As a biostatistician, Dr. Felicity Enders spends much of her time analyzing medical research and crunching of the numbers we read about in newspapers and medical journals. In this interview, Dr. Enders reveals how this behind-the-scenes work is actually the frontline in addressing racism in healthcare. Join Lee Hawkins as he learns about the new data-collection approaches being used to track patient health over time and how they reveal the devastating “accelerated aging” effects of racism and chronic stress.
“We have a lot of data in the now, but we’re not looking back over someone’s lifetime to see what may be impacting what’s happening in their health today. And that’s really important, because we see in research that people who have a lot of stress over their lifetime can have accelerated biological aging, meaning that their bodies at the cellular level are aging faster. And that leads to chronic health diseases that really can impact lives and experiences and bring about premature death. And it’s very problematic.” – Felicity Enders, Ph.D.
Read the transcript:
Lee Hawkins: Welcome to Mayo Clinic’s Rise for Equity podcast. I’m the host, Lee Hawkins, and our guest today is Dr. Felicity Enders, who is a professor of biostatistics at Mayo Clinic. And a great deal of her work focuses on educating researchers, breaking important new ground in the areas of both education and diversity, with emphasis on inclusion and diversity in research and the collection of data.
Lee Hawkins: Welcome to you. How are you?
Felicity Enders: Thank you so much for having me, Lee. It is a great pleasure to be here today.
Lee Hawkins: All right. I must admit, you’re the first real live biostatistician I’ve ever met. Can you explain what biostatistics is?
Felicity Enders: So this is actually not something I’m great at explaining. I tend to get pretty technical. My husband has trained me over the years to say I research the numbers for medical research, and so all that stuff behind the scenes that helps give you the answers that you see in the press or in medical research papers.
Lee Hawkins: And you mentioned the press. You know, in the press every couple months there will be something that comes out about disparities in medicine, in health care, racial disparities primarily but gender disparities as well. And a lot of this can become disheartening over time. And one of the things that you and I have spoken about is the fact that we’re getting better at identifying the problems and the challenge is really about the outcomes and improving in bringing about solutions.
Felicity Enders: That is absolutely correct. So we’re getting better and better data all the time. We’re really seeing improved measurement. We have amazing imaging. But really what we’re seeing is we have more clarity of the problem, but we’re not seeing that clarity in terms of solutions for health equity. And we are seeing really tremendous differences in health, primarily by race, but also by other factors.
And, you know, there’s a lot of people working on this problem from many different angles. It’s a big nut to crack. One of the issues that I see is that this vast increase in data that we see is data about what’s happening with someone right now in their life. You know, we have imaging, we have little sensors on our on our wrists that track how we’re doing.
It’s a lot of data in the now, but we’re not looking back over someone’s lifetime to see what may be impacting what’s happening in their health today. And that’s really important because we see in research that people who have a lot of stress over their lifetime can have accelerated biological aging, meaning that their bodies at the cellular level are aging faster, and that leads to chronic health diseases that really can impact lives and experiences and bring about premature death. And it’s very problematic.
Lee Hawkins: Are we even collecting data historically over a person’s lifetime?
Felicity Enders: That’s a great question. Currently, we’re not really doing that. If you have a physician who has the time, they’re trying to get a medical history, but that may not include the history of things that have happened outside of the person’s medical experiences that could impact their stress over their lifetime. Now, there are ways to measure accelerated aging, but they’re invasive and they’re expensive and things that are invasive and expensive that don’t affect everyone we’re not going to measure. But my work has been just over the past year has been trying to develop survey measures to estimate someone’s accelerated biological aging by estimating how much stress they have been under over the course of their life. So this is a lot like what we do in smoking research. In smoking research, you don’t just ask someone to smoke, yes or no, but you also ask how many packs of cigarettes do they smoke per day and when did they start smoking?
How many years have they been smoking over their lifetime? And that gives you a measure of the accumulated impact of tobacco on their health. This is the same idea, but for stress and also for discrimination. In some ways now I think stress is perhaps a better measure because there’s so many sources of discrimination that are not always something that the person can perceive.
So when we talk about structural racism, the infrastructure may be very different based on where someone lives and that is something that someone feels as a stressor, but they may not think about that as discrimination. And it’s not being done personally to them, but it certainly causes a source of stress in their life.
Lee Hawkins: And of course, there’s the old saying When the majority population catches a cