Category: Guest Blogs

I was pregnant and labeled high-risk due to my “advanced maternal age” (a term I hope someone revisits in the near future). My regular ob-gyn recommended that I see a high-risk specialist because I had miscarried during my first pregnancy and to make sure the pregnancy was advancing as expected. During my first trimester, my pregnancy visits were filled with anxiety, especially given my prior miscarriage. Visiting the high-risk specialist was no exception.  I recall my husband gently taking my hand in the waiting room and quietly reminding me that the visit was just precautionary.

We were led into the exam room for an ultrasound and to meet the specialist. I undressed nervously and put on a paper gown. The medical assistant asked me to lay on the exam table with my feet in the requisite stirrups; I waited for the physician to come in, my husband sitting beside me in a chair. You learn to accept that vulnerability and pregnancy go hand in hand. In this case, I was feeling particularly exposed (pun intended) with a thin piece of paper separating my naked body from anyone who walked in the room, my legs in the air. But I trusted that this was all just part of the health care experience.

The physician walked in the room, with a male medical student trailing behind. He proceeded to introduce the student to my husband, but not to me. The student shook hands with my husband. The physician, whom I had not met before, didn’t directly acknowledge me. I think the student was somewhat embarrassed that he was not introduced to me and so he awkwardly said hello – all while I was laying on the table, legs in the air, exposed to the world. The rest of the visit was somewhat unremarkable. The physician completed his exam and the pair left the room. 

I went on to have a healthy, beautiful baby boy with my regular ob-gyn. But that visit left an indelible mark. Did the physician and his student not acknowledge me because I am a woman? Was I somehow considered inferior because I am a woman and did not deserve acknowledgment? Why did he shake hands and engage in conversation with my husband and not me? It all left me feeling even more vulnerable. And sadly, the physician was setting an example for his student. How many other women would experience the feeling of being “less-than?”

I have spent much of my professional life advocating for patients in vulnerable communities. My experience was minor when I think of the number of women of color who have felt vulnerable and ignored in health care settings. Building trust in health care starts with the very basics: courtesy, respect, and dignity. A kind word, an acknowledgement of me and the vulnerability I (along with every other woman I know in that situation) felt at the time, and perhaps a better gown, would have gone a long way to eliminating fear, establishing a trusting connection, and having a satisfactory patient experience.

With a lifelong passion for ensuring that all individuals have access to high-quality healthcare, Wendy has served in senior leadership roles in patient advocacy, quality, and patient safety in a variety of healthcare settings. She is currently the President of the Health Care Improvement Foundation, an organization committed to improving the health and lives of the community through collaborative solutions.

I had tears in my eyes, and I was not alone.

The whole room was silent as Charles Johnson told the story of his wife Kira. Kira was healthy, fit, full of life, and gave birth to her second son, Langston, via C-section. Twelve hours later, she was dead. 

Minute after minute, hour after hour, frantic calls for assistance went ignored, and Kira slowly bled to death from an undetected hemorrhage, from care delays, and perhaps because she and her husband were not the same color as other moms in the unit. In the 12 hours between when Kira brought life into the world and lost her own, her husband pleaded with medical staff to tend to his wife’s worsening condition, only to be told that she “was not a priority right now.” She died in one of the nation’s leading hospitals, surrounded by technology and people that could have saved her.

Charles told us (the leadership of UnitedHealthcare) that Black mothers die at 3-4x the rate of white mothers. He told us about the rising maternal mortality rates in the U.S., and he challenged us to fix it.  He said, “If you can fix it for moms like Kira, you can fix if for the nation.” 

We took Charles’ challenge as a call to action. We got to work.

Focusing on three states, UnitedHealthcare identified gaps in care among our Medicaid enrollees for postpartum care, and designed culturally and regionally tailored interventions to reduce disparities. We focused on promoting early and comprehensive postpartum care. We supported community health workers to evaluate and assist members with their unique needs in Michigan, Ohio, and Hawaii. These activities included home visits, local primary care and obstetric nurse partnerships, and care coordination. As a result, between 2018 and 2019, UnitedHealthcare reduced disparities in timely postpartum care for Black women by 42.4% in Michigan (from 15.1% to 8.7%), 83.2% in Ohio (from 19.6% to 3.3%), and 40.3% for rural women in Hawaii (from 12.9% to 7.7%).

While I am proud of this work (led by Mike Currie, our head of Health Equity Services, and Janice Huckaby, our CMO of Maternal-Child Health), and it received a 2020 CMS Health Equity Award, I am still troubled. 

How do we just make things work without the need for a “special program?” What do we need to today so there are no other Kira’s? 

Can I look Charles in the eye and say, “We’ve fixed it?”

For more see:

• https://4kira4moms.com/
• https://www.cms.gov/About-CMS/Agency-Information/OMH/equity-initiatives/equity-awards

The Johnsons’ story is in the public record, re-told here with Mr. Johnson’s permission. The views expressed in this post are my personal opinions and are not those of UnitedHealth Group or its affiliates.

Lewis G. Sandy, MD, FACP, is Executive Vice President, Clinical Advancement, at UnitedHealth Group where he focuses on clinical innovation, payment/delivery reform practice and policy, and physician/health professional collaboration.

I am an African American woman in my 50s who grew up in the inner city of Cleveland. I still reside there, and I live with chronic pain every day. I am a patient who has experienced unpleasant, unnecessary and unjust situations while navigating the U.S. health care system.

When I was in my 40s, I experienced an awful miscarriage at home. After arriving at the hospital with the father of my children, I waited in a partitioned room in the ER for several hours alone, feeling sad, guilty and hurt, and not fully understanding what had just happened. My partner chose to stay in the waiting area because he was just as sad, hurt and confused about what had just happened to us. While I waited in the ER, the fetus was placed on a metal tray nearby and covered with a white cloth. Eventually a nurse came over and asked “Do you want the fetus to be sent to the lab?” I was confused by the question and unsure about what sending the fetus to the lab really meant, but I said yes.

I was then discharged without any of my clinicians asking how I felt. No one knew, or seemed to care, what state of mind I was in after having just lost a child. I went home alone. Later, a nurse practitioner friend of mine told me what agreeing to send the fetus to the lab really meant. I never saw my baby again and never had a chance to say goodbye. When discussing this with a social worker at a follow up appointment I was told, “Oh, you can have another one.”

A few years later I was diagnosed with Ankylosing Spondylitis, an inflammatory disease that, over time, causes small bones in the spine to fuse together, resulting in joint and back pain, and making the spine less flexible. I was the third in my family to receive this diagnosis. After many visits to pain specialists, it was suggested that I undergo radiofrequency ablation to help ease the pain associated with the condition. I was very upset, angry and depressed to learn that my health insurance would not approve the light sedation recommended for such a procedure. The only relief the insurance company approved for the painful procedure was a numbing medication. That was one of the worst procedures I have ever had.

Some weeks later I met with a rheumatologist to discuss the positive results of my HLA-B27 test. He entered the room and asked “Why are you here today?” I shared my test results with him. He replied “This is a Caucasian disease. Do you have Caucasian in your family?” I didn’t know that diseases saw color. Did my care depend on how I answered that question?

I asked the rheumatologist if he would discuss my symptoms with my pain specialist. He did, and at my next visit with the pain specialist, my cousin also shared her diagnosis with him and explained that she had previously experienced the same symptoms and pain that I was now having. He sarcastically commented, “Oh, you didn’t need that radiofrequency ablation after all?”

And when I wrote down some symptoms that I was experiencing and gave it to my doctor, he dismissed me immediately, folding up the piece of paper and putting it in his pocket. This happened again when I met with a new rheumatologist.

I often wish for my doctor to be someone who can relate to me. I want them to really hear me and value what I have to say when it comes to my care, and be sensitive to the many challenges and health disparities I deal with on a daily basis. I want them to let go of any negative impressions or stereotypes they may have of me and see me for who I am, a human being. I ask that clinicians deliver quality care, listen and empathize with patients. Get involved and advocate for changes to our health care system. Join Health Improvement Partnership-Cuyahoga (HIP-C) in addressing structural racism. Read Health Disparities: Weaving a New Understanding Through Case Narratives. Recruit community health workers and staff members who reflect the diversity of the communities they serve. Finally, provide more cultural competency training for clinicians and build partnerships with grassroots organizations who are the boots on the ground.

Delores Collins aka Ms. Dee, C-CHW, earned her Associates of Science Degree in Interdisciplinary studies – Early Childhood Development from Kaplan University. She is the Founder and Executive Director of A Vision of Change, Inc. (AVOC), which offers prevention, intervention, and academic services throughout Ohio.

