Ensuring that everyone has access to healthcare is essential. Access should be coupled with an emphasis on screening and prevention efforts, as well. For example, patients without healthcare access are diagnosed with cancers at later stages, which leads to worse outcomes. Being able to catch those cancers earlier with appropriate screening would directly impact survival. Being able to prevent some cancers altogether on a large scale, using the HPV vaccine, for example, would be even better.
As a part of my interview series with leaders in healthcare, I had the pleasure to interview Dr. Tiffany Avery.
Dr. Tiffany Avery is Medical Director of Oncology at NantHealth. Prior to her role at NantHealth, she served as an Assistant Professor of Oncology at Thomas Jefferson University and Wake Forest Baptist Health. She earned her BS and MPH in Epidemiology from Tulane University, and MD from LSU Health Sciences Center-New Orleans. In her academic roles, she was involved in clinical trials for breast cancer patients and research investigating survival disparities in cancer. She has recently also earned certification in Lifestyle Medicine, and remains involved in work aimed at reducing survival disparities in cancer.
Thank you so much for doing this with us! Can you tell us a story about what brought you to this specific career path?
I never thought I would be an oncologist, to be honest. Unfortunately, I’ve had a lot of personal experience with cancer in my family. Once I had the opportunity to experience the other side of cancer care — not from a family perspective — but from the physician’s role, I loved it. I enjoyed the science behind it, and I also found that the practice of oncology demands attention to the physician-patient relationship and to the patient’s support systems, as well as consideration of the whole person in treatment. Those aspects indeed drew me in. I also have a degree in public health with a focus on epidemiology. I have always had an interest in population health and factors that impact society’s health on a large scale. So, the attention to disparities, prevention, and screening in cancer care appealed to me. In my current position, I’m able to consider the impact of the healthcare system on cancer care broadly to understand what’s happening across the country, and I find that especially compelling. It is an excellent mix of all of my interests.
What do you think makes your company stand out? Can you share a story?
I’m very proud of how NantHealth focuses on addressing some of the large health care issues in innovative ways. One example that comes to mind is Eviti Advisor, a database of evidence-based treatment options across cancer types. The sheer volume of trials and advances in cancer care is a testament to the oncology community’s success. Still, it can be complex to consider all of the options for a given patient. Eviti Advisor can help doctors consider all available options for a patient, accounting for side effects and costs, and can serve as a shared decision-making tool for the physician and the patient.
What advice would you give to other healthcare leaders to help their team to thrive?
When I think back to teams that I’ve worked with, the most successful situations are those in which people are in positions that leverage their strengths and interests and given space to do that. Treating all team members with respect and empathy is paramount — especially in healthcare. Everyone has a role to play and all functions are important — from the hospital CEO to the people working in housekeeping who literally keep the operation running day to day. When people feel valued for their contributions, then the best outcome is realized.
Ok, thank you for that. Let’s jump to the main focus of our interview. According to this study cited by Newsweek, the US healthcare system is ranked as the worst among high income nations. This seems shocking. Can you share with us 3–5 reasons why you think the US is ranked so poorly?
One significant problem with the U.S. Healthcare system is the disparities in medical outcomes. While we have realized some of the most incredible medical advances, those gains are not shared equally among all populations in this country. For example, the data shows us that Black women suffer from higher maternal mortality rates in the U.S. Likewise, Black patients die at higher rates from cancer than other populations. Rural populations are at increased risk of developing and dying of cancer than other populations, as well. The reasons for this are multifactorial and include issues with access to care, the bias in medicine, and the social determinants of health that underpin the prevalence of chronic conditions, such as obesity and diabetes. These chronic conditions lead to worse outcomes across the board. Tackling the prevalence of chronic conditions requires looking at the choices that an individual makes and recognizing the impact of the environment in which they live on those choices and conditions. That is, recognizing the impact of the social determinants of health — those conditions in the environments in which people live that impact overall health.
Another issue is with the U.S. public health system. As we live through the coronavirus pandemic, we can see that we have a weakness in handling public health. While we have worldwide experts in public health, epidemiology, and infectious disease here in the U.S., the need to have a coordinated effort in the face of a pandemic has been highlighted. We see the effect of a lack of coordinated effort now as we see the second wave of coronavirus cases, unfortunately, on the rise across the country.
Millions of Americans lack access to adequate healthcare — a primary factor in the prevalence of healthcare disparities, which I mentioned previously. Without access to healthcare, opportunities for optimal treatment of disease and prevention and screening get missed in a large swath of the population. We see the downstream effects as later-stage cancer diagnoses, for example. Healthcare access isn’t just insurance; it also includes the availability of medical practices or hospitals in a community. Lack of healthcare facilities is seen both in rural communities and in urban, underserved populations.
You are a “healthcare insider”. If you had the power to make a change, can you share 5 changes that need to be made to improve the overall US healthcare system? Please share a story or example for each.
As I mentioned previously, there is more recognition now on the social determinants of health, and this is where I feel we can make a great improvement in U.S. healthcare. That is the acknowledgment that so much of healthcare happens not in the hospital or medical offices but in the communities where people live. A person’s health is impacted by what choices they make in diet, exercise, sleep, and stress management, but those choices are significantly affected by the environment in which they live. For example, there are thousands of identified food deserts across the U.S. — areas where access to grocery stores with fresh food options is limited. These occur in both rural and urban areas. Often, these areas that lack grocery stores are in communities where transportation is also limited, which exacerbates the problem. I think back to when I chose to focus on getting five servings of fruits and vegetables a day in my diet; I did it while living within a couple of miles of four grocery stores with plenty of fresh produce readily available. A person who lives in a food desert with more fast food than fresh food options faces a different challenge in making that kind of change. And so, while our desire to improve may be the same, the barriers are very different. When we think about how these factors add up — access to fresh food, access to safe spaces for exercise, living in a community affected by pollution or with little access to healthcare — we can begin to understand how chronic conditions such as obesity, diabetes, and high blood pressure are prevalent in communities. There are so many complexities involved in realizing equal health outcomes for everyone across the country.
Second, ensuring that everyone has access to healthcare is essential. Access should be coupled with an emphasis on screening and prevention efforts, as well. For example, patients without healthcare access are diagnosed with cancers at later stages, which leads to worse outcomes. Being able to catch those cancers earlier with appropriate screening would directly impact survival. Being able to prevent some cancers altogether on a large scale, using the HPV vaccine, for example, would be even better.
Third, we need to put more effort into achieving and maintaining wellness. I’ve heard that the U.S. healthcare system is more “sick care” than health care. While advances and cures for disease are of paramount importance, lifestyle changes can address some of the chronic conditions that complicate healthcare outcomes. As an oncologist, I tend to think about this more in terms of cancer outcomes, and we know that obesity and diabetes impact survival in some cancers. Also, the development of many cancers is associated with obesity, excessive alcohol use, and smoking. As discussed before, these chronic conditions and lifestyle habits need to be addressed both personally and with a more significant effort within communities. A greater emphasis on wellness would benefit everyone.
Fourth, for oncology, better access to clinical trials is essential. Most cancer patients receive treatment in community practices, but many clinical trials take place in academic settings. This presents a barrier for many patients in having access to cutting edge treatment. It also means that those results are not as representative as they could be in terms of “real-world” patients. This manifests in terms of the underrepresentation of some sociodemographic groups, for example. Another aspect of this is that it can be challenging to accrue patients to trials, so clinical trials can take years to complete or may even close altogether, which is a lost opportunity. Health care can make significant efforts in meeting the patients where they are to ensure a more representative sample, access to a larger proportion of patients, and timely completion of more trials.
Fifth, we are learning more about the biases in medicine and how it can impact patients’ healthcare outcomes. Recent research has identified how bias affects patient-provider interactions, adherence to prescribed treatments, and patient outcomes. Addressing bias in medicine could also decrease distrust for the medical community and potentially reduce the disparities found in our system.
Ok, it’s very nice to suggest changes, but what concrete steps would have to be done to actually manifest these changes? What can a) individuals, b) corporations, c) communities and d) leaders do to help?
I would love to see our healthcare system continue to move towards health equity, which is an equal opportunity for all people to realize the same health opportunities. Because the roots of healthcare inequity are multifactorial, that will take everyone working together. So, individuals can take their health into their own hands and start to make lifestyle changes like increasing fruit and vegetable consumption and physical activity, quitting smoking or never starting, avoiding excessive alcohol consumption, getting 7–8 hours of sleep, etc. Also, individuals can advocate for themselves where possible by asking for the appropriate screening tests, asking doctors for recommendations regarding chronic disease management, and so on.
Communities are vital in moving the needle toward health equity. The power of social connection is recognized for overall well-being and for facilitating lasting lifestyle change. In this regard, communities can function as both support systems and as change advocates. For example, communities can support each other in wellness goals and advocate for the resources that are missing. I am noticing the rise of food co-ops in food deserts where communities provide fresh food options where this resource is lacking. In this way, people can advocate for what they recognize is needed in their area. There are also social media groups popping up for exercise enthusiasts, vegetarians, and the like. This is where the impact of social media is fascinating to me. The idea that the support needed and the shared community to make lifestyle changes can come from outside your traditional geographic location is powerful.
In terms of corporations and leaders aiding the move toward health equity, partnership with communities is key. Thankfully, there has been a volume of research to document healthcare disparities so that we can all understand that differences exist in the system. Now, we are emphasizing how to address these differences. I would like to see input from the impacted communities in this process. Tangible results could be realized by investment into community partnerships with leaders and corporations, particularly addressing those social determinants of health that can be improved. Healthcare leaders can also focus on what factors may be contributing to disparities in their own system. For example, for underserved cancer populations, access to patient navigators helps to improve care. So, an effort to increase this type of support in a hospital system is critical. Efforts to increase clinical trial access and screening in the surrounding community can also be undertaken by health systems, as another example.
I’m interested in the interplay between the general healthcare system and the mental health system. Right now, we have two parallel tracks, mental/behavioral health and general health. What are your thoughts about this status quo? What would you suggest to improve this? This is a fascinating question. I haven’t worked in mental and behavioral health to know the realities of that part of the system. But, I would love to know more about the impact of untreated mental and behavioral health on chronic conditions. I’ve read statistics about how the closure of mental health facilities has impacted homelessness. So that has always struck me as a critical part of our healthcare system to be addressed. Again, this comes back to the social determinants of health in some ways.
How would you define an “excellent healthcare provider”?
I think most simply, it is a person who has the patient’s best interest at the center of treatment. This involves considering the whole person — not just their condition, but who they are as a person, their environment, their lifestyle, their family supports system — the whole picture.
Can you please give us your favorite “Life Lesson Quote”? Can you share how that was relevant to you in your life?
I have two refrigerator magnets at eye level, so I see them every day. The first is from Henry Ford-“Whether you think you can or you think you can’t-you’re right” The second is from Archbishop Desmond Tutu-“Do your little bit of good where you are; it’s those little bits of good put together that overwhelm the world.” Add that to the golden rule of “Do unto others as you would have them do unto you,” and I think you have the trifecta. That’s 3, but I try to keep them all top of mind as I move through the world — from big issues like tackling health inequity to small ones like dealing with the everyday issue that crops up.
Are you working on any exciting new projects now? How do you think that will help people?
Yes- I am working toward my certification in lifestyle Medicine. This focuses on the pillars of a healthy lifestyle to address the root causes of chronic diseases, such as obesity and diabetes, which are prevalent in our society. There is attention to what you would expect, like a whole-food, plant-based diet, smoking cessation, physical activity, stress management, and the like. There is also a focus on how actually to help people make these necessary changes. That’s key!. Most people have a sense of what is beneficial or harmful to health in general, but the real work is how you can make these changes. It’s not easy, so I appreciate learning how to help facilitate that. I also started a podcast, called 3 Black Docs, with two friends, who are also oncologists. We aim to present information regarding cancer treatments, screening, and prevention to the Black community. We also talk quite a bit about healthcare disparities, why these exist, and how to address these issues. We do this all in the backdrop of friends having fun talking about these critical topics, so hopefully, the target audience will want to listen!
What are your favorite books, podcasts, or resources that inspire you to be a better healthcare leader? Can you explain why you like them?
I like the book Mindset by Carol Dweck, which discusses the differences between fixed and growth mindsets and how a growth mindset is the key to success. I also thought Blue Zones by Dan Buettner was a fascinating read discussing the lifestyle of the longest-lived communities worldwide. I also recommend Being Mortal by Atul Gawande which is a very powerful book about end of life decisions and how we approach end of life in the U.S. Lastly, I would recommend The Immortal Life of Henrietta Lacks by Rebecca Skloot, which brings so many aspects of cancer disparities into focus as she discusses the origin of the well-known HeLa cells used throughout medical research.
You are a person of great influence. If you could inspire a movement that would bring the most amount of good to the most amount of people, what would that be?
As mentioned before, I would love to see large-scale partnerships between corporations/healthcare leaders and underserved communities — giving the impacted communities a seat at the table. I would also love to see a focus on wellness in our healthcare system, addressing the root causes of disease, which are often lifestyle issues.