Coping with scarce baby formula; checking for medical biases; dealing with aphasia: Upstate Medical University's HealthLink on Air for Sunday, May 29, 2022

Host Amber Smith: Coming up next on Upstate's "HealthLink on Air:" a pediatrician gives advice about the baby formula shortage ...

Winter Berry, DO: ... It's OK to feel unsure about what to do, but there are a lot of solutions out there. ...

Host Amber Smith: ... A medical ethicist shares a checklist that helps identify bias ...

Amy Caruso Brown, MD: ... We find that patients with disabilities get fewer preventive health screenings than able-bodied patients, and that seems to come from some, maybe not even consciously, but some unconscious assumptions about the well-being and quality of life of disabled people . ...

Host Amber Smith: ... And a speech therapist explains what's important to know about aphasia ...

Lauren Westby: ... Aphasia typically occurs after a stroke or a head injury, but it can also come on very gradually from a slow-growing tumor or maybe a neurological condition."

Host Amber Smith: All that, and a visit from The Healing Muse, coming up after the news.

This is Upstate Medical University's "HealthLink on Air," your chance to explore health, science and medicine with the experts from Central New York's only academic medical center. I'm your host, Amber Smith. On this week's show, a medical ethicist shares a checklist that helps identify bias. Then, a speech therapist explains what's important to know about aphasia. But first, a pediatrician shares some ideas for parents during the baby formula shortage.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." With the ongoing shortage of baby formula in America and fears that this will not resolve quickly, I'm turning to Upstate pediatrician Winter Berry for suggestions for what parents can do. Welcome back to "HealthLink on Air," Dr. Berry.

Winter Berry, DO: Thanks so much for having me.

Host Amber Smith: Now, Abbott Nutrition recalled three types of infant formula several months ago. That, coupled with more general supply chain issues, has left many parents worried about feeding their babies. What are you telling parents to do?

Winter Berry, DO: The first thing I tell parents is that it is normal to be nervous about this. And this is sort of an unprecedented shortage, that parents haven't had to approach similar circumstances in therecent past. So it's OK to feel unsure about what to do, but there are a lot of solutions out there.

The big-picture answer is that there is support available to you. There is always advice through your pediatrician. So if you're unsure, feel free to ask, that's what we're here for. And also creativity, as far as where to get your feeding for your baby from, and how to acquire it, is required at this time.

But there's always a solution that can be sought.

Host Amber Smith: Is it OK to switch brands if the one that you've been using is not available?

Winter Berry, DO: Yes, absolutely. So there are some online resources. I would caution to use a reputable source for the online resources, but there are absolutely safe switches that can be made and that can be within brands, different types of, say, the same brand Enfamil formula or Similac, but there can also be substitutions between brands.

You could switch from Enfamil to Similac or to a generic formula, and there are many equivalent options for what is most accessible in your area or in your circumstance. That substitution becomes a little bit more complicated with certain children, certain underlying conditions. But the majority of children can safely make switches to other types of formulas.

Host Amber Smith: So generic versus store brand is OK. What about switching from milk-based to soy-based?

Winter Berry, DO: So, yes, generic is an equivalent product with the same safety profile and nutritional profiles. So if that is an option for your family, it is often a more cost -effective option. And it's absolutely a switch that can be made, and thankfully, most generics have a spot on the label that say, "equivalent to X." So you can tell that you're getting an equivalent substitution to the formula that you're used to. As far as soy-based goes, there's a very narrow group of children with underlying medical conditions that we would not advise soy for, but that's something you'd likely already know from your pediatrician.

And I know this will sound repetitive, but if you're unsure, always feel free to call us and ask about the substitution. There is a small percentage of children with milk-protein intolerance who would also be intolerant to soy. So if you know that milk protein is something your child is sensitive to, I would ask your doctor before you make a switch to soy.

Host Amber Smith: When can babies start drinking regular milk?

Winter Berry, DO: I want to give two answers to that question. Under usual circumstances, when formula and breast milk are readily available, we recommend introducing cow's milk at 12 months of age. As this formula shortage has continued to widen, we are also widening the availability of temporary use of cow's milk. That is to say, we advise cow's milk as a substitute only in certain situations or emergent situations where no formula substitute is available, and only over 6 months of age. We do not recommend other milk substitutes such as plant-based milks or other animal milks, and if you are going to use cow's milk, we advise using it for as short a period of time as possible, not more than 24 ounces in a day, and you need to be sure to supplement iron, in addition to that cow's milk, because cow's milk is not a good source of iron. That can be some dietary sources, but it also may mean you need advice from your pediatrician for either a vitamin or a prescription for iron itself to adequately supplement your baby.

So if you're planning to use cow's milk in place of formula even briefly, you need to check in with your doctor about that first. And to be perfectly clear, as soon as formula becomes available again, we recommend switching back to formula.

Host Amber Smith: What about transitioning a baby to regular food? How soon can that be done?

Winter Berry, DO: So again, in usual circumstances, we advise waiting until about 6 months of age. Some babies are ready a little bit earlier, and that's a developmental milestone, when they're able to handle food off of a spoon. That's somewhere between 4 to 6 months of age. In these circumstances, some parents may be tempted to offer more and more complementary foods as formula is less available.