My one-year old grandson has a “lip tie.” His mother is a Black registered nurse who provides home care. My son is a laborer.

After a visit to a pediatrician in mid-June 2021, my son called and shared with me that when my grandson was examined, the pediatrician confirmed that indeed it was a lip tie. A lip tie can make nursing challenging and create issues with weight gain in newborn babies. This condition is not hard to spot and is simple to treat with the help of a pediatrician and lactation consultant. The pediatrician’s advice was to leave it alone and that most likely my grandson would “fall on his face” at some point and the trauma would tear the lip tie free. My son and his partner, angry and in tears, said they would never return to that doctor. Young Black adults, ages 18-39 years old, have the lowest levels of trust for doctors and hospitals.

Caregivers must become more competent in collaborating with all people receiving care, especially historically marginalized populations. They must develop responses to vulnerability, rather than assuming the care teams alone have the answers, and they must be aware of interpersonal privilege and power hierarchies. Caregivers and care teams have to learn to recognize power hierarchies, practice humility, work to close the power distance where they can, and use their status for good where appropriate and possible. These things build trust. 

The health care community can commit to removing barriers and building trust by taking these steps:

• Share power with all people of color and elevate their voices and concerns.
• Educate yourself about racism (interpersonal, institutional, structural), understand it and join in the work to dismantle it.
• Set out on a personal journey to reflect on your own privilege.
• Acknowledge that you will never fully understand the lived experiences of people of color, but that you can respect and value that experience.
• Acknowledge the injustice of both the past and the present.
• Take action to help repair and heal our systems and communities by using your power in your sphere of influence to advance equity.

Trust, once lost, takes time and significant effort to rebuild. We must commit to earning trust every day through action and changed behavior. Showing love, apologizing and seeking reconciliation are keys to restoring trust.

With the removal of these barriers, better ability would enter health and healthcare services. The industry would become more honorable, more endurable and more attractive to people of color, who we sometimes forget are also human beings, and naturally wish to live the lives of human beings (adapted from W. E. B. Du Bois, 1899).

We will breathe again, a collective breath of justice, equity and liberation.

Dr. Ronald Wyatt is Vice President and Patient Safety Officer with MCIC Vermont, a major medical malpractice company. He is an internationally known patient safety and health equity subject matter expert and is faculty on the IHI Pursuing Equity Initiative and the ACGME Equity Matters Initiative.

The Kaiser Permanente Health Care Program has historically had a special relationship with the African-American community. Part of this relationship dates back to the early years of World War II. In January 1942, as the American merchant marine fleet was being decimated by Axis submarine attacks, President Franklin Roosevelt called upon the industrialist Henry J. Kaiser to rapidly organize to produce replacement ships, which later became known as “Liberty Ships.” By June, Kaiser had organized a force of over 90,000 workers and was producing ships in Oakland and Richmond, California and Vancouver, Washington.

Many of these men and women were African-Americans who had migrated from the South in search of work. They weren’t eligible for military service at the time, and Kaiser was seen as trusted figure among working people. In the end, these ships and the people who produced them were vital to our ultimate victory in the war.

In recent years, Kaiser Permanente intensified its focus on control of hypertension. Hypertension and its sequelae are more common among African-Americans, especially men. And most studies have shown poorer control of blood pressure among African-Americans than in other racial groups. In seeking to address this disparity among its own members, Kaiser Permanente needed to deal with the prevalence of mistrust of American health care among African-Americans, particularly because memories of the Tuskegee “experiments” persist.

In 2000, Kaiser Permanente developed a large-scale program to improve blood pressure control for all of its members. By 2010, despite great general progress, it was evident that even in Kaiser Permanente’s pre-paid system, African-American members still had lower control than members of other racial groups. So in 2010, Kaiser Permanente instituted the Equitable Health Care Outcomes Program (ECHO). One of the first priorities was to once again address the disparity in hypertension control for African-American members. ECHO is a multi-part program, one aspect of which is outreach to the African-American community through education and culturally appropriate trusted communication techniques. By 2014 the disparity in hypertension control had been halved: from 8.1% to 3.9%. An independent analysis of preventive services in Medicare Advantage plans, published in the same year, showed no racial disparity in hypertension control in Kaiser Permanente. This was not the case in the other plans studied.

There are already indications that hypertension control levels among all racial groups slipped during the COVID-19 pandemic. Equally worrisome are reports that COVID-19 vaccine acceptance among African-Americans is low, again because of distrust of the heath care system. Now is the time to begin anew, to organize systematic coordinated care and communication processes tailored to the African-American community to increase their trust in our health systems. We must replace the toxic legacy of Tuskegee with new examples of health care equity for all, and embed equity in our shared consciousness and consciences.

Dr. Crosson worked as a practicing physician and executive for Kaiser Permanente for 35 years, including 10 years as the Executive Director of the Permanente Federation, the national physician component of Kaiser Permanente. He subsequently served as a Group Vice President of the American Medical Association and as Chairman of the Congressional Medicare Payment Advisory Commission (MedPAC).

I work in a large safety net hospital in Boston. Early in the pandemic, when all of the primary care clinic operations were closed, I began to do COVID-19 screening in our Influenza Like Illness clinic (ILI). Unfortunately, we had few test kits available at the time, which meant testing only the highest-risk individuals. I remember having very difficult conversations with patients about why I couldn’t test them, even though I knew there were drive-in clinics across town testing any patients who came through. Fast forward to the availability of COVID-19 vaccines: we now have an abundance of vaccines in stock but face a very large minority of patients who deliberate whether or not to receive them. The question that I heard once – but I suspect has been voiced multiple times – is: “You wouldn’t test us when we asked to be tested. Now you want to give us something we don’t know the long-term consequences of?”

We’re struggling to vaccinate all of our patients (many of whom are at high risk of serious COVID-19 illness) because there is clear lack of trust in the health system to do what we clinicians believe to be in patients’ best interest.

I’m reading Medical Apartheid, a book written in 2007 by health and science writer Harriet Washington, who chronicles hundreds of years of medical mistreatment and involuntary experimentation on African Americans. Considering this history, I fully appreciate why our patients are very ambivalent about something many physicians see as potentially lifesaving. Most everyone is familiar with the Tuskegee Study, a federally sponsored study of the natural history of syphilis that ran from 1932 to 1972 in which treatment was withheld from a cohort of African Americans who had been told they were receiving treatment. What many people don’t appreciate is the long history of enforced experimentation on enslaved people in our country, including surgical procedures (without anesthesia) by some of medical history’s “giants.”

So how do I, as a white male physician with clear privilege, establish trust with my patients so they will accept the vaccine that I believe could save their lives as newer, more deadly variants come into our community? A few of my patients have told me that my recommendation is sufficient for them. But I most often hear “I’ll wait and see.”

My institution is working diligently to identify ways to engage patients in this conversation and move them from ambivalence to acceptance, but it’s difficult. Even our clinicians of color are struggling with this. We all know that lost trust is hard to regain. It begins when all patients feel welcome wherever they go for care. All patients need to feel that they are heard and that their concerns are validated. There also needs to be a universal commitment to eliminating racism from health care. This won’t happen overnight, but every institution needs to start right away. The next pandemic is not far off.

Dr. Tulsky is a primary care internist at Boston Medical Center. He also serves on ABIM governance as the chair of the Internal Medicine Specialty Board and chair-elect of the ABIM Council.

“Assaultive: Patient attempted to strike a nurse in the face with his fist. Plan: Notify Public Safety when patient is present for treatment or services. Public Safety will work collaboratively with clinical/administrative staff to determine appropriate action plan (i.e. patient-safety search, extra patrols, short-post, etc.) when at all practical.”

This could have been my father. In a fit of delirium near the end of many years struggling with early onset Alzheimer’s disease, he was uncharacteristically assaultive to my mother during one of her visits, pushing her to the ground and pulling her hair. I don’t know if a similar public safety alert is highlighted in yellow in the corner of my father’s hospital chart, but it stung to read the alert about my patient, Mr. S, and imagine the assumptions another provider might arrive upon when scanning the chart. Or to envision a random “patient-safety search” launched against Mr. S at an outpatient follow-up visit.

Like my father, Mr. S was a gentle giant with an easy-going and humble air about him. That was until sepsis, strokes, and uremia from missing dialysis due to line access issues left him utterly confused about his surroundings and distressed to the point of trying to flee, culminating in the aforementioned event. Thankfully, a combination of antibiotics and hemodialysis delivered Mr. S out of his delirious agitation within a day or two. But I worried that this written notification could have longstanding and potentially dangerous health effects for Mr. S.

I did not have the same concerns for my father. My father was a white man and Mr. S is a Black man. My parents and I have had the privilege of navigating the hospital system and the outside world without constant concerns about being mislabeled as public safety threats. 

When I wrote the administration to dispute/amend Mr. S’s public safety flag, I was told that the public safety flags are an “objective documentation of a safety event” and not meant to be punitive. But there are many decisions and biases that enter into how an event is reported, be it in a public safety flag, in a patient history and physical, in a newspaper article, or in a textbook. Deciding what context to include or exclude is one factor that shapes the narrative. Moreover, the flag system may not be intended to be punitive, but the recommended actions (searches, patrols, and short-posts) have toxic effects on a person’s trust of the medical system and clinicians within it. A letter from a group of sickle cell clinicians at my institution documented several instances where Public Safety’s involvement triggered by the flag system led to humiliating and dehumanizing experiences for Black patients, including seemingly unwarranted physical searches and escorts. Mr. S is not a public safety threat and I will keep advocating for his flag to be removed.  

Public safety flags are commonplace across electronic medical systems in the United States. I fear that these flags can be weaponized in the way that a call to 911 in the outside world can be used to endanger a person of color. Are the public safety flags making the medical community – both staff and patients – safer? Or are they perpetuating systemic racism within a setting intended to care?

Alyse Wheelock, MD is a second year fellow in Infectious Diseases at Boston Medical Center. Her research interests are in Chagas disease and other tropical diseases affecting immigrants and refugees in the United States.

As a child, I was taught that we dress in our Sunday best when going to the doctor. Why? Growing up, we were told stories of health care practitioners mistreating patients based solely on their appearance, or even the neighborhood they came from. So, if we wore our very best clothes, then maybe…just maybe…we might be taken seriously. We might be seen, heard and trusted as patients. And in turn, the likelihood of being mistreated subsided.

Each of us has, at our deepest core, the need to be seen and heard. We want our experiences validated, and we want to know that our voices matter. But what happens when you are not seen or heard? What happens when individuals, organizations, or even professionals don’t see you or don’t hear you? 

In the last year, we have seen the centuries-long disparities in health care further exacerbated by the COVID-19 pandemic. We have watched in real time how the pandemic disproportionately impacted Black, Latino, and American Indian/Alaska Native people with significantly higher infection rates, hospitalizations, and deaths. What is clearer than ever is that health is foundational and anything that makes it harder for us to get healthy, stay healthy, or recover when we’re sick will inevitably widen the longevity gap.   

Several months ago, my primary care doctor referred me to a specialist. The specialist was nearly two hours late for the appointment. When he finally entered the room, he quickly asked me a series of questions and, two or three words into my answer, he cut me off and told me what he thought was going on because he had “seen” previous cases like this. I barely got a word in. As he continued talking over me and at me, his phone rang. He picked it up mid-sentence and started talking about another patient to the person on the line.

Following their conversation, he returned his attention to me and picked right back up where he left off. The entire encounter was rushed. He asked the questions and seemed to have all the answers – all because two words into my visit he decided he’d “seen” this before (even though I was a brand new patient). At the end of the appointment, I did not feel seen. I did not feel heard. And I had no sense of trust. Competency and credibility are one thing. But there is no trust when there is a lack of empathy, communication, and eye contact. Patients can and sometimes do leave a doctor’s office scared of impending test results, or nervous about a diagnosis. No one should have to leave a doctor’s office feeling devalued, disappointed, angry, and discouraged. 

It’s easy to look at disparities in health care as a crisis that is too big to solve. It’s not. Rather than thinking about overcoming these obstacles as a measure of success, we need to think about removing or preventing these obstacles in the first place. As health care professionals, simply taking the time to make patients feel seen and heard will build trust. You’re the ones on the front lines, seeing those who are hurting, listening to a list of symptoms, examining the situation, and solving a problem. 

With trust, patients will have the ability to make the best decisions for themselves and their families. It won’t matter if physicians see us in our Sunday best or in an exam robe. If we foster trust, we’ll see each other as human.

Jean Accius, PhD is senior vice president for AARP Thought Leadership and International Affairs. His areas of expertise include aging, caregiving and long-term care policy.

