM: We’re going to be launching Second Opinion Consults, focused on fibroids to start, for Black women. And the reason being the NIH has a statistic that shows by the time women, Black women, turn 50, 80 percent of Black women would have been diagnosed with fibroids at some point in their life.

That’s a significant number. There’s also data that shows that Black women are disproportionately told to get, or referred to get, hysterectomies when there are less invasive interventions that should be offered to them. Because of that, oftentimes Black women are looking for second opinions. Like, “This doctor is telling me I have to get a hysterectomy, but I know I want to have children,” or, “I just don’t want to have to go through a hysterectomy. That’s a pretty serious surgery.” They should be given a space to get a second opinion from a doctor who they know has been vetted by a trusted platform or a group of people so that they can get a second opinion and feel like, “Hey, I have all the information that I need to make an informed decision about what’s in the best interest for me and my health.”

So we’re starting off with fibroids, again, because of the disproportionate impact that it has on Black women, and the disproportionate referrals to hysterectomies and invasive interventions that Black women often get. I’ll also add that telehealth — I kind of alluded to this at the beginning of our conversation — that there’s an opportunity to leverage technology to bridge the access gap between Black patients and Black providers.

For every Black patient that wants to see a Black doctor for in-person care, that’s likely not going to be the case just given the statistics of how many Black doctors exist, and versus how many Black people exist within the U.S. That said, there’s an opportunity to leverage telehealth as a way to connect patients to providers of color to get second opinion consults, or even for just virtual care. And so, that’s the role that we’re playing with our platform. We’re going to be launching that later on this year.

JOEL BERVELL: I’m so glad you brought up telehealth because I think that’s such an important point for how to reach patients who’ve maybe not had access. And like you’re saying, haven’t been able to find a doctor in the area, but they know they exist out there, and just want to have that access.

It really surged, especially during the pandemic, availability of that remote option accelerated, and it worked for a lot of people. But since then a lot’s changed, from licensing to privacy. From your experience, what are Black women saying about their interest in telehealth? From our perspective, it looks like a great option. But does everyone think that way, and are there gaps in how it can actually help out? What are we missing right now in order to get it to be at a place where we can actually be using it in order to bridge the gaps in health care disparities?

ASHLEY WISDOM: So actually, a Rock Health study showed that . . . a report rather, showed that telemedicine has gotten to the 80 percent adoption rate. So that, I think we all kind of know that we can credit that to COVID, and the need to push to telehealth or virtual care during a time where patients weren’t able to go for in-person care.

And underserved communities, historically, marginalized communities actually have seen an increased adoption to telehealth solutions. And the report also called out that asynchronous synchronous consults actually have been in higher demand from patients who are utilizing telehealth. That’s been interesting. Seeing that data was great validation for us. We’ve gotten feedback that they want a telemedicine solution to connect them to culturally responsive health care providers. To augment the care that they may be limited to, based on their insurance network, or based on where they’re located geographically.

I do think that there are gaps and hurdles to overcome when it comes to making telemedicine a bit more accessible, especially with licensing. And so, on our side as a tech company, we’re going to have to make sure that all of the clinicians or physicians that we employ or contract with, that they are licensed in all 50 states to make sure that we are able to meet the needs of women irrespective of where they may be located.

Some of those remaining gaps that exist with accessibility is . . . sometimes people in rural areas don’t have broadband access and won’t be able to do a video consult. Which also, again, could make the case for why second opinion, or even audio-only, consults could be a stopgap for that. But in addition to that, there’s also the lack of data. They may have smartphones, but they don’t have the data to also be able to join a virtual visit with the provider. So there are some structural things that still need to be addressed in order to make sure that telemedicine and virtual care is as accessible to as many patients as possible.

JOEL BERVELL: That digital divide that you kind of talked about, the divide between people that can and can’t use just digital resources is huge, especially for Black Americans. Lower levels of Black Americans make up digital workers overall and live in more areas that don’t have access to broadband, or areas that don’t have free WiFi at the library or other places like that. Are there other regulatory challenges? You mentioned one being that physicians have to be licensed in all 50 states. What are other regulatory challenges are being faced right now in order to get telemedicine to be off the ground?

ASHLEY WISDOM: I think also the types of providers that are able to provide virtual care services. There aren’t as many physicians as there are the ability for nurse practitioners to provide those virtual consults. I think enabling different types of health care providers to be licensed and supportive with providing virtual care services, especially when we think about mental health. Making sure that therapists also are able to expand their licenses to provide services beyond specific geographic areas.