The minimum we recommend of formula, in addition to those complementary foods, is about 24 ounces per day. And you can increase the amounts of complimentary foods, if you're having to pull back a little bit on the formula you're giving. Really a broad variety of foods are safe for infants, complementary foods, the only things we caution against are choking hazards, or if you know your child has a specific sensitivity to a certain food, obviously you would avoid that as well.

Host Amber Smith: Now there are a lot of recipes online for "make your own baby formula." Why is that not a good idea?

Winter Berry, DO: So many of the formulas circulating, for starters, are relatively dated, for lack of a better term. Those were formula recipes that were used decades ago and in place of what is now commercially available, much more comprehensive nutrition that's in formula. The formula that is commercially available today has very complex nutritional contents and meets the specific needs of an infant in their first year of life.

And that is impossible to replicate with a home recipe. The home formula recipes also have risk for electrolyte imbalances, iron deficiency, as I mentioned, an inadequate nutrition broadly and can lead to serious illness or complications for a child. So as reassuring as some of those social media posts can be, that is not something that should be used to substitute for formula.

Host Amber Smith: Is there a safe way to cobble something together using your blender at home to take regular food and blend it or anything like that?

Winter Berry, DO: Anything you'd be using at home would fall under the category of complementary foods and wouldn't replace formula. If parents are in the situation where they feel like they're ready to make their own formula, based on a recipe they've found, I would suggest reaching out to a community agency or your pediatrician to find a way to come across formula instead of that.

Or as I mentioned before, consider, if your child is over 6 months, using cow's milk for a short period of time and then trying to get back to formula. And there's a breadth of supports available for families who are struggling with finding formula. There are social service and safety-net agencies, your family may qualify for WIC, which is Women, Infants and Children, a nutritional supplemental program. There is a program called Help Me Grow, which helps parents navigate available resources in the community, and they can help find creative sources. And then we also recommend families trying smaller stores, things like pharmacies or corner stores, which might not normally be a place they buy formula, but may have a little bit more of a supply

Host Amber Smith: if you have some formula, but you want to make sure that it lasts, is it OK to thin it out a little bit and not use as much of it as you normally would?

Winter Berry, DO: That's a great question. And it's very tempting to do, because it seems like, well, if it's complete nutrition, I could just make it a little less potent, and it would be fine. The problem with that is that the safety and nutritional content of the formula has been safety tested with the recipe that's on the can.

So by diluting it, you, again, especially in younger infants, can risk things like inadequate calories, proteins, fat and electrolyte abnormality. So we recommend mixing it exactly as it said on the can. There are, again, are some infants in special situations who need to mix it even more concentrated than it says on the can, but that's something that your doctor would have told you ahead of time. And if that's the case, we again recommend continuing to mix the formula as directed by your doctor.

Host Amber Smith: Breastfeeding might be an option for some moms, but if a woman has stopped breastfeeding, or she never started when her baby was born, is she able to go back to breastfeeding?

Winter Berry, DO: That is an option for some moms. I want to be clear that there should be no value judgment made for parents who choose to formula-feed their children or cannot breastfeed their children. There has been some rhetoric online that this problem would be solved if everyone just breastfed their babies.

And I want to be clear that that is not an option for all parents, and that's OK. However, if parents wish to breastfeed, and have either taken a break or did not initiate, it is possible to initiate that process, called relactation, that usually requires the support of a physician or a lactation specialist.

And that is absolutely something that can be supported, but I would recommend families reach out for assistance in that process to be sure that they have enough support to do so successfully, but yes, that can be an option for families.

Host Amber Smith: Well, Dr. Berry, thank you for this important information.

Winter Berry, DO: Thank you so much.

Host Amber Smith: My guest has been Dr. Winter Berry. She's an associate professor of pediatrics at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

One way to recognize bias in the field of medicine -- next on Upstate's "HealthLink on Air."

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air." Bias is when you have an inclination or prejudice for or against something, not based on evidence. Today, I'm talking about preventing bias with Dr. Amy Caruso Brown. She's a pediatric oncologist and bioethicist at Upstate who has done quite a bit of research in the area of racial, ethnic and cultural disparities in medical treatment and the provision of health care to diverse populations. And she also teaches medical students. She's created a bias checklist that medical schools are using to help produce curriculums that are, hopefully, free of bias. Welcome back to "HealthLink on Air," Dr. Brown.

Amy Caruso Brown, MD: Thank you for having me. I'm so happy to be here with you.

Host Amber Smith: We spoke about this subject a few years ago, and now your bias checklist is being used by other medical schools. And I understand you've received some grant funding as well. What will the grant money allow you to do?

Amy Caruso Brown, MD: Yes, we just received a grant, a president's grant, from the Macy Foundation, which supports medical education and educational innovation. The main purpose of that grant is to support building a website, a multimedia tool kit with all of the different components that we've developed to support schools that are adopting checklist approaches to reviewing curricula for bias, the purpose being, we have so many resources that we've created, and I've been asked to give many workshops around the country now. And we really felt the need to have everything in one place, where it was readily accessible and where users could identify themselves by their role.