During intern year I introduced myself to Mr. Smith (name changed), an older white man.

“Hello I am Dr. Adetoye. I will be taking care of you during this hospital admission.”

When the attending led us back to the room for team rounds, Mr. Smith addressed me as a nurse.  The word hung in the air, but no one, including the white attending physician, addressed it. The intersectionality of being a woman and a woman of color meant that I was unsure which had triggered this comment, but I was uncomfortable either way.

I wanted to talk with someone who would understand. But in my large department, there were only two Black female physicians. I was a new intern, and I hesitated to burden them. I did not want to add to their ‘minority tax’ burden as the only Black woman on faculty. So, I kept it to myself.

In my last year of residency, I was working in a hospital in a predominantly white rural community. While writing patient notes, I overheard two men and a woman outside the room discussing whether it was appropriate for police to kneel on George Floyd’s neck when he was resisting arrest. They agreed it was, though the woman felt he should not have been allowed to die. When I stepped into the hallway, the two white security guards and white nurse that had been conversing stopped abruptly and watched me pass. I kept walking.

Down the hall, I passed a Black security guard and impulsively thanked him for being there. He said, “You are welcome, Doctor. Things are crazy out there. I will be here all night. If you need anything, do not hesitate to ask.” I thanked him again, slipped into my call room, and began to cry.

As the sole Black resident in this hospital, I was afraid and stunned. How could the staff that I relied on discuss the merits of murder? This time, I talked to my residency leadership. To my surprise and pleasure, they were concerned and responsive, and we worked on ways to improve the climate at the hospital.

We cannot assume that the day-to-day experience of seeing patients is uniform for all. We know there are better patient outcomes and patient satisfaction with racial/ethnic congruence between patients and clinicians. The programs that train young physicians must take the lead to create a safer and more equitable environment for all. This can be done by taking several steps:

1. Understand the communities where trainees work, identify potential challenges, and communicate these with trainees.
2. Make clear that discrimination will not be tolerated by the program.
3. Educate staff and faculty about these experiences and teach them to recognize and address microaggressions and support trainees.
4. Provide time for faculty of color to serve as mentors so minority trainees need not seek this on their own.
5. Institutionalize these policies so they are not dependent on the good will of one individual.

We can do better. Increasing medicine’s physician diversity and supporting trainees with these difficult experiences will prepare us all to better care for the world’s diverse patient population.

Dr. Adetoye is a Clinical Lecturer in the Department of Family Medicine at the University of Michigan. She attended medical school at Michigan State University and completed a residency in Family Medicine at the University of Michigan.

Engaging and sustaining patient and community relationships in health care and health systems can prove challenging, but when health care is practiced in a culturally responsive manner, results can be both rewarding and beneficial to patients and clinicians alike. By utilizing a predetermined safe space for discussions and personal sharing, patients and relevant stakeholders (including front line staff and clinicians) are better able to capitalize on opportunities to listen and learn from one another.

Working together to develop and set terms of engagement can help frame how these discussions can move forward in an inclusive way – where all parties participate in a trust-building decision-making activity.

To facilitate such an activity:

• Discussion participants should determine ‘why’ a change is needed and ‘who’ should be invited to the trust-building decision table.
• Participants should discuss potential barriers to building trust in your health care setting using models where a person-centered balanced approach is taken, not a traditional hierarchal one.
• The room must have appropriate representation. Discussion participants should include historically under-resourced and diverse community members who can provide productive insights so all participants can benefit and learn something new.
• When reflecting on your organization or clinic and determining how to address equity and inequities, review internal anti-racism policies and brainstorm how to build trust within your care system. This is the time to reach out to your local community and invite community members as partners to create a care delivery model that works for them and for you.

Sacrifices will be made, and barriers will be dismantled, while paving relationships and determining together what trust in health care can be. Trust will likely be defined differently by each participant during your inclusive engagement activity. Make the time, be open for frank discussions, and open your heart to build trust and respect with each other. We are only humans after all.

Janice Tufte resides in Seattle and is a patient collaborator involved with health systems research, evidence production, clinical practice quality improvement and human readable digital informed knowledge generation. She recently co-authored a paper currently under review with the Journal of Health Design that discusses the importance of collectively designing research and is working with AcademyHealth’s Paradigm Project in developing a new research protoype.  Learn more about Janice at www.janicetufte.com.