“How can we be so underrepresented and expect a big change?” – Interview with Dr. Aja McCutchen
In a data driven world, it’ll become acutely obvious that our system is broken in terms of racial disparity. The drugs we have don’t work for all demographics. GI physician community is quite imbalanced in terms of race. Patients and future physicians will gravitate toward a more inclusive medical practice.
It’s already apparent that social determinants of health (SDH) influence health outcomes. Whether we recognize it or not, diversity and inclusion affects all of gastroenterology. It’ll affect the future of GI. It’ll affect private practice GI — for sure.
One of the most qualified people in our industry to understand this important topic is Dr. Aja McCutchen. She’s a Board Member of United Digestive and Chair of Diversity, Equity and Inclusion at Digestive Health Physicians Association (DHPA).
In this interview, she shares her story – from the suburbs of Cleveland (“crazy Dave” drew her to medicine) to leading the field (GI has only 1% African American women). You’ll clearly understand the importance of paying attention to diversity and inclusion.
Watch this incredible interview.
◘ Dr. Aja McCutchen’s journey: Leading a field with only 1% African American women
◘ “What do you find most fascinating about the field now?”
◘ “One of the things that’s fascinating about medicine is that, you never stop learning, you never stop growing”
◘ What does diversity and inclusion mean?
◘ “Inclusion is celebrating the diversity”
◘ Is inclusion and diversity a problem or an opportunity?
◘ “Some people unfortunately, look at different groups and have some preconceived notions”
◘ “Sometimes differences are not accepted, when they absolutely must be celebrated and embraced”
◘ What are the [inequity] problems in healthcare?
◘ Why should the industry pay attention to this aspect of medicine?
◘ “There’s a big gap in the medical literature in terms of representation of black and brown patients”
◘ Is there a glass ceiling [in GI]?
◘ “My black patients would come into the room and they would say: We are so happy to see you here. We have never seen a black GI doctor”
◘ Being an African American or being a woman – which one is more challenging?
◘ “If you look at numbers, 4% of gastroenterologists are African Americans and less than 1% are women”
◘ As the Chair of Diversity, Equity and Inclusion at DHPA, what is the agenda?
◘ How does racism and bigotry play out in healthcare?
◘ Five, ten years out, what is the vision to address this aspect?
The Transcribed Interview:
Praveen Suthrum: Dr. Aja McCutchen a warm welcome to the Scope Forward show. I’m really excited that we’re having this important conversation today.
Dr. Aja McCutchen: Absolutely, it’s my absolute pleasure and honor to be here this morning with you Praveen.
Praveen Suthrum: For our audience, let me read out your background so they know what you represent. Dr. Aja McCutchen is part of the board of directors for United digested, she’s on the United Digestive’s Physician Executive Committee for a second term, and acts as Chair for the quality improvement committee. Additionally, she is the chair of diversity, equity and inclusion for DHPA- The digestive health physicians Association, Dr. McCutchen is an associate professor of the Medical College of Georgia University of Georgia program and participated in starting up the health disparity improvement task force for Northeast Georgia hospitals. She’s actively involved with the Georgia chapter of the Crohn’s and Colitis Foundation, leading a bi monthly virtual group. She’s a volunteer and advisor for the non-profit saving our daughters. Dr. Aja McCutchen, that’s an amazing background and I want to start from the beginning. How did you end up leading a field that has only 1% African American women?
Dr. Aja McCutchen: That’s a great question and certainly not a straightforward answer. But I’ll start in the beginning, because they at the beginning, I think is very important and sort of shaping who we are, because it’s early on that we’re fairly impressionable. In the beginning, I realized very early that life was a limited journey. I was fascinated with the sciences and I remember telling my mother at a very young age that I wanted to be a physician. And she said why? I said that I just admire the role of the physician and the community as a healer. I was fascinated by the sciences, I was a kid that was sort of digging to the water line in the backyard, because I heard that there was water in the earth. And I was also very interested and intrigued with people. So, one of the early stories that I wrote about in my personal statement for medical school was actually about a gentleman that lived on our street and the kids called him ‘Crazy Dave’. And the reason they called him ‘Crazy Dave’ was because he would walk down the street, and he would actually talk to himself. But instead of me sort of behaving like the rest of the kids and taking a backseat approach or distancing myself, I was completely interested. What actually made Dave different? What was he thinking in his head? That really was fascinating. It was sort of that interest in people and interest in being a healer that actually had me early on very interested in going into medicine. And I think that having mentorship and sponsorship is ever so important as well in terms of my journey through gastroenterology. And it was throughout my entire training in career that I was fortunate enough to have mentors to identify my enthusiasm and passion for learning.
Praveen Suthrum: Amazing story Aja, what do you find most fascinating about the field now?