Are you someone who's using the checklist because you're creating a lecture of your own? Are you a dean who wants to adopt this for your whole school? Are you a community member, an advocate who would like to see this used in your community? And the website will help us quickly route people to the right resources for their role.

Host Amber Smith: So how many medical schools have professors who are using your bias checklist? Do you know?

Amy Caruso Brown, MD: I don't know the absolute number. I know I have been contacted by somewhere between 25 and 30 institutions. It probably increases every week. I think I hear from someone new at least once a week who's heard about the checklist in one way or another. And we have people from 15 schools who meet with us regularly.

We meet every other month just to troubleshoot and talk through how we're using it in our respective institutions. What problems or barriers we're running into? What ways in which we think we might want to change the tool or additional things we want to adopt to help support use of the tool. And I have heard from, at this point, one veterinary school (that) contacted me and said, "Do you think this could be adapted for veterinary medicine?"

And I said, "I think it could. Do I know how? That's not my area of expertise, but I'd love to see you go for it."

Host Amber Smith: Well, I was going to ask: The checklist is designed, or it originally was designed, for medical school. Is it expanding to other health professions, too?

Amy Caruso Brown, MD: Yes. I guess to go back a little bit, what happened is we developed the checklist initially on paper and then in electronic version, which we made publicly facing and publicly accessible so that anyone could go to it and use it online. And we published some studies on that. And then we just started hearing from people who had found it one way or another, who wanted to work with us. And pretty quickly we started hearing from other health professionals. I have heard from nutritionists. We have many people from nursing programs. There's at least I think four nursing schools that are really committed to this work around the country. And they've spun off their own subgroup that meets regularly because the needs are a little bit different.

Bias is not specific to any one profession. It's interprofessional, these things we see, like undertreating the pain of black patients, and even to black children, who get their pain routinely undertreated in our emergency rooms. That's not coming from any one member of the health care team. That's the biases in society affecting the education of the whole team and then how they practice.

But the needs are a little bit different in terms of how you review curricula. We see, in medical education, for instance, that there's a lot of siloing. So the person who gives one lecture may not know what the next lecturer in line is talking about. The person who's coming in after them may or may not know anything about that person's content, where what we see when we've worked with the nursing programs, is they tend to have one faculty member who is running the entire course, giving most of the lectures, leading most of the sessions and knows exactly what's going on. So it's a little bit different in that way.

Host Amber Smith: I have more questions, but first let me ask you, what is the "siloing" that you mentioned?

Amy Caruso Brown, MD: Siloing in curricula are when the curriculum is broken up into small pieces that are taught by lots of different people. There may not be enough coordination between those different educators.

So that, say, you have someone who's coming in to talk about the pathophysiology of a particular organ, what happens when this organ is not working well. And then later you may have a clinician, a physician or a nurse or another health professional, come in to talk about treating patients with diseases of that organ.

And ideally, those people would get together and have coordinated so that their material complements each other's, but when you have curricula that are very "siloed," there may not be that coordination. I think where it's really important is that the only person who experiences an entire, say, MD program from start to finish, is the student. Everyone else is just seeing their pieces. And hopefully those pieces are big enough that we don't have a lot of problem with siloing, but even when the pieces are as big as courses or clerkships, which are the rotations the students go through, only the student is really going to see the whole spectrum of how bias manifested in that curriculum. Maybe I'll just add the best example, which is when we were starting our work with the checklist,I asked a student to review a case I was working on, and it was a bilingual, Spanish-speaking family, set in New York City. And they're making end-of-life decisions for a father with Alzheimer's disease. And they're Catholic, and we talk a little bit about, you know, religion and faith and how does that matter at the end of life?

But the student, after reviewing it, said to me, "It's really, really nice to see a Latino family that is not undocumented or migrant farm workers." And when I talked to her, she told me all of the cases she had had over the year where the patient was described as Spanish speaking, the patient was also a migrant farm worker. And it wasn't any one faculty member doing all of these cases. It was many different educators thinking, "Hey, this is an underserved group with important health care needs. We should talk about it," but because they weren't coordinated with each other, because they were siloed, what we end up with is a really clear bias over the whole curriculum.

Host Amber Smith: Can you walk us through how the checklist works?

Amy Caruso Brown, MD: Sure. If you go to the public-facing version, we have a tiny URL to make it accessible, but it's housed on REDCap, which is a platform for this kind of data collection. So if you go there, you will see sort of an introduction, a link that says if you've never used this before, and you don't know anything about this, you might want to go here and read the FAQ (frequently asked questions), and then there's some other resources. And eventually that will link to the website that the grant is supporting, so that we'll be able to steer people in very specific directions.

