Building Trust Between Provider and Patient | SMA Dialogue Series with Aaron Henry, MSHS, PA-C

Toyese Oyeyemi: I’m really excited for this next edition of the SMA dialogue series coming to us live from Washington, DC. One of my good friends and colleagues, Professor Aaron Henry, who is a faculty professor at the George Washington University in the School of Medicine and Health Sciences. I’m really excited to have you here. Aaron, what’s going on? How are you? 

Aaron Henry: I’m doing great. And I just want to thank you for having me here today. It’s a great experience and definitely, definitely a big fan of the cause. And excited to work with you and SMA. 

Oyeyemi: Man, we’re really excited to have you. It’s been quite the summer. It’s been quite the year. I think we’ve all been trying to navigate a lot of the different policy landscapes in health professions education and health workforce. One of the things that we’ve talked about is the changing landscape in the PA world in particular. I wanted to talk to you a little bit about that.

Also want to make sure that I get a chance to, you know, kind of hear a little bit more. You had a commentary piece, “Why Black Men are Dying to be Successful,” that I actually thought was, for many reasons, really salient and really, really interesting. So I’ll come back to that in a little bit. But, I mean, first I’d love to be able to kind of hear a little bit about yourself so that people know who we’re talking about, a little bit about who Professor Henry is. 

Henry: Sure. So my name’s Aaron Henry. I am a PA. I’ve been a practicing PA for, going on 16 years now. Before becoming a PA, I was a combat Navy corpsman. I served two tours of duty in Iraq. I just always have had a love for science, and I loved engaging with people. 

So pretty early on, I figured out that the health care route was for me. I was on the fence between– I actually was going to be an athletic trainer. My undergrad is in sports medicine, but when I was in the military, I believe I was on my first deployment to Iraq, I met a PA and I was like, wow, that’s what I want to do.

And I was on the fence between med school, PA school when I talked to a couple folks. And they’re like, you know, PA is a really good, good field. And the first PAs were Vietnam era trained Navy corpsmen. So there was just so much alignment and history there. And I got out of the military, got into GW, graduated from the program class of 2010, and I’ve worked in emergency medicine directly out of PA school, pivoted into urgent and primary care and developed an interest in men’s health.

I actually got my health coaching certification, started a men’s health YouTube channel, wrote blog posts. Around the time of COVID I started to get a little burned out. and after graduating from PA school, I would always precept medical students, I would stay aligned with the PA program, and I would teach lectures here and there. And I knew at some point I would want to return to teach. And there was an opening, you know, the stars and planets aligned and I got into faculty in 2022 and I still had my passion for men’s health, especially Black men seeing the disparities. 

And I enrolled into the PhD program at GW in Translational Health Science where my work focuses on improving Black men’s health through bridging the trust gap between Black men and health care providers to improve access, build stronger relationships to decrease those preventable chronic illnesses that go under the radar. Because a lot of them just don’t feel a connection and don’t want to go in and get those preventative screenings. So that’s sort of the, I guess, cliff note version of what got me here, a little bit about my background and with SMA the mission and health care workforce, it just all made sense. So, I’m really thrilled about it. 

Oyeyemi: And we’re thrilled to have you in this space. I appreciate you being able to kind of detail some of your background. You know, one of the things that you mentioned that I actually find to be really interesting is about, and you mentioned this in that “Why Black Men are Dying to be Successful” commentary piece. I had a chance to read it, actually, I was reading it again this morning on the train. And, you know, there’s a couple of things there that I thought right off the top would be excellent to be able kind of get perspective on. You actually just mentioned one of them, which is this idea of mistrust amongst providers, the health care system and Black men in particular.

I know that that’s an area of focus of yours. But the second one, and this feels like, you know, this kind of like a multi-layered, multi-level sort of thing here. You also kind of talk about all of these different sort of structural determinants of health that are not- they have nothing to do with the actual care delivery system, with access to the to the writer, to the interpersonal relationship between a Black male and the provider, but simply the conditions that Black men exist in in the United States and how that actually affects the health.

So we’re talking, at least my interpretation of the way you read you wrote this, which I thought was a really like, terrific piece, is that we’re dealing with a couple of different levels here. I’m talking about Black men and health and health, which is one, those structural upstream determinants, and then of course, more downstream, the relationship with the health care system.

I want to dive into both of those for just a moment, because I’m curious about your perspective on each of those. So maybe we start with the piece that I think a lot more people are a little more familiar with, which is the direct experience with the health care system and even individually with the provider.

Henry: Sure, sure. So for those who didn’t read the piece, I wrote a commentary talking about the paradoxical relationship between Black men of higher socioeconomic status and poorer health outcomes. In most cases, higher pay, higher salaries, more wealth, usually equals better health for most populations, you have better access, can afford the drugs, you can afford more access to providers, essentially, in higher quality care, if you will.

But, what research found there was a study that I quoted in my paper that showed that Black men who have the higher socioeconomic status, I believe, 200% higher than the federal poverty level, actually have poorer health outcomes compared to white counterparts and for a variety of reasons. And that goes into the structural piece that you talk about and there’s a term that we’ve heard of, “intersectionality,” where we look at how various social characteristics tie into someone’s identity.

So, for example, in especially Western society, being a man is often looked at as having privilege. Men make higher pay than women. I mean, these are things that we know. Well, when you throw a race in there, being a Black man, it’s often perceived as, okay, you’re a man, you make higher pay. But when you intersect with race and how discrimination plays, that can have a negative effect.

And for men of higher socioeconomic status, being in those spaces where you don’t see other people like you as well, puts a lot of allostatic load on someone to perform better, to provide for your family. You’re working hard or taking on extra loads, which takes a toll on your health. With sleep, cortisol, stress levels, poor eating, not exercising, not spending time with family.

So that’s what I wanted to touch on and really show: don’t assume because someone has a six figure salary that they’re in good health. You have to look at the person, the whole picture holistically. So that’s what I touched on in that piece with those social determinants of health. You know how those things intersect. 

Oyeyemi:  I remember early in public health training, hearing all of the different examples of, you know, we were always talked about in different correlations and associations between different demographic factors and race/ethnicity.

It kind of what the, how we look at, associate relative risk of certain illnesses and,, what the incidence and prevalence rate is of, across different, conditions. And I remember, you know, thinking one of the most common examples that we had always kind of talked about is that Black women in particular, you know, income and socioeconomic status is not, in fact, a, you know, modifying factor for, you know, for adverse health conditions, particularly as it related to, of course, you know, I think, maternal morbidity and mortality was, you know, often seen as being the, you know, that example that was being used. And so it’s a while to me that there’s all of these different factors that are at play and you talk about intersectionality, those– you just mentioned a couple. There are so many other conditions, and circumstances in which people are living that also have some type of modifying effect. Right? Urban, rural– 

Henry: Your environment. Absolutely. Yeah, absolutely. But then as we touch into what SMA and the Mullan Institute talks about, health care workforce. How the health care workforce, who largely don’t come from minority backgrounds, deliver care to populations that historically are less trusting.  How do you do that? Because that is a barrier. 

Oyeyemi: Well I mean, so, that’s an interesting question because I think, and that actually leads me to sort of like another point that I really want to get your take on this. Often one of the ironies of the work that we do, especially as it relates sometimes to but specifically to workforce diversity, is this idea of, you know, part of our goal is to, you know, increase the diversity of the healthcare workforce, increase the number of underrepresented minorities who are in these spaces, because we know that that is actually a protective factor for community health and a benefit at large for all people, not simply for a specific group. It actually is of benefit to the entirety of our country and to our society to improve the health of communities that have been most marginalized historically. Right. But with many of the different, sort of, methods that are used to address this, like these longstanding inequities, it’s easy for some people,

I’ve seen, you know, come across articles on this, we hear it in some classrooms, we’ve seen all these perspective pieces on it. Some people then I think maybe falsely equate that with, oh, I’ve interpreted that, interpreted that as, a white physician, or a white PA, or a White nurse practitioner is not capable of providing quality care to a Black patient or to a Black community. Right? That’s not necessarily what we’re saying. Is that, is that where you’re, is that accurate to say, is that correct? 

Henry: Absolutely. What I see, and especially being both someone who’s been in the field and worked in emergency medicine, urgent care, primary care, engage with different health care providers, different populations, then also being in health education.

The issue is that a lot of health care providers aren’t trained how to build trust. And that’s my focus for– there is talk or there are sessions in medical school, PA school that talk about social determinants of health. In fact, I’m teaching Health, Justice and Society for the PA program taking over for Dr. Howard Straker, who’s been, mentor, you know, a mentor of mine for, you know, since I was in PA school.

So those courses exist. But what about how to engage with these populations? You know, we learn anatomy, physiology, pathology, histology. But what about those interpersonal relationships where that matters the most? No matter how smart you are, how quick you are to come up with a diagnosis, if you can’t connect with the patient, how is that going to work?

So I think it needs to start there in the health professions. Yeah, there could be workshops and training and there have been many methods to try to resolve, you know, bias and discrimination. But it really, I believe, in my opinion, starts in the health education. It starts while they’re learning those basic sciences, learning how to engage with people. Because we can’t solve the lack of representation in the health professions overnight.

You know, for example, for the PA profession, less than 1% of practicing PAs are Black men. That’s not going to change overnight. Then when you look at the political things that are happening now. But what we can do is design interventions, designed curriculum to train those before they get out into the workplace, especially while they’re very enthusiastic about learning about medicine, because we all came to these fields to help people.

Oyeyemi: Yeah. Well said, And I think the– just to kind of tie that up, the false equivalency around, racial concordance between, you know, providers and patients being the end all be all for how we, you know, resolve patient trust. I think it’s, you know, it’s been overstated and I don’t think it’s accurate.

I don’t know if that is what many people are calling for when they’ve talked about diversifying the health care workforce. I think it really has been a “this and” right? It’s a recognition that we do need more providers of color and exactly what you’ve just touched on, those who are already in training, there are opportunities for those students needs to be properly equipped to be caretakers and healers and, thoughtful, conscious, thinkers when it comes to patient care. And not just on the patient care side,

Right, but also in terms of those of us who work more on the systems and policy side and those of us who don’t have, you know, don’t see patients, but still have influence on the way that patient care is actually delivered. That’s a lot of kind of what’s going on within, you know, sort of, the clinical training component of this.

I want a quick step back, though, and kind of talk a little bit more broadly about the big picture of  it all. The health care system and you talk about mistrust. And I think that something that I know comes up in conversation pretty often in my space is, you know, there’s something about where we are right now as a society that there’s just a general mistrust in a lot of institutions.

There’s a lot of mistrust in a lot of systems. When I say “institutions,” I’m talking about the institution of education, the institution of scientific research, the institution of American politics, the institution of government. There’s so much mistrust now, and, you know, for a multitude of reasons that we probably point to.

Right, you know, misinformation, active disinformation, I would argue that we as a society maybe don’t necessarily value some of the things that maybe we took for granted a little bit more like, you know, reading. I don’t know if it’s really still reading and writing, you know, who would have thought? I don’t know if those things are still being placed on the same level of value as they were, say, 15, 20, 25 years ago?

That’s debatable. You know, I’m always curious to hear other people’s thoughts on that, but like, but you know, what do you what do you think are some of the reasons for this general mistrust, both in terms of the health care system, in terms potentially of a provider, but then also like, what does that say about the bigger concern of mistrust in society and how can we how can we address that? 

Henry: Well, I think you touched on a couple of big things and there’s a lot of mistrust. Just– you can’t deny it. I mean, the data is out there for minority populations for a variety of reasons. Historically, there have been, I mean, Tuskegee is often quoted, but sterilization of Black and Latino women, you know, back in the days. Just so many things. Look at, you know, denial of entrance into medical schools or professional associations, people of color not being admitted, leading to things like HBCUs, medical schools for people of color.

That’s already there, that’s documented and unfortunately, it still goes on today. And the sad thing is that especially in this day and age, the political environment is essentially throwing gasoline on the flames. It’s exacerbating these disparities and this lack of trust. But then what you mentioned lack of trust in sort of the things that were traditionally accepted as evidence based, reliable sources of information. Institutions like the CDC, NIH, now, I mean, now you’re seeing political rhetoric thrown into these institutions, which for me, when I saw, you know, this is shut down due to XYZ party, I’m like, what?

What is going on? So all of that confusion and additional rhetoric from certain political folks who throw their personal spin, not evidence based, people listen to that. For some people, their only source of information is social media or certain news stations. And they’re going to take that as law and discredit all the work, all the decades of evidence based medicine that has saved lives and kept populations healthy.

And this is a very fragile time for medical schools, schools the public health, what we do for providers, for health policy advocates, because we’re combating so many things on the individual and on the legislative level, which is- which is dangerous. But we need people to hold the line and debunk these things. But it’s tiring. Health care providers going with the patient, and you have all the evidence, you’ve talked to them, you’ve got a good history.

You have objective findings from lab or imaging. Some patients who say, “no, you know, I, I don’t think this is what it is” despite having evidence there. Now you have to listen to patients and take their perspective. But it’s very dangerous if we’re not taking vaccinations or medications, which have been proven to be safe and can help you.

But if you have political figures or, you know, popular figures, debunking these evidence-based things, it becomes a big problem.

Oyeyemi: Yeah, yeah, it undermines a lot. And it, makes it– you have noise coming from every direction. It makes it very difficult to understand where to be looking at where to be listening to, who to be listening to. And, yeah, it’s unfortunate that I think, you know, there I think there are bad faith actors in society who have some type of incentive to discredit some type of either existing or budding system or voice. Including those that honestly have been what have been at the heart of public safety and public health. Which is really unfortunate because, that’s the most vulnerable component of any society is the health of the public, right?

Which is the reason why public health and all of the systems that make up the constellation of public health are so important. And that includes, you know, the workforce in these different systems. Yeah, the medical system, the education system [laughs] that that leads into that, without question, I couldn’t agree more. You know, let me ask you this because I think, I mentioned before the “Why Black Men are Dying to be Successful” commentary, which, you know, I do encourage everybody to go out and read. It’s an excellent and short read.

But really, a lot of, you know, it packs a punch. And I think that one of the things that I picked up from it is something that you actually mentioned at the top of this talk, which is around burnout. And I know that you would even kind of, given an example and, and it’s interesting, as I was reading it and, and then listening to you talk now, I don’t even know if, you know, I think t the beginning of the, of the commentary piece, you kind of described your mom and, you know, her working a couple of jobs and how normalized that was. And it always felt like a little bit of a “oh, that’s not even that’s not even the burnout that we were talking about,” but like, it’s almost like there was an implied burnout. The burnout that you actually ended up talking about was something entirely different from the burnout that was prefaced at the beginning, talking about your mother and how she had to work these two jobs, and how that was just normalized across, you know, your neighborhood and community. It’s like, oh, okay, this is really meta now, because now you’re talking about–

Henry: Exactly, this is normal. 

Oyeyemi: Right? You point out that burnout as being sort of like that wasn’t even the main thesis of the commentary was that it was other burnout. And you talked about it, you mentioned a few minutes ago as you were talking about your background in your training, how you were burnt out.

You said that you said that word right off the top. So I’m curious to know you kind of think about your own, you know, your own personal story. The professional story, the experience that you had growing up in the neighborhood that you did, and with the experiences that you had with your mom. And then part of what we’re now talking about with some of what causes burnout. I mean, how do those things, how are all those things connected? How are your views shaped? 

Henry: Yeah. So like I said earlier, we go into health care to help people. When I imagine being a PA, like, you know, I’m going to see my patients, have time. I was really– well, am really big into fitness and like I said, sports medicine in my undergrad really transforming lives and living healthier lives. And I imagined sitting and having time with my patients and really delivering not just the Western medicine and, you know, diagnosing and here are  your prescriptions.

But hey, let’s get you off of these medications. Let’s understand why you have hypertension or diabetes. But the reality is what I quickly learned that that’s not how it works in our health care system, there’s such a demand for health care. A shortage of health care providers for one. And then also just the model of health care payment, the insurance system.

The third party billing and just the rapid– it becomes almost a hamster wheel where it’s a business with health care, becomes a business model where you have to see a lot of patients to generate revenue. For example, I worked in an urgent care center in one where, a 14 hour shift, I had in 14 hour I saw almost 90 patients, almost 90 patients. In family medicine where you think, okay, well, that’s where I’m going to have time to sit and talk to providers.

I’ve had friends, PAs, MDs, who were seeing 30 patients, which is you’re seeing like have certain quotas for patients and an hour. So how do you get a good history? How do you get to know someone in 10, 15 minutes in emergency medicine, the E.R. that’s kind of understandable. That’s the name of the game there, because the goal is to identify life threatening illness, take care of them.