Dr. Aja McCutchen: I think the field is very interesting, because it continues to be this nice blend of medicine and surgery. I’m very interested in the innovation that’s taking place in the field. One of the things that’s always fascinating about medicine is that, you never stop learning, you never stop growing. And it’s a field that’s now being driven by artificial intelligence, the digital world. Lots of fascinating movement. And the integration of technology right now is absolutely fascinating.
Praveen Suthrum: Excellent, I’d love to talk more about that. But I want to get into the topic of our discussion today, which is on diversity. So, I was wondering if I were an alien landing from Mars, how on earth would you explain to me what diversity and inclusion means?
Dr. Aja McCutchen: That’s a really good question Praveen. I think if you were from elsewhere, and you came here to our beautiful earth, then I would say here in our world, we’re a beautiful blend of various people and these various people have different skin colors, we have different family structures, different ways of thinking, different places that we live, different beliefs and that is a diverse world. And inclusion is actually celebrating that diversity, making sure that because of these variations that we have, that everyone feels like they are a part of something, that they belong to something, that there is an opportunity to optimize, and leverage the strength that we have based on the diversity that we have.
Praveen Suthrum: So the alien in me wants to ask, if I look at the inside of you, it’s all the same. Is this a problem? Or is this an opportunity?
Dr. Aja McCutchen: It should be looked at Praveen as an opportunity, right? Because, when you look from a multi- dimensional standpoint, people from different backgrounds have different experiences. If we were all the same, then it would be very cookie cut, we wouldn’t have anything different to offer. And so having diversity in a place is really a plus, it’s a bonus, it’s a win- win situation. But unfortunately, there are some deep rooted structural issues that have gone on. We had slavery 400 years ago, that has resulted in a group of marginalized individuals that have been historically discriminated against, so we don’t have the same opportunities. And some people, unfortunately, look at various different groups and have some preconceived notions that absolutely shouldn’t be the case.
Just think about a box of chocolates. You have your favorite box of chocolates, and you like the box of chocolates to have the caramel in it, because that’s what you grew up with. That’s what you know, well say I gave you a box of chocolates, you bite into it, and oh, it’s cherry in the middle. Oh, wait, that’s different. I’m not sure if I actually liked that cherry or not. And that’s where it doesn’t make a lot of sense in terms of the biology because humans, we’re like 99.9%, biologically the same. But when we experience differences, sometimes those differences are not accepted, when they absolutely should be celebrated and embraced.
Praveen Suthrum: I want to talk about healthcare, contextualize this for us, for healthcare as an industry. So, what are the problems?
Dr. Aja McCutchen: This is a loaded question. We know that there are multiple examples of inequities in healthcare. From an access standpoint, to disparities and outcomes standpoint, to representation in medicine standpoint. This was really highlighted right in 2020, during the COVID pandemic. In 2020, I think that’s where a lot of issues sort of bubbled up and came to a head. Reverend Al Sharpton said, we can turn a moment into momentum. But with COVID, I think that was our moment to turn this moment into a momentum because we saw glaring and staggering disparities in COVID-19 outcomes. Black and brown patients were three times more likely to die from COVID. But we also saw during this time, an increase in colorectal cancer disparity outcomes. We lost several of our leaders in the black community to colon cancer and several celebrities. With Chadwick Bozeman going in the same year as Natalie Desselle, the community was sort of like what is happening here? Why are we experiencing colorectal cancer at a young age? The word got out that there are big disparities here in colon cancer outcomes, where African Americans are 20% more likely to get diagnosed with colon cancer and 40% greater likelihood of dying from colon cancer, and its sort of these inequities and disparities in healthcare outcomes that I think were highlighted the need to make some changes.
Praveen Suthrum: I’m going to ask a question that people may not normally ask. They may be thinking in their heads, I’m too busy with my practice problems, all this technology stuff that I’m supposed to be doing, why should I pay attention to this aspect of medicine? What would you say to them?
Dr. Aja McCutchen: We have to remember why we went into medicine Praveen. We have to remember that we came into medicine to be healers, we are here to make sure that our patients have the best outcome possible. How can we look a patient in the face and tell them we’re here to help you, but we don’t even try to understand what their barriers are? Remember, there’s a big gap in the medical literature in terms of representation of black and brown patients. So even when I’m offering a particular therapy, because we’re absent in the literature, and we’re absent in the clinical trials, I don’t even know if the therapy that I’m offering you with 100% certainty, although nothing is 100%. But I don’t know if it’s going to be helpful or harmful to you, because we’re absent in the literature. If I don’t understand your social background or social barriers, I can’t really optimize my care for you and ensure that you have a good outcome. So as doctors committed to helping and healing patients, it is absolutely imperative that we integrate and try to understand the social determinants of health and how various differences in background, ethnicity, gender, all of these things play a role in patient outcomes.