But right now there's just an FAQ and a glossary -- that is helpful. Then you go into a section that asks about who you are and why you're using it. And that's mostly for our quality improvement and review, that we want to know who our users are. We designed it for anyone in an education role, and that might include a student teaching peers, or a resident (physician) teaching medical students, anyone in an education role, to be able to use, to review their own content and to do that independently. I kind of want to save it as in the privacy of their own home or office, just to do that sort of deep self-reflection work about "What am I teaching?" and "How might all these biases that are prevalent in our society, the systemic racism, the sexism and misogyny, how might that be influencing what I'm teaching?"

But we also see that people want to use and do use the checklist in other ways, that course directors sometimes want to use it to review the content of the faculty who are lecturing in their course, mentors might want to look at something their mentee is preparing.

Students might want to assess something they saw presented, a lecture they've already sat through or a small group case that they participated in. So they might want to go back and say, "Something in that content worried me, or I'm not sure about that. And I'd like to use the checklist."

So the first part asks who you are, why you're here, what you're using it (for). If you are from Upstate, we have a whole bunch of other questions that help us pinpoint what part of the Upstate curriculum you're reviewing. And again, that's for our internal tracking, to know how much of the Upstate content is being reviewed.

And then it's broken into domains, and each domain represents an area that we know where we know bias in health care and in the treatment of patients and families is a real problem. And that's coming from the medical and the health professions' literature.

First one is race and ethnicity. That's one a lot of people know a lot about, but there's sections on gender, on sex, on sexuality, on sexual orientation, all these different pieces. On age: there's a lot of age bias in medicine. On disability: another area we don't talk about, but where it's really pervasive, we find that patients with disabilities get fewer preventive health screenings than able-bodied patients, and that seems to come from some, maybe not even consciously, but some unconscious assumptions about the well-being and quality of life of disabled people, of assuming, say, that they're not having sex, and therefore you may not need to do the counseling you would provide other patients. And of course that's not true.

So there's all those domains. Each domain has a question that says, "Is this something you're teaching about in your session?" If you answer yes, you will see some more questions that are really common ways that we have seen bias show up in health care professions and health care professions' education. For instance, for gender, you will see one that asks whether you are using the term "atypical" or "variant" to talk about symptoms in women, because we see that that is very common in the medical literature and medical language, that diseases do present differently in women, in people with female anatomy or female hormones than they do in inpatients with male hormones or male anatomy. And because a lot of studies were done with the idea of the middle-aged man of a certain size as the default patient, the way symptoms show up in women gets labeled atypical or variant, even though anything that's showing up some way in 50% of the population is really not atypical and not variant, but that kind of language is going to shape how future doctors and health care providers think about symptoms and what they look for, what their default is, what they're expecting, and what they consider unexpected. For each domain, there's questions like that.

If you say, "No, I don't talk about this," there is a question that just asks the user to pause and reflect on whether it's something they should be talking about. If you say you don't talk about disability in medicine, where disability is in almost everything we do, the checklist will ask you, "Well, do you think maybe you should?" And the answer is not always yes. There's always a box that you can check that says, "I'm just not sure. I don't know what the right answer is here." And then there's a question about whether the ways in which you're talking about this topic could perpetuate shame, bias, stereotypes or stigma. And that includes a drop-down box with some of the common ways we've seen this show up. So things like fat shaming, equating a particular body size with health; that's very common, or a particular BMI (body mass index) with health, even though again, not backed up in the (medical) literature.So all of these examples are things that we know are pretty common.

They show up a lot in medical education and health professions education. And we also know from studies that have been done across our fields, that they're not true, or they're not supported by the science, or they're not useful in caring for patients. A lot of the things that I learned, learning to associate certain diseases with epidemiology around race, so knowing that certain -- I'm a pediatric oncologist -- that certain malignancies show up more in white children than black children or vice versa. And yet that is never helpful to me. That's not how I make diagnoses. You're always going to see patients who don't look or sound or act the way the stereotypical patient in the textbook does.

And at the end of the day, we're looking at the whole picture. We're very often looking at their physical exam and labs. And for me, I, in the end, I'm making diagnoses based on pathology. If someone has a tumor, I'm going to send the tumor to the lab and ask them to tell me what it is. I'm not going to say, "This patient is this race, therefore, it's less likely that it's this." That's how we write standardized test questions. That's not how we practice. And that's not how we want our students to practice.

So, after answering all of those questions and going through each domain, and it's set up to try to be efficient so that people can quickly answer no for things that don't apply to their content and move on.

And then there's logic embedded into the checklist that will analyze the answers and give a box for each one that says, "You should be a little bit worried about bias." If that's the case, you may not see the box, but if that's the case, the box will drop down and say, "You should think about this a little bit more. Here are some resources. Here's my contact information, or other schools that have adopted this have their own internal leadership point of contact because I really, when I talk to educators, encourage them when they're using it to feel really comfortable asking questions and not see this as the beginning and the end, but just as a beginning to doing this work into reflecting on their content.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Dr. Amy Caruso Brown about the bias checklist she created for medical and health education.

So it's not just focused on race or gender, but do you have a sense, since people have been using the checklist, of the most common types of bias that are bubbling up?