JOEL BERVELL: Absolutely. One thing I think about too is just . . . I mean, I’m from a younger generation. I call myself a Zellenial. All right, between Gen Z and Millennial. But it’s also been very fascinating seeing older doctors adopt technology. And so, I was not necessarily concerned about that, but curious about how it would work for people that maybe aren’t used to it.

I know my medical school, now, we actually learned how to give virtual care, and it’s pretty . . . it can be difficult if you’re having to evaluate a patient for a torn knee ligament without actually seeing them. Sometimes you have to get them to come in. I’m curious: what are your thoughts on some of those digital literacy issues when it comes to our current physician workforce and the future physician workforce?

ASHLEY WISDOM: I definitely think that health care institutions, health systems, academic medical centers should provide that training. And that could be CMB-accredited to incentivize folks to get outside of their comfort zone and learn how to provide care through these different modalities. I think that that’s definitely one of the ways that we can address that. I know on the patient side, which is where a lot of my focus or emphasis tends to be on, there are companies that are creating solutions to support older patients with how to navigate apps, how to utilize their EHR, and see their medical records.

That’s been really great to see how the digital divide is being addressed on the patient side, but you raise a great point around providers. If there’s interest, be able to learn how to provide care through different modalities. And virtual care right now is top of mind for a lot of folks, that they shouldn’t be left behind.

JOEL BERVELL: Absolutely. Yeah. Can you describe for listeners what women’s primary life events are, and how those tend to generate needs or requests for health care support? Especially when it comes to mental health support? For example, we know that reproductive events starting with access to contraception, fertility and conception, access to abortion, birth experiences, and postpartum depression are all triggers that lead you to request health care. Are there other ones that you’ve seen just from working within your community that you’ve heard from women about, these are key things that lead me to go to the physician, to the doctor?

ASHLEY WISDOM: So many women between ages 18 up until 34, a lot of women talk about going to college. Sometimes, I’m in a new city, and I need to . . . this is my first time managing my own health without the support of my parents. That tends to be a really critical moment in a woman’s health care journey of, how do I start to vet out health care providers that I feel comfortable with? How do I know what questions to ask and what things I should be prioritizing as a new young adult trying to manage my health?

Women have also shared entering the workforce, and when it comes to mental health, being a Black woman entering into corporate spaces where sometimes you may be the only, or very few, that, that can be a trigger for needing mental health support to learn how to navigate a professional setting.

Those have been too, have been brought to our attention, is like these are kind of moments in time that women really need extra support with engaging with health care, and finding the most appropriate health care providers to support them with their needs in that particular moment in time.

JOEL BERVELL: Absolutely. I feel like there’s been a lot of conversation, writing, podcasting even, about the state of Black mental health care, specifically in the wake of George Floyd and the pandemic. When you launched, you mentioned that you anticipated mental health needs. How has your hypothesis tracked with the feedback that you’ve got in demand, especially now?

ASHLEY WISDOM: Yeah, so when we launched our Care Squad program and care squads are physician designed peer support groups. For each care squad, it’s focused on a particular health condition. For example, fibroids, we’re getting ready to launch a care squad focused on fibroids, endometriosis, or care experiences like mental health and wellness, or managing postpartum recovery, navigating fertility.

Each care squad curriculum has been designed by a board-certified physician that specializes in that particular area. The women have access to this educational content that’s also culturally tailored, and they’re matched with a cohort of six to eight other Black women who are either managing that particular condition or going through that similar care experience.

When we came up with a concept for care squads, we wanted to match health education with community for support. We started to think through, “Okay, what are the conditions or care experiences that we wanted to focus on first?”

We are very much community-driven. We don’t believe in just building products, and then people will come. We want to hear from women what they want. And so, we surveyed women and we asked them . . . we basically put about five different topics in front of them. The first being mental health and wellness. One being fertility issues, the other being dermatological issues, and then postpartum support. Then we left an open field for like, “Are there any other topics that we didn’t list here that you’d be interested in seeing a care squad built around?”

We got over a hundred responses, and about 60 percent of them requested or wanted to sign up for a mental health and wellness care squad program. And that’s why that was the first one that we developed, and it was the first one that went to market because our members really were looking for support with managing their mental health and wellness.

JOEL BERVELL: Wow! That’s a huge number, that so many people were saying the same thing, that they needed that specific service. I guess, I mean, it makes sense. Historically, women are twice as likely to experience an episode of major depression as compared to men. Yet, studies do show that Black women are only half as likely to seek help. We’ve talked about availability of providers, stigma — all these barriers are real. What is your take on how much has just been talk, how much has been action in terms of changes that are being made, and how effective has the action been?

ASHLEY WISDOM: Yeah, I think there has been a lot of talk for a long time. I do think we’re at a head now, where when COVID hit, we recognized that there was going to be a huge mental health crisis off the heels of COVID. And the Black community was impacted the most severely by COVID. If the mental health crisis is right on the horizon, you can only imagine who’s also been the most severely impacted by mental health issues related to COVID, not related to COVID, and it’s largely Black people.

And women engage with the health care system more frequently and typically are the mental health decision-makers in their household. And so, we want to . . . not to say that women are more important, but we really want women to be well, especially if they’re having to be the caretakers for other people.

And so, I’m glad that I’m now seeing more conversations about more integrative approaches to health care, and not just talking about women’s health through the lens of maternal health, or reproductive health. And part of that holistic care is making sure that our mental health is taken care of. I’ve seen brick-and-mortar companies that are now bringing health care, bringing mental health care into the same space as primary care. And so, I’m starting to see the beginnings of people being more thoughtful about the delivery of mental health care and how to make it more accessible, and how to make it less stigmatized so that more women are able to access it.

JOEL BERVELL: Tell me what you see in the pipeline for culturally competent care, and do you see young professionals ready to answer that call?

ASHLEY WISDOM: I think now that people are connecting the dots between how culturally competent care is improving outcomes, reducing costs, and the health care system is starting to put things in place to incentivize providers to care more about that, that we’re seeing people shift away from the status quo, and think about ways that they can learn how to provide culturally competent care.

Like, for example, we’re really thinking through transparency. Any provider, irrespective of race and ethnicity, can sign up and join the Health in Her HUE platform, go through our onboarding process, commit to our health equity pledge. But we also allow our members to leave reviews on the providers based on bedside manner, the ease of access to creating an appointment with that provider, the way that the patient perceives the cultural sensitivity of the provider. Creating that transparency so that women can say, “Hey, I saw this provider, and here’s how my experience was,” so that the provider can see the feedback and also so that other women can feel confident or comfortable based on the experiences of another patient.

One of the ways that we thought through partnering with companies like Violet is, as providers engage with that training, it’ll be reflected on their provider profile. Let’s say you’re a white doctor, white cishet [cisgender and heterosexual] doctor, but you’ve engaged with training that supports you in learning how to provide more affirming care to a Black LGBTQ+–identifying patient. That you’ll have a badge on your profile that shows that you’ve engaged with content that’s kind of trained you to provide more affirming care to patients of that community.

And so, those are some of the ways that we can start to, one, train health care providers in providing more culturally competent or culturally responsive and affirming care. And then also creating transparency on the patient side that, although this provider may not come from your same community or identify the way that you identify, they are going the length to learn how to provide that culturally competent care to you.

JOEL BERVELL: Absolutely. And as we close out this conversation, I just want to hear from you, what are your most urgent agenda items the next three years, and the next five years?

ASHLEY WISDOM: My most urgent agenda item is making sure that Black women feel connected to a point of care where they feel affirmed. Health in Her HUE’s name, the HUE obviously represents color, but it’s actually an acronym. So it’s Health in Her Heard and Understood Experiences. And that’s really what we’re trying to accomplish. We want Black women and women of color to feel heard and understood in their health care experiences and be connected to providers that can provide that type of care.

There’s a report that showed that one in five Black women actually avoid seeking care because of the fear of experiencing discrimination. For me, that’s very frightening because that means you’re likely not engaging with preventative health care, and that can mean later diagnoses for you or misdiagnoses. And so I really want Black women to engage with more preventative health care so that, let’s say by the time a woman wants to have a child, that she’s been able to maintain her health in a way where she’ll have a healthy pregnancy. I’m really thinking through the upstream ways that women of color can manage their health effectively, so that they have better outcomes long term.

JOEL BERVELL: Amazing. Ashlee, thank you so much for joining us on The Dose, and for making sure that women everywhere are being heard and understood. I appreciate everything that you’re doing, and I know so many people do too. Thank you so much.

ASHLEY WISDOM: Thank you for having me, Joel. This is great.

JOEL BERVELL: This episode of The Dose was produced by Jody Becker, Mickey Capper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is “Arizona Moon” by Blue Dot Sessions. If you want to check us out online, visit the dose.show. There you’ll be able to learn more about today’s episode and explore other resources. That’s it for The Dose. I’m Joel Bervell, and thank you for listening.