But it was really sort of even after that, when I when I did go into fellowship in this area, I realized that there was a lack of representation in GI. Because my black patients would actually come into the room, and they were saying, we’re so happy to see you here, we’ve never seen a black GI doctor. These were moments that were sort of very interesting. At this point, kind of I was still fairly young, so I had not overly thought about these various barriers. But unfortunately, as I progressed in the field, maybe my awareness heightened as I was moving forward. And I did come across a couple of interesting things. I specifically remember going into private practice, and there was a role that I wanted at the hospital. And I said, I would like to be the next director of endoscopy at the hospital. I threw my name in the hat and I heard nothing. I said, what is the process by which I can be elected then for director of endoscopy? And again, I heard nothing. The next thing I knew, there was another gentleman, a white male that was given the director of endoscopy. I asked, can you explain to me what the process is? Because at some point, I’d like to be the hospital’s director of endoscopy. And no one could ever explain, how I would be able to reach that position. And so that was actually an eye- opening experience for me, when I realized that I don’t think they want me in this position.
Praveen Suthrum: I want to ask you, you know, amongst these two aspects of diversity, African American and woman, which do you keep hitting more?
Dr. Aja McCutchen: Being a double minority is challenging, because being a minority in general you’re always taught that you have to be twice as good. That you have to do twice the amount of work to achieve the same goals, you have to do twice the amount of work to get the recognition that you need. Being a double minority means that when you’re in a room full of people, and you’re experiencing these various situations, where you feel like you’re not heard, or you feel like you’re not valued, it’s difficult to tease out, you often try to tease out, what is it? Is it because I’m a woman? Is it because my skin looks different? What is it about me that is causing my peers essentially that I value and respect to not value or respect, what I’m bringing to the table? I think it’s important though, at least from a female perspective, I was able to really surround myself with a tribe of women, and we have created these safe environments to share our experiences. I think in terms of being a woman in GI, for the past decade, we’ve had GI roundtables and so I think we are making great strides in terms of female representation in GI.
In terms of having this second hit, we’re not there yet, we have a lot of work to do. And if you look at the numbers, the numbers are staggering themselves. 4% of gastroenterologists are African American and less than 1% were African American women and that has to change. It’s been well documented that patient outcomes improve when you have appropriate representation. So how can we be so underrepresented and expect to make a big change? We have to improve the pipeline here.
Praveen Suthrum: That actually takes me to my next question, which is your role as the chair of Diversity, Equity and Inclusion at DHPA? What is your agenda?
Dr. Aja McCutchen: DHPA came together and said, we absolutely need to make it a part of our very fabric and be intentional about making sure that we incorporate diversity, equity and inclusion in our mission. It started where we came together as an organization, there were about 13 of us on a call. When we formed the committee, we began to exchange stories. We had to be transparent at this time, we had to be vulnerable at this time. And we and we realized that each of our lives had been impacted, touched in some way by the sobering events of 2020 and that’s how the committee was formed. But as we began to sort of exchange this dialogue, we realized that this was a gargantuan task. It was deep rooted, it was multi-dimensional, it was not only individual racism and bigotry, but there was structural racism, and this is a problem that was not going to be solved overnight. My message to the committee was, we don’t have all the answers today. This is definitely going to be a journey and not a destination. And I emphasize that I don’t want this to be a flavor of the month. And as I began to reflect on my own experiences, I didn’t realize how many moments I had where I felt isolated in this field. I shared some of those experiences and I guess brought in a certain enthusiasm and passion. And they said, why don’t you lead these efforts? That is how our committee was formed. The committee was actually quite diverse in and of itself in terms of representation. We have people on the committee that had various sort of interest in terms of problems or challenges that they wanted to solve. We began to sort of organize ourselves into various domains, and sort of approached the problem from understanding that it’s a multi-dimensional problem and we organized ourselves into working groups. We had three main premises- One, we knew that we needed to improve representation from the top down, we needed to be intentional about doing that. Improving representation, leadership, and improving representation and diversity in our staff, all the way down to the pipeline that was the first aspect.
Two is there needs to be some self-reflection in medicine. We sometimes don’t recognize that a lot of people have this impervious lens, and they don’t even recognize how we are the system. And if we don’t recognize our own shortcomings, then we’re not doing anyone a service here. We began to focus on the collection of data. We are a data driven society at this point, right? How can we know where we need to go if we don’t start to research and collect data? So, our second group was sort of a research working group, where we would then begin to- One curate a group of resources that we could all use as sort of a central repository of Diversity, Equity and Inclusion resources. And two, we began to send out some surveys to really understand what the current climate was in our various member practices, we have over 100 member practices that we’re doing that on.
The next important part was collaboration. Because you can save a lot of time, money and resources by talking to other organizations and beginning to share best practices. It’s important that as we try to approach this gargantuan task, reducing disparities and improving representation so that our outcomes are much better. We have to realize that we’re not in a vacuum in GI. And I see personally, a lot of gaps in in the field still, in terms of there is academia. And when you hear about programs you hear about with a University of Maryland has his program, and this person has been appointed to lead this diversity program out of Johns Hopkins. But what about the community, we’re sitting right here in the community, we’re serving a significant portion of patients, but we’re not necessarily connected with some of the other societies. I made it a point to reach out and collaborate with our larger societies, community organizations. And collectively if we share best practices and ideas, rather than reinvent the wheel, we can actually focus on propelling the field forward in terms of diversity, equity and inclusion.
There’s a movement towards value-based care. As we think about value-based care, we’re checking these boxes all the time. Did the patient have their colonoscopy? Did the patient have their flu shot? What about the social determinants of health? Did we follow this patient through to make sure that they had the ability to access their care? Did someone advocate for them to make sure that they could meet their goals in terms of getting them to the oncologist? Did we focus on making sure that social determinants of health did not get in the way of our patients having the best outcomes possible?
Praveen Suthrum: I wish you all the best in what you’re setting out to do. I do have a couple of more questions. One was on racism and bigotry itself, both in patient communities and in our system. I wanted your view on how do you see it play out?
Dr. Aja McCutchen: Racism and bigotry have been glaring and medical care in particularly in minority neighborhoods. Access to quality care is an issue and has a direct impact on life expectancy. And we have seen over and over again, inferior outcomes. We know that, for example, infant mortality is higher in underserved and underrepresented communities. We know that maternal mortality is higher, again, COVID. When you look at our field, in particular inflammatory bowel disease, the outcomes are worse. Black and brown patients have higher rates of hospitalization, worst disease are offered less biological therapies. This is something that has been pretty staggering. If you look at the history here, there’s been something called redlining that has occurred over the years. They take various zip codes and sort of risk stratify people and this results in patients being excluded from various services. If we don’t set up high quality care centers in the communities that needed the most. How can we really change the narrative here? Racism has been present for quite some time and it’s not going to go away overnight. It’s important that we recognize that it is present and that biases are present. I recently sat on a panel looking at clinical trial participation. One of the biases that was present was there were patients that were not even being offered a clinical trial, because there was the assumption that perhaps they didn’t have the transportation or the education in order to really understand the material, and therefore they wouldn’t follow through, and they would not even be offered a clinical trial. If we’re absent from the literature, how do I know that a medication works for you? If we’re moving towards algorithms and personalized medicine and pharmacogenomics? How will I know that the algorithm that’s going to be spit out for your colon cancer actually applies if you weren’t actually offered participation in the basic research? Or we don’t have your genomic information to know how you’re going to respond to a certain therapy?
Praveen Suthrum: I want to wrap up this wonderful conversation with the final question, what is your vision for the future? Let’s fast forward. I love to talk about the future, usually in the context of digital and business. But here’s a completely different future that I want to see from your lens. 5-10 years down, what is the vision or to address this aspect? At least for GI if not for healthcare.
Dr. Aja McCutchen: I don’t expect that this long legacy of challenge with structural and systemic bias to be remedied overnight. But in a data driven world, I’d love to see us rowing in the right direction, I would love to see us with the various exercises that we’re doing now actually creating muscle memory and seeing improvement in representation, improvement in outcomes, reduction of disparity and a presence that is growing of black and brown communities in the literature. In order to do that, what we have to do now is we actually have to face the drivers of disparity head on at this point. We need to start by improving clinical trial representation, that’s what needs to happen now. We need to start addressing social determinants of health, we need to start becoming a part of our community an extension of our community, and we need to start providing a GI culturally relevant material. I will never forget the time where I told a patient to go on the fodmap diet. On the fodmap diet, I said you need to stay away from apricots. He said, I don’t I don’t even know what that is, I don’t need that. And we both just laughed, and I’m like, probably you don’t eat Apricot. We need to make sure that we are providing culturally relevant material, we need to make sure that we work on improving the pipeline. And we need to make sure that we began to collect data and reflect on that data and make adjustments as necessary. And this needs to be a part of our very fabric.
Collaboration is an absolute powerful tool as well, we need to start collaborating with community leaders, other organizations, educators, other GI providers, our major societies. Doing all of this is how we will challenge the status quo. And this is how change will ultimately be made. I don’t expect in five years for a problem to be solved, because again, it’s a journey and not a destination. But I do expect in 5 to 10 years that we will look back on the data that we have collected and realize that now we’re rowing in the right direction.
Praveen Suthrum: Thanks so much, Dr. Aja McCutchen for this excellent conversation and sharing your views all the way from your story how you began, to now where you are and where you’re going.
Dr. Aja McCutchen: Absolutely my pleasure to be here. Thank you for having me.
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By Praveen Suthrum, President & Co-Founder, NextServices.
COVID-19: The Way Forward for Gastroenterology Practices