The Dose - Diagnosing Racism: How One Med Student Sparked a Big Change

Episode Date: April 7, 2023

On this special season of The Dose, guest host Joel Bervell is hosting a series of conversations with experts and leaders in health equity. In examining how we can uproot racism in our healthcare system, we are starting at the beginning of many healthcare careers: medical school. Naomi Nkinsi was one of the few Black students in her cohort at University of Washington School of Medicine. She noticed that the images in her lectures depicted Black patients living in impoverished and hygienic conditions, while pictures of white patients showed polished school photos. Nkinsi recognized that the disparity in images reinforced harmful biases for her classmates, and she began to advocate for a change.  Through a back-and-forth with her university’s administration, Nkinsi continued to advocate against racism. She eventually sparked a conversation that led to the reversal of the race-based component of the eGFR equation in many settings, thus removing a barrier to proper kidney treatment for thousands of Black patients. On the latest episode of The Dose, Nnkinsi joins Joel Bervell to discuss why and how she continues to challenge racism, despite institutional pushback, and shares what medical schools can learn from their students.  “The days I didn't say anything, I felt worse than when I did,” Nkinsi says. “I had already been outspoken, I already had the reputation of the angry Black student. Other classmates already viewed me as unprofessional… ​​​​So if I already have that reputation, then I should just keep speaking out because it's not going to get worse.”   Citations Health inequities and the inappropriate use of race in nephrology  

The Dose is a production of the Commonwealth Fund, a foundation dedicated to healthcare for everyone. Congratulations! I mean, this is a big day for you. I literally, I went to stalk your social media first, so I could be like, okay, do I say congratulations? Or I'm just like, you got this, you know? Smart move, smart move. But yeah, I got the good email, so I'm very happy. Yay, I'm so proud of you. Thank you. You're glowing right now.

You look not stressed at all. I'm so jealous. All right. I'm going to get started. Hey, everyone. It's a new season of The Dose, and we're launching a new look. My name is Joel Berval, and I'm here to host four episodes on health equity. I'm a medical student, and I'm currently on an orthopedic research fellowship at Johns Hopkins University.

I graduated from Washington State University School of Medicine in 2024. You may have already met me on TikTok or Instagram, and if not, consider this your invitation to see what I'm up to over there. I'm known as the Medical Myth Buster, now with over 120 million views on my videos that tackle the hidden history of medicine, racial disparities, and biases in healthcare. So thanks for having me, and I promise I have extraordinary guests lined up for a series of compelling conversations that you won't hear anywhere else. So let's go. My guest on this episode is Naomi Nkinzi.

When Naomi arrived at the University of Washington School of Medicine just four years ago, she noticed something lots of medical students of color have noticed, including myself. Part of the learning for medical students requires absorbing decades of information about disparities and outcomes for Black and brown people. Well, Naomi also noticed, like a lot of us have, that the images of Black patients in her lectures were very different from the kinds of images she saw of white patients. And she noticed that diagnostic equations, like the EGFR equation that's used to measure kidney functioning, were racially biased and just wrong. So Naomi spoke up, pushed back, and her activism has led to huge differences nationwide in medicine. And we'll hear all about it. But why is medical school like that?

In medical school, we encounter teaching that honestly has racism baked into it, and for a long time it's gone unnoticed and sometimes unchallenged. Part of it is because we're constantly evaluated by professors, upper class peers, and attending physicians, and our success depends on doing things the right way. Questioning the curriculum and the culture of medical school is often not done for those exact reasons. But Naomi has questioned and challenged norms, and she's had an enormous impact in the real world. How the GFR test is now administered is changing, and hundreds of thousands of patients will be touched by that. And so it's my great pleasure to welcome to The Dose, Naomi and Kinsey.

Welcome to the show, and congratulations on finding out that you matched. Thank you so much, Joel. It's an absolute pleasure to be here and it's an absolute pleasure to be here knowing that I've matched into Regency. Yes, you can sit back, relax a little bit more. Yeah. So I'm going to just jump straight into the questions. So like me, you're one of the few Black medical students in your medical class. You're one of five. I was one of two in my class. And medical school is just in the United States is traditionally a predominantly white space. So no surprises there. But I know you had some surprises when you went in for your first lectures and the PowerPoints you went to. I'm wondering if you can take us back to that first moment of being in medical school and realizing that it wasn't made for people who looked like us? Yeah. So I think for me, when I went into medicine, I always thought, you know, medicine would be kind of, in a sense, an equalizer, right? The human body, you can look at it objectively, you can do your anatomical dissections, et cetera. Obviously, I knew that there was going to be racism, but what I wasn't prepared for was how that racism is directly taught to medical students to enact into their own communities.