But family medicine, which is often quoted as the gatekeeper, you need time to talk to people. And even in my research that I’m doing for my PhD, looking at the barriers and facilitators to trust for Black men and health care providers, rushed encounters being dismissed, those are all big, those are big themes about negative experiences and things that perpetuate mistrust.

So at a systemic level I think that creates burnout. It really does because providers working in those systems have these quotas, the need for on the billing and the coding and the documentation. So it becomes more of administrative work crossing your t’s dotting your i’s for billing and so that you don’t get sued, [laughs] essentially. So then how do you then factor in or build in trust with the patients?

If you’re running back and forth and– it causes burnout, it causes a lot of burnout for providers. In fact, in looking for stats for MDs, suicide is high in the health care profession. You know, there’s a lot of moral injury there. There are a lot of other, you know, a lot of psychological toll that I think isn’t talked about a lot enough.

Oyeyemi: I mean, I don’t know anybody who hasn’t had some type of experience or story that they can kind of share about, you know, people that, their provider missing something, missing the mark, you know, missing something. And, you know, those of us who work in this space probably have a better understanding of what some of the reasons are for why these things get missed.

And you kind of talked about some of that, the amount of time that the number of patients and the amount of time that it can be allocated to each patient. The reality is, is that, you know, our communities and patients, they don’t– they don’t see that, they don’t care, and they don’t they shouldn’t. The system needs to improve, right?

It shouldn’t be a situation where we’re, you know, simply, focused on educating and informing the public as to why these things are issues, why, you know, the provider only has, the physician only has, you know, X number of minutes to see them. That can be a Band-Aid. But the reality is that the system needs to change.

Henry: Absolutely, absolutely. And then that will help patients and providers. So that one thing changing that one model, will these big corporations take a hit financially? Yes. But it’s what matters the most, delivering quality care, you know, preserving the health, especially mental health, of your providers so that they can do their jobs properly. Now those are big discussions and it takes bold action to do that. 

Oyeyemi: No question about that. I’m gonna get you out of here on this because I know we’re just about that time. And maybe you were about to segue into that a touch. What did the people need to know? What’s the message from Professor Henry to the network? 

Henry: So I think I would just, you know, bring in what I just said. It takes bold action, bold decisions, because we’re in some very interesting times right now where not only evidence based knowledge is under assault, universities are under assault, diversity is under assault, even to the level of admissions, you know, decisions made about caps for tuition assistance affects who can apply, who can afford it. And then you have to look at, okay, those folks who get admitted, how likely are they to go to underserved populations or populations that aren’t lucrative or fields that aren’t lucrative? So then yet again, you’ll have a deficit in the primary care fields, which historically have been paid the lowest, but are so critical for identifying these diseases and preventing diseases before they get into the ICU, before they get into the E.R., before they get into the morgue.

So I think we collectively, educators, clinicians, public health leaders, legislators need to reimagine the health care system, the health care model, and really see what’s most important, because a sick nation is dangerous for everyone. You know, a healthy nation is a strong nation. So I would say that’s my message. 

Oyeyemi: Well said. Well, we really appreciate your time. Aaron Henry is Assistant Professor and Co-Director of Clinical Education at George Washington University, the PA program is in the School of Medicine and Health Sciences. I appreciate– before I let you out on this, before I let you go. You got off to solve this long debate: physician assistant, physician associate? For those of us who don’t work in that space, always curious about the preferred nomenclature. I noticed even in the article, you had a little bit of a slash between the two. Are you able to give guidance to which of those two should be, more socialized and normalized? Or do you, are you going are you going to, do you want to abstain from both input on that?

Henry: I would leave that as TBD. It’s ongoing. 

Oyeyemi: It’s an ongoing conversation in the field. That’s helpful. I think it’s actually helpful for those of us who are not PAs to have insight into some of the fact that these things are still being kind of sorted out and indirection is being, better understood. So I appreciate you giving a little bit of insight.

Henry: No problem, and what I will say about that is I think we get so caught up in the names and, a lot of ego, a lot of things come into play. But again, what is the mission? It’s to take care of our communities, to take care of our people. And we worked as a team, you know, as a team.

So I’ll let the higher powers that be figure out the nomenclature. 

Oyeyemi: And we’ll focus on the work that’s right here. Well said. Well said, and I appreciate you. Aaron, thanks so much for the time. And thank you all for tuning in and listening. And we’ll see you next time. 

Henry: Thank you. 

Oyeyemi: Thank you.