Amy Caruso Brown, MD: Yeah, we do, but they're actually all pretty common. Some are just harder to identify than others, and I think part of what we're seeing is that, as a profession, we're getting better at kinds of bias that have gotten a lot of attention, but not better across the board. I was just talking a little bit about racial, essentialism and epidemiology associated with race without an explanation. That might be the single most common form of bias. We love to put up graphs and say, look, here are the populations where these diseases occur.But we don't often follow that up with relevant information that is helpful to the future health care practitioner. So, great to know that this disease occurs more in people with this ethnic background than people with that ethnic background, but how does that actually help me take care of the patients? So we still see that a lot. And what we've tried to work on with faculty is saying, it doesn't mean you always need to cut that out. Sometimes it's irrelevant, and you should just cut it out of your lecture, but often the students want more information, and they need more information, they need to know is that association occurring because people from certain populations have been historically disadvantaged. They have experienced intergenerational trauma, toxic stress from racism, so they haven't accumulated the generational wealth that other population groups have. And that is of course, particularly true for black Americans. And so they have less access to care. And maybe that's why we're seeing this disease association.

Sometimes it is genetics. It's just not genetic as much as the way we've been teaching implies. I think sickle cell disease is a great example because we know a lot about why sickle cell disease occurs in the populations that it occurs. And we can explain all of that to students. So what we've tried to do with those examples in other areas is to say, we just need to give students a little more content and context. We need to help them understand why this association is occurring.

And then, what are they going to use that information for? Are we teaching to the test? Is this a fact to spit out later that they'll never actually use when they go out and treat patients? Or is this a really important area of inequity, where they need to know it because they need to work with the communities that they're going into to help get rid of this inequity, to help resolve that health disparity.

But then I think other areas have gotten much less attention, and there's maybe a little more ambiguity around them. So, gender as a spectrum is a newer concept for a lot of our faculty, very few of our students. Most of our students are very, very comfortable with gender not being binary, with it being a spectrum where people may identify as male, female, in between, neither.

And so we see some disagreements between students and faculty over how that should be presented, how that should be taught. And then, I think disability and weight are still really neglected as areas of bias, that we see a lot of them, but they don't get as much attention, and it can be hard to get traction around the idea that weight isn't a simple medical concept, and losing weight is not just as easy as saying, "Well, you should lose weight, and then you'll be healthier."

Host Amber Smith: Have students identified biases that aren't necessarily covered in your checklist?

Amy Caruso Brown, MD: You asked about the most pervasive kinds of bias. And I didn't mention the one that the students independently bring up the most, which is interprofessional bias, that they see how different specialties criticize each other. And they see how nurses may talk behind the doctors' backs, the doctors say, "Oh, my God, that nurse," and it really troubles the students. They haven't been absorbed into the culture enough to ignore it, but I just saw on a Facebook group I belong to, a physician moms group, a surgeon saying, "Please stop telling students this; it's not true. Please stop telling students that they can't be surgeons and be involved moms and dads," involved parents in general. And yet, I still hear it all the time. We still see a gender gap in who goes into surgery; some of it may be preferences, but I think a lot of it is mentoring, that we're still telling students, you know, you should pick this field or that field because of gender biases. That's really frustrating, but the students definitely notice that interprofessional bias in ways that I think faculty sometimes miss.

Host Amber Smith: I'm curious about how this will ultimately affect patients or whether patients will even notice anything different in their medical appointments. If we fast-forward a few years, when the students who went through these curriculums that have been looked at for bias, will they be different providers and will patients recognize that?

Amy Caruso Brown, MD: Yes. So that's our hope. We work very closely with the office of evaluation, assessment and research with Dr. Lauren Germain, and I think one of the challenges is that we can report things like how many areas of the curriculum am I finding bias? What are the common areas of bias? How often do people who use the checklist make changes? And I'm very interested in all of that data. We're starting to look at, does routine use of the checklist change educators' comfort level, talking about these topics? So if you're regularly reviewing your material for bias and thinking about these different domains and issues, does that make you more comfortable talking to a colleague or a student about racism? Does it make you more comfortable incorporating teaching about racism and health into your content?

So those are the things we've started to figure out how to measure. We're starting to look at students' perceptions of the learning environment, but of course the goalis patient-oriented outcomes. What we really want to see is that students who learn in a less biased environment who receive a curriculum that doesn't perpetuate these myths and biases and stereotypes, that when they go out and see patients, they're better prepared to take care of patients from diverse backgrounds, that they're not defaulting to stereotypes and algorithms that will lead them to misdiagnoses, because we know that's a major source of medical error, is missing a diagnosis, not doing the right test or not thinking that the test is necessary.

Much of that probably comes from biases we teach. We saw that over the last several decades with women and heart attacks, right? That one's gotten a lot of attention, that women's heart attacks were being missed because physicians have learned a particular presentation that was typical of male patients and wasn't the way female patients were presenting.

So the goal being, if we do this across the whole curriculum, maybe we can address that problem from the top down, instead of addressing it with each individual disease, where we finally get enough evidence to say, "OK, we've been teaching that wrong," or "We haven't been teaching people to look for this, and we should."

But that's far down the line, and it's a hard thing to measure. How much does one, within a society that is still really struggling with these biases, where I think there's a lot of agreement within medicine and a lot of agreement in some parts of the country, but still a lot of disagreement in other parts of the country and reluctance to even acknowledge that these are real problems.

So how much does our tool make a difference in that situation? I think that's going to be hard to measure. I still hope we'll get thereand that we'll see that. As one student put it, "Standardized test questions teach students to make snap judgments and not look back, with very little information."

And I think what we're trying to do with the tool and what I'm trying to do in the classes I teach is push back on that and say, we need to always be asking ourselves: What biases am I bringing into this room? And I'm not just thinking, even then, about racial, ethnic, or cultural biases, but also, have I heard that this family is difficult? Have I heard that, hey, they're not giving the medications right, or they don't understand anything? Because I'm bringing all of that into the room. And how can I learn to put that aside, so that I can come in and see this family with a clean slate, acknowledging my biases, because they're going to be there, and being able to recognize them, but then being able to put them aside.

Host Amber Smith: It seems like a higher level of professionalism, really, what you're describing.

Amy Caruso Brown, MD: Exactly, exactly.

Host Amber Smith: So your checklists may be able to shape the education of people who are going to become doctors in the coming years. What about the ones who are already practicing medicine?

I wonder if there are effective ways for those doctors to recognize their biases.

Amy Caruso Brown, MD: Yes, that's a great point and a great question. Certainly for the checklist itself, we encourage the use across the spectrum of medical education, so that could be a speaker who is doing continuing medical education, not just for students and residents, but for faculty. I use this on my own presentations all the time. We certainly encourage it in residency education, where there are more opportunities, but the only thing that we have found we really can't apply a checklist to is, unfortunately, the kind of informal education that happens all the time. The teaching we do on rounds, which is often directed at our residents, but there's also a lot of teaching happening between practicing physicians, where someone calls me as a hematology-oncology consultant and has a question about anemia or wonders if this could be childhood cancer, and I'm doing education back with that person in that conversation. And it's maybe one of my colleagues or partners or a physician at another hospital. That's an informal situation in which it's hard to apply a checklist to something you're not planning ahead of time, but what we're looking to see, and we're hoping to see, is that many of us do formal education as well, that if we use the checklist regularly, what people are telling us is that they start to ask themselves the questions when they're talking in informal situations, that they find that it started to shape their thinking and becoming a habit so that maybe they're not clicking the boxes, in the way that they would if they were preparing a lecture or writing a small group case for students to discuss. But they're still thinking about the questions as they're providing that informal education. And I also hope as a reflective tool, you may, as an educator or practicing physician or a nurse or a physical therapist, sit down with a checklist, not knowing anything, going through, thinking, "Hmm, I think this may apply. What else can I learn about this?" So I hope that it's a trigger for continuing education for a lot of people who are in practice and who are using it themselves. They may start out thinking, "Oh, my goal is to make sure that I don't pass on bias to the students," but they may end up learning new things about their practice that changes how they take care of their patients.

Host Amber Smith: Well, Dr. Brown, thank you for making time to tell us about this. I appreciate it.

Amy Caruso Brown, MD: You're welcome. Thank you for having me.

Host Amber Smith: My guest has been Dr. Amy Caruso Brown. She's a pediatrician and bioethicist who also teaches medical students at Upstate. I'm Amber Smith for Upstate's "HealthLink on Air."

Next on Upstate's "HealthLink on Air" -- what you need to know about aphasia.

From Upstate Medical University in Syracuse, New York, I'm Amber Smith. This is "HealthLink on Air."

More than 2 million Americans are affected by aphasia, but many of us had no idea what it was until news that the actor Bruce Willis had the condition.

Aphasia can affect speech as well as how a person writes and understands both spoken and written language. Today, I'm talking about aphasia with speech-language pathologist Lauren Westby from Upstate's department of physical medicine and rehabilitation. Welcome back to "HealthLink on Air," Ms. Westby.

Lauren Westby: Thank you.

Host Amber Smith: How do you describe aphasia?

Lauren Westby: Aphasia is actually caused by damage to the language centers.

Well, our brain is composed of two hemispheres, and language centers are on the left side of the brain. So the damage to the language centers on the left side of the brain can cause aphasia. Aphasia typically occurs after a stroke or a head injury, but it can also come on very gradually from a slow-growing tumor or maybe a neurological condition. It affects your ability to communicate. It can affect your ability to express information, say the words you want to say. But language is multifaceted, and it can affect the other components of language as well, including understanding and reading and writing.

Host Amber Smith: Is it a disease on its own -- aphasia -- or is it a symptom of a disease?

Lauren Westby: It's a symptom of a disease. It can be caused by a stroke or head injury, or again, from the slow-growing tumor or neurological condition, but it doesn't really exist on its own.

Host Amber Smith: Would someone with aphasia recognize that they have it or that something's not right?

Lauren Westby: They might recognize it. It depends on the type of aphasia that they have. It's very dependent on the location of the injury, so somebody with more of a fluent aphasia, like a Wernicke's aphasia, where they have trouble being able to understand language, they may actually have more trouble recognizing where their errors are, as opposed to somebody who has more of a nonfluent aphasia, like a Broca's aphasia, which is where they may understand a little bit better but have more trouble with their output. And then they may recognize their errors more readily.

Host Amber Smith: So it sounds like the symptoms might be different for anyone depending on exactly where this is, but it's the left side of the brain?

Lauren Westby: The left side, yes. And there's actually different types of aphasias. So, as I was saying just a second ago, there's a nonfluent aphasia, which is called Broca's aphasia. And those people may have a better ability to understand than they are able to speak, and they have more trouble getting words out. They may speak in short sentences or omit words, and these are the patients that may have more ability to recognize their errors, as opposed to the fluent aphasia, where they speak much more easily and fluently, but what they're coming out with doesn't make as much sense. The, receptive language is much more impaired in this group. And then our global aphasias are our patients who have the most severe aphasia, in which all the modalities of language are affected.

Host Amber Smith: Is there necessarily cognitive damage if someone has an aphasia?

Lauren Westby: So not necessarily; intelligence has not changed. However, depending on the nature of the injury, cognition can be impacted. So if it's more of a degenerative disease, so more of a progressive primary aphasia that correlates with the dementia or a traumatic brain injury, we might see some additional cognitive deficits in conjunction with the language impairments.

Host Amber Smith: Well, with dementia and stroke affecting usually older people, you probably see this in older people, or do you ever see aphasia in younger (people)?

Lauren Westby: Yeah, we can see aphasia in younger people. It does typically impact an older population than younger, but I think across the ages, we can see aphasia.

Host Amber Smith: Does aphasia run in families or is it genetic? If your father had it, are you more likely to get it?

Lauren Westby: No. Most aphasias are caused by the circumstances, and they're not inherited, although there is some research that primary progressive aphasia has been linked to inherited factors. So about 40% to 50% of people with a primary progressive aphasia have other family members who are also affected by the disease.

Host Amber Smith: Well, let's talk about treatment. Can the damage be reversed?

Lauren Westby: In terms of stroke and brain recovery, the typical timeframe for recovery is about six months to a year. And that recovery is going to depend on a number of conditions, including the cause and extent of the damage in the brain, but the brain is also changing and learning. And so you can see a recovery for much longer than that, but your speech-language pathologist is going to be the person that will do your assessment and develop an individualized treatment plan.

Host Amber Smith: What does speech therapy consist of for people who struggle to find the right word or struggle to speak? What does speech therapy involve?

Lauren Westby: Speech and language therapy aims to improve the person's ability to communicate by restoring as much language as possible. So, teaching how to make up for lost language skills and then maybe finding other methods of communication, we typically try and find a modality of language that's not impacted, for example, use of gestures or communication boards. Drawing and writing can be effective tools. For people who have more mild impairments, we might do things like script training. So, script training is picking maybe a specific area that would be the most effective for being able to communicate in a specific situation. So for example, I'm actually using script training now to help one of my patients. In conjunction with the communication board, I have him say, "I need," and then use the communication to point to what his needs are.

Host Amber Smith: I've read that some people with aphasia resist going out in public -- they're very self-conscious -- and I wonder if becoming isolated has an impact on the symptoms or their ability to recover anything?

Lauren Westby: Communication requires practice, so it's important to continue to utilize the skills that are learned in therapy. But it is hard for a person with aphasia to want to communicate; it can hinder that. But they may benefit from participating in local support groups, aphasia groups and ongoing therapy.

Host Amber Smith: This is Upstate's "HealthLink on Air," with your host, Amber Smith. I'm talking with Lauren Westby, a speech-language pathologist at Upstate.

Congressional Rep. Gabby Giffords developed aphasia after she was shot, more than a decade ago. And she's written about the challenge of speaking and how she often, still, to this day, drops prepositions and conjunctions, small words -- such as "in," "on," "and" -- that help hold a sentence together. Why are those particular words hard for someone to remember?

Lauren Westby: In aphasia, you can have difficulty with using basic grammar, ordering of words and difficulty with sentence structure. It's actually a common feature and people with aphasia, especially Broca's, so that nonfluent aphasia. People with aphasia are often able to use content words, like nouns and verbs, like when looking at a picture, they might be able to say the word "tree" or "car," but will have trouble with other small words that complete the sentence or thought.

Host Amber Smith: Bruce Willis was in the news recently when his family announced that he had aphasia. And it made me wonder about the job of an actor, having lines to memorize, maybe that would not be possible for someone with aphasia.

Are there other jobs that people with aphasia would still be able to do?

Lauren Westby: In general, it can be very debilitating, but we also in therapy are working to find a way for them to communicate the most effectively. So sometimes that script training that I was talking about can be really useful in those areas. Maybe being able to use a certain amount of communication or words to be able to participate in a vocational skill can be really helpful. But yeah, there are certainly many areas that people with aphasia can continue to work. It doesn't sound like there's anything a person can do to prevent aphasia.

Well, I think that might be a good plug for (the stroke-warning acronym) FAST, since stroke is actually the highest, correlating factor for aphasia: 25% to 40% of people who have strokes have a type of aphasia. So making sure that you're using those symptoms of FAST, so Facial drooping, Arm weakness, Speech slurring and the importance of Time in getting to the hospital.

Host Amber Smith: Good point. How would you suggest loved ones communicate with someone who has aphasia? Does speaking slowly help?

Lauren Westby: It can. That's actually one of the recommendations, is to speak slowly. A lot of times eliminating background noise or extraneous noise can be really helpful, keeping your language pretty short, but not condescending, writing down key words if their ability to read is preserved. Also, making sure you have their attention before speaking can be helpful, and allowing them an opportunity to formulate their thoughts. But I think also it's important to think about other ways to communicate, and to use context to help, also any kind of modality of language that might still be preserved may be helpful.

So, incorporating more writing or gestures, any kind of context in the environment, can be really helpful for helping communication.

Host Amber Smith: So, email or texting -- would that maybe help with being able to stay in touch with someone who has trouble speaking, but still wants to communicate?

With texting, it may be actually similar to how their output is. So if their language output is the same as their writing, then being able to write a text message may be just as difficult. What about how important is it to speak in person, so that they can see you, versus over the phone?

Lauren Westby: It probably is a lot easier because they can use a lot of different components of our communication to help with their understanding. So actually 93% of our communication is nonverbal, so they're going to use things like facial expressions, context cues, as well as gestures to help them understand the language. Also being able to look at your mouth can be helpful.

Host Amber Smith: When you, as a speech therapist, are working with someone who's recovering from a stroke and has got symptoms of aphasia, it seems to me that the progress might come in increments. Do you ever find yourself in the position where you're having to, along with teaching the speech therapy, teach patience?

Lauren Westby: You mean like family and friends?

Host Amber Smith: And the patients themselves. I mean, I imagine it must be frustrating to want to be able to speak and struggle and you're trying to do what the speech therapist prescribes, and if it doesn't come easily or quickly, it's got to be frustrating.

Lauren Westby: I think this also ties back to, you know, not a lot of people understand aphasia. So they're coming in with a stroke, and all of a sudden it's hard to be able to communicate, but "Why? I didn't know that that was a symptom of a stroke." And so the importance of education to both the patient and family and friends is extremely important.

Host Amber Smith: Before we wrap up, let me ask you once more to go over the different types, or the main types, of aphasia and the symptoms of each one.

Lauren Westby: There are distinctly three different types of aphasia. So the first is more of a nonfluent aphasia. So with nonfluent aphasia, or Broca's aphasia, -- people with this type of aphasia, they understand what other people say better than they can speak. They typically will struggle to get their words out, speak in very short sentences and omit words. They may be more aware of these impairments and become frustrated.

Fluent aphasia, also called Wernicke's: They may speak easily and fluently. However, the sentences that they're producing often don't make sense. They often don't understand spoken language as well, and often don't realize that others can't understand them.

And then global aphasia, all the modalities of language are affected. They may lose almost all language function, and they may speak in single words or not be able to speak at all.

Host Amber Smith: Do you see crossover where you might have a patient who has a lot of symptoms of one type and maybe some symptoms of other types as well?

Lauren Westby: Sure. I think we have these distinct categories, but I also think that sometimes you can see maybe somebody who has more of a receptive language deficit, fluent Wernicke's aphasia. They may still be progressing and especially in an acute rehab setting. And so the comprehension is improving. And then in global aphasia, same thing, they can still be progressing through. So we may see more expressive deficits, and then receptive language is improving. Or we may see that receptive language is improving and expressive language is not.

Host Amber Smith: Ms. Westby, this has been very informative, and I really appreciate you making time for this interview.

Lauren Westby: You're welcome. Thank you for having me.

Host Amber Smith: My guest has been speech-language pathologist Lauren Westby from Upstate's department of physical medicine and rehabilitation. I'm Amber Smith for Upstate's "HealthLink on Air."

And now, Deirdre Neilen, editor of Upstate's literary and visual arts journal, The Healing Muse, with this week's selection.

Deirdre Neilen, PhD: Teddy Goetz is a medical student whose goal is to help people feel seen. Their poem "Green Thumb" offers a very different take on the future dreams of a physician. Here is "Green Thumb":

As doctors, she says,

We are in the business of second chances.

We fight for those caught in the crossfire.

Yet, I wonder,

Bad capitalist that I am,

What could it mean to make the first one last?

Planting vacant lots into

Parks

Prunes gun violence.

What a jubilant day it would be

To hang up my stethoscope,

And become a gardener instead.

Host Amber Smith: This has been Upstate's "HealthLink on Air," brought to you each week by Upstate Medical University in Syracuse, New York. Next week on "HealthLink on Air," the connection between COVID and new cases of diabetes in children. If you missed any of today's show, or for more information on a variety of health, science and medical topics, visit our website at healthlinkonair.org. Upstate's "HealthLink on Air" is produced by Jim Howe, with sound engineering by Stephen Shaw. This is your host, Amber Smith, thanking you for listening.