So one of the examples of this is one of the first blocks of my medical school career. We were learning about different genetic syndromes that have physical characteristics in patients. And I noticed very clearly that there was a difference in the way that the Black patients were portrayed as compared to the white patients. So for example, the white patients, all the images of them were their family photos, their school photos. We could see all the clear manifestations of their genetic syndrome, but their humanity was maintained. In contrast, we were also shown images of Black families with genetic syndromes, and one of them that really stood out to me was this image of a mother and her two children in their underwear, backs faced to us. They looked like they were dirty. It reminded me of an image

that I would see in a history textbook discussing chattel slavery. And to me, just that contrast of how Black people were portrayed compared to white people it was so obvious and sitting there as one of the only black people in my class I was like this is how the medical system views me this is how my professors see me I sit here every day and I'm seen as less than human um and that's when I started speaking out because I was like there's no way I'm gonna let this stand for all four years of medical school absolutely I love that story of actually speaking up because a lot of students don't do that but I'm curious how did that series of incidents around those images impact your impressions as a first year medical student yeah I mean it was a moment in

time where I realized that not only am I going to have to be, I already knew from my parents that I have to be twice as good as all the other classmates in order to get the half amount of the respect. But I also knew that I had to be twice as good because somebody has to be looking out for people that look like me when they go into the healthcare setting. So I felt an additional sense of pressure that I have to be kind of the voice for all the Black community in order to speak up for us and the kind of healthcare that we deserve. And then additionally, there was the pressure that as one of the few Black students, I was very visible. I was one third of the black female class population in the Seattle cohort. So the sense that I had to be perfect in every other way because I was being so outspoken. I

knew that if I'm going to be someone that speaks up about racism, I have to have all my other bases covered. I can't afford to do badly on exam. I can't afford to do badly on clinical clerkships because everyone's eyes are going to be looking at me. That particular experience in speaking out actually went really poorly. So I had emailed the professor to discuss the images. I even offered to look for new images. And the response was very negative. I actually got a very long email from him where it was obvious that he had been offended by me pointing out that the images that he was using were racist he started talking about how you know we use a lot of medicine from from nazi scientists and am i speaking out against that as well and i was like whoa you know how did this go from

me asking you to change new images to now we're talking about nazis it um the result was that you know the next day in lecture he kind of had this whole monologue about racism and about how he's not racist and nobody in the class knew what was going on because these were private conversations between him and i so everyone was kind of looking around like what is happening but it was very much directed at me. And this started kind of like a year long process just because I reported that one incident. It was a whole year before that whole issue was resolved. Wow. Yeah. So you can see how exhausting it becomes. the pressures of being a black medical student, of being one of the only, of feeling like you have to do well on everything. But then also the response that we as students sometimes get when we try to change a system, denial or trying to push it off or saying, are you fighting for

everything? And I feel like so many professors do that. So props to you for kind of sticking with it. And with that behind you, how did you then decide to go on to speak about the kidney diagnostics lecture? You just kind of let us know that it didn't go well the first time, yet you still kept fighting. So how did that unfold? Yeah, I think, you know, the reason I kept speaking up was because for me, it felt worse to not say anything. It was really, really emotionally straining to sit in class every day and hear about how people that look like me are viewed as inferior hear about how our lab diagnostics are different our health outcomes are different and not be able to say something because it was also this sense that if I don't say anything no one else is going to say anything and then everyone's going to believe that these

kind of myths about black people are true so that was one thing where it the days i didn't say anything i felt worse than when i did the other was because i had already been outspoken i already had the reputation of the angry black student other classmates already viewed me as unprofessional i know they talked about it with each other because i heard about it like other professors already viewed me as unprofessional. I know they talked about it with each other because I heard about it. Like other professors already viewed me as a troublemaker. So I was like, my reputation is already, I'm already being viewed negatively because I'm speaking out. So if I already have that reputation, then I should just keep speaking out because it's not going to get worse, you know? And at the same time, recognizing that because I was known for speaking out, I had to make sure that everything else, all my other ducks were in

a row, right? Like I had to make sure that I was still getting the passing grades in order to have the privilege to be able to say something. Absolutely. So tell us about that day. What happened when you were kind of sitting in class and you learned about the gfr equation or how did you even come to learn about it yeah that day was it was interesting day um so i our school has a flipped model so we learn about we do our reading beforehand before going to lecture um so i had learned and read about the egfr and i remember reading about it in our course materials and thinking this doesn't make sense that there would be a different calculation if someone is Black. Like we had done our anatomy lab. I knew that kidneys didn't look any different.

I couldn't find any pathway where like melanin played a role in the kidneys. So I started reading more about how this equation came to be. And that's when I really learned that the reason that there was a black coefficient for EGFR was because of the belief that black people had more muscle mass. So I'm someone that grew up running track and field in high school. I've heard all the black people have more muscles joke. So to me, I was like, this is something that is so blatantly racist. I don't understand how it's something that continues to be in our healthcare system. So in class that day, the professor was giving a lecture about, you know, EGFR. He brought it up briefly and said, you know, we do a correction if the patient is black. There's a lot of science proving this and that's just the way it's done. And he was

kind of like ready to move on. So I raised my um because they always say if you have a question you should ask i was like all right well i've got some questions um so i raised my hand and i was like you know can you tell me exactly why black people have to have this adjusted value because to me it doesn't make sense and for my reading it looks like this adjustment was made because of the belief that Black people have more muscles. And he really couldn't answer that question. So I just kind of pressed forward and I said, well, think about it this way. If I am a Black person and I get a kidney transplant from a white person, which EGFR equation would you use? Is that kidney now Black because it was inside me,

or is it white because it came from a white person? How black does someone have to be to get the black coefficient for people that are mixed race, right? Who gets to decide whether the person is black? Is it the physician deciding? Is it the patient self-reporting? And then when you look at papers showing that in other parts of the world, we don't use that same coefficient. So I'm from the Democratic Republic of Congo. So my kidneys somehow needed to be corrected for when I moved to the US. Somehow they became completely different. So it just didn't make sense. And the response I got from the professor was actually very poor. This was a pretty large lecture because it was a mix with the dental students and the medical students. So there were students that were complaining that I got from the professor was actually very poor. This was a pretty large lecture because it was mixed with the dental students and the medical students. So there were students that were complaining that I was being disruptive. The professor was complaining that I was being

disruptive. And they ended the lecture. And then we got an email from our school administrators from the deans saying that they would be holding a second lecture to talk about racism because there were so many disruptions from the first lecture. Wow. So then we had an impromptu second lecture to talk about racism because there were so many disruptions from the first lecture. Wow. So then we had an impromptu second lecture and the deans were there very prominently in the front row. I was like, okay, like everyone's watching, like they're making a very big deal out of this. And I thought, well, now everyone's here. So let me just keep asking the same questions so everybody gets to hear them. Yep. the result of that actually there was a nephrologist there by the name of dr bessie young who she was actually brought in to counter my questioning and over the course of my discussions

with her during this lecture and afterwards she actually was like, oh, wait, this is a problem. So from there, it was a matter of getting faculty allies. So getting people with nephrology and family medicine, et cetera, and laboratory medicine. Because what I learned from this experience is that it's one thing for a medical student to say something, especially at that point. This was the first block of my first year of medical school. So I feel like people were very hesitant to listen to me because they felt that it was offensive that a first year medical student was making claims that what they were doing was wrong,

that what they've been doing for decades was incorrect. And it was another thing for them to hear it from their own faculty members. Absolutely. And I just want to take a second to pause and just like applaud you for how incredible you were that even in that moment where you didn't know how things were going to go or the professors pushing back that you kept with what you believed in. And I remember similar to you when I was sitting inside my class and heard about GFR, I was just like, what in the world? Like, that's crazy that we have. And for me, it's the fact that it's a black versus a non-black. Exactly. Right. Like there's no other race. It's only black people that for some reason,

like you said, like it makes it assume like all black people are different for some reason. And the only thing that really comes down to was the muscle mass that was kind of being built off of. But I think it's so fascinating. I think there's so much power in medical students like yourself actually stepping up and talking about it. I'm curious, how did those experiences then change kind of your approach to your own education over the next few years? Yeah, it changed a lot. I think, you know, I'm from an immigrant background. You learn from your parents that education is everything, right? You listen to your professors. You are there to gain knowledge from them. It changed the way I view the people that are tasked with educating me. So for me, now when I

learn something, I do my own work to gain more information about the background, right? How are these tests that we're learning? How were they developed, et cetera? it also made me realize that the people that are teaching us like they don't know everything um they also were kind of taught with that same doctrine of you know you're a medical student you learn what we're teaching you you accept it as fact and you don't question it um so then they teach us that same kind of flawed information and what i think i learned from this is that it's always always always good to question what you're being taught it's always good to dig and learn more information and to also recognize that as a student you also have a lot to offer to

your professors the pedagogy of medical school where it's kind of a, you know, they say jump and we're supposed to say how high I think is so backwards. Medical students come from a variety of different backgrounds. Like I came from a pretty strong research background. You know, I have a lived experience background. We have a lot to offer to our professors, but they have to be willing to listen and actually learn. Absolutely. And for me, I'm like, well, when I'm an attending, I have to be ready to listen and learn too, because I'm sure there's things that the younger generation of medical students are going to point out to me. So I have to be able to reciprocate that.

And I remember an article that was published in Nature. I was hoping you could share a little bit about what happened there. Yeah. So this was a very frustrating situation where I played a major role in changing EGFR calculations at my institution. And I later found out that some of the people that I think were the most vocal against my change or the most vocal against me speaking up, ended up publishing a paper about the changes in EGFR. And I found out about it on Twitter, which was very upsetting. It's one of those instances that I think a lot of outspoken students of color can relate to where once what you're saying goes from being unpopular to people recognizing that it's true, and it gets gets picked up and people are congratulating it,

congratulating the institution, history is rewritten very quickly. In the sense that now you almost have the sense that everyone thought that this was a good thing to change. Everyone believed that EGFR shouldn't be race corrected. So for me, it felt like a slap in the face that this was something that I really put myself on the line for. I risked my medical career. I risked my spot at medical school to speak up on this and then to not even be really acknowledged or involved in the work moving forward. But I think that's a lesson to other people to show that, you know, institutions will try to rewrite history and you have to just be willing to speak up and say your piece and have people that are in your corner that are willing to say like, hey, this isn't actually how it happened. I kind of want to go back to that moment too,

of like what you're talking about with the changes that are happening. Because I think we kind of glossed over how you not just brought up a problem, but you actually saw that through and were instrumental getting it changed. So could you talk to us a little bit about what does the GFR equation look like today and how you think your role, being so outspoken, impacted it getting changed? Yeah, so today we have a new GFR equation. It's called the 2021 CKD-EPI equation. So that is what clinicians are supposed to use to calculate someone's GFR. It does not include a race coefficient. So the University of Washington hospital system made that change in 2020, and then several other hospital systems

followed suit. What then happened following this is myself and other students kind of launched a campaign via social media and public-facing media. So for myself, speaking on NPR, CNN, MSNBC, doing South by Southwest with you, another kind of like very public facing media to tell the public, like, this is what we're using to calculate GFR. If you're black, your GFR calculation is being altered. And this is what we should be moving to. So I began working with an organization that was created by students. It's called the Institute for Healing and Justice in Medicine. And we really recognize that individual changes in hospital systems isn't sustainable for the movement that we're trying to make. It's one thing for individual hospital systems to make a change.

What we really needed to happen is that the governing bodies of kidney medicine make an official change so that the hospital systems that are unwilling to kind of move and follow the science are now pressured by their governing bodies to do so. So we were able to meet with the chief medical officer of the National Kidney Foundation. We were able to get involved in discussions with them in selecting members for task force to reinvestigate the use of race. We also sent several letters to members of Congress to talk about the use of race-based medical algorithms. And the result was that the National Kidney Foundation and the American Society of Nephrology did their own research, put together task force, and they found that the use

of race correction in calculations of EGFR was inappropriate and not scientifically sound. So now the official recommendations is that all hospital systems move toward the non-race corrected EGFR. And I think the even bigger change that happened earlier this year is the change to the wait lists for kidney transplantation. So following the recommendations of the National Kidney Foundation and the American Society of Nephrology, the governing body for organ donations announced that they will be recalculating the wait lists for Black patients who had their EGFR calculated using the race coefficient. So what we're hoping to see

is that more Black people are going to qualify for kidney transplants. And additionally, more Black people will qualify for healthcare coverage, for specialist coverage, for other medications where you need to have a certain EGFR value to qualify. That's incredible. It's huge. I mean, you are a medical student who led this to happen nationwide. I think about that a lot, that you've now opened up the doors for 3.3 million more black Americans to be able to see a specialist, to potentially get a kidney transplant if they need it, to have their GFR seen for who they are and not by their race.

I think that's absolutely incredible what you've done. I brag about you all the time. It's like my crowning achievement. I think, you know, this really came full circle for me in my last year of school where my mom was diagnosed with fibromuscular dysplasia, which it's a disorder of the blood vessels. And one of the blood vessels that impacts is the renal arteries. And in order to track people's disease progress, you have to track their EGFR. So being able to go to clinic visits to my mom and see that like her EGFR is not race calculated. I know that her disease is being tracked accurately that I just like had tears in my eyes. And I remember she had told her doctor, like, that's my daughter made that change. She's the one that changed the EGFR. Wow.

So, yeah, it's, you know, it kind of goes back to what I was saying earlier, where when you're one of the few in your class, you sit there and you think, this is how they're going to treat my family. This is how they're going to treat my loved ones. And now to be able to have that tangible change where I know that this treatment is directly impacting someone that I love. It's been huge. Why do you think you've been able to have that impact when there was people before that may not have been able to? Yeah, EGFR is not new news, right? People have talked about race correction EGFR for a while now. I can think of like Dr. Vanessa Grubbs, who's been talking about this for years now. I think one of the reasons why this change happened so rapidly

is an unfortunate combination of multiple things. One, there was the COVID pandemic, where more and more people were concerned about the type of healthcare they were getting. Specifically, more and more Black people were concerned about the unequal health care that they were getting and more and more people were online i think also with kind of this quote-unquote racial awakening that the united states had um following the deaths of brianna taylor and amad aubrey i think more people were willing to talk about racism and specifically racism in medicine. And I think, you know, our generation of medical students who are so much on social media and online, we were able to really kind of push that conversation forward. So I think that is what kind of brought this more to people's attention. It was one of those stories where it was very easy

to point out the racism because of that calculation, very blatantly saying if they're black multiplied by x value, that it was it was something that was easy for the media to explain to the general population, as opposed to other aspects of racism, like the images that are used, for example, that are kind of harder for people to conceptualize why that's racist. Absolutely. I remember when I first made my GFR equation on TikTok, I just felt like it was, like you said, it was so easy to get that point across because it's very tangible. When you have something like this that's easily seen and allows people to have an entry point into understanding how disparities in medicine kind of get weaved into things. So how do you think med schools should be evolving now? Yeah, I think, you know, so much of med school, as you know, we discussed earlier, is top down, where the professors are

kind of the beacon of all knowledge. I would love to see medical schools evolve such that students have more power. And what I mean by that is that students don't have to feel like they're risking everything in order to speak up when they see something is wrong. I want med schools to be more open and have more discussions about racism. I know some of the feedback that I got when I talked about racism in classes was that, well, we're here to learn about science. We're here to learn about medicine. Why do you have to bring race into everything? Like, it's because race has been brought into everything. Like I'm not the one that put race in the GFR. You guys are the ones that did that.

Now you don't wanna talk about it? So I think we need to evolve to have, to be able to have more honest conversations. I would also, I mean, this is even a second conversation, learning that representation isn't everything, right doing a disservice to people to bring them in, have them beaten down, treated poorly, and come out of it thinking, you know, maybe they're right. Maybe I don't have a place in medicine. Maybe I don't have a place in healthcare. That's so important, what you just said. And I think about like the pathway before you get into medical school, right? There's that. So how do you actually get introduced into the field of STEM? But then there's when you're in there, like you're talking about, are they actually supporting you? Are they

doing things to make sure that you feel seen, that students that have traditionally not been in institutions like that are supported? But then also what comes afterwards, right? How are you engaging people to help come back in if they need to, to support the people that were there? Or how are you making sure that people continue beyond? So I think all of that is really, really important. And I also think about the hidden curriculum. And I'm curious if you could kind of talk about that a little bit. Yeah, I mean, the hidden curriculum in medicine is kind of this, this idea that there are certain ways that you're supposed to interact with professors, there are certain things that you're supposed to do that are not spoken. But somehow everyone knows that you're supposed to do them, right? So you're expected to do research for different specialties. Not everyone knows that they're

supposed to do research and not everyone has connections to get research. Other areas of hidden curriculum are like the way that you interact with your professors, right? So for me, it was a little bit like I have people in my field that are in medicine. So I feel like I had a little bit of an easier time. But it was difficult to figure out who exactly is an ally and who isn't. I think especially as a student of color now, especially that white people are afraid to be called racist more than they're afraid to be racist. That it's hard to find allies that are actually there for you, right? So finding professors that are willing to have your back in those tough

moments and not just kind of behind the scenes, right? Finding people that are able to speak up for you when something's happening and not just come up to you afterwards and say, I'm so sorry that happened to you. I'm hoping to learn and grow from this experience. I'm like, okay, learn and grow. But like, what does that do for me in the moment? Yeah. How did you find allies inside your institution, especially when there is so much pushback against you? And I guess what advice would you have for students that are feeling like they can't find an ally at their institution? Yeah. So the way I went about it was actually by going to office hours, oddly enough, which sounds like an odd recommendation. But for specific units that I was having a lot of trouble with, I would meet with those professors repeatedly, because what it did is one as a person. And I could kind of feel out, is this someone that I can actually go to and talk to when I'm having issues? So one of my allies

is someone that I met because I was having a hard time with the pulmonology curriculum. And I went to see him every day after exam to walk through. These are the issues I had with the exam. Other ways are to look for professors that are already doing the work. So what I mean by that is people that are already involved in like pathway programs for minority students, et cetera, because you know that they are willing to stick up for students of color. They're willing to create opportunities for them. And it can be tricky because, again, when I say when representation doesn't always mean support, it's not always the people of color that are higher ups at your institution that are going to be the ones that are supportive of you. Right. Sometimes they're the ones that are going to do the most damage. I think it's an issue with as you move up in academia, there's more and more pressure to maintain the status quo as opposed to trying to change it.

When we look to the next five to 10 years of where medical schools can go in order to be more inclusive, in order to actually tackle equity issues, in your ideal world, what would medical schools be doing to prepare future doctors for the world that's out there? Yeah, I think this starts with changing the prereqs for medical school, right? So, so many of the prereqs are focused on the hard science, which is critically important to be a physician, but patients don't come to us in a vacuum, right? They're members of their community, they have families, and in order to be a physician that can serve these patients, we need to have a better understanding of the social determinants of health and the other things that impact an individual's health and a community's health.

So requiring more public health-based courses before going into medical school, I think, would be really useful. Requiring more sociology courses, more courses to understand, you know, the roles that racism, sexism, homophobia, etc., ableism have played into medicine. I think when we're in medical school, having courses on the history of medicine. So we're taught all of these exams and labs and, you know, all of these like facts that some of them we won't even ever use. but we're almost never taught about how these were actually developed and how medicine has not always been, has frequently actually been on the wrong side of history. Because of that, I think we're prone to repeating it. So having a history of medicine course that students are required to take, I think would also help. I would also say

that in order to achieve greater equity, I mean, the cost of applying to medical school and going to medical school is ridiculous. There's no reason why people should be taking out loans just to apply to school. So reducing those costs and also reducing the cost of actually being a student, because by doing that, we're actually, we're pre-selecting who is able to be in this field. And that limits the kind of actually being a student. Because by doing that, we're actually, we're pre-selecting who is able to be in this field. And that limits the kind of perspectives that we have access to. Well, I'm hoping that someone listening to this

will be taking those pieces of advice because that was so salient. And I think you hit on all the different levers that we need to be hitting on in order to improve health equity. Naomi, I want to say thank you so much for talking to me today on The Dose. You are incredible, amazing. And everyone, so Naomi graduates from the University

of Washington School of Medicine in May. And today she just found out that she's officially heading to residency for family medicine. We know she's going to be a great doctor. Thank you so much for having me. It was an absolute pleasure. Yeah, thank you. And as always, please tweet if you like anything you heard. Give us a shout out if you have ideas for the podcast. Once again, I'm Joel Bervell. Thanks for listening to The Dose, a podcast of the Commonwealth Fund. See you next time.

This episode of The Dose was produced by Jodi Becker, Mickey Kapper, and Naomi Leibovitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is Arizona Moon by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There, you'll be able to learn more about today's episode

and explore other resources. That's it for The Dose. I'm Joel Bervell, and thank you for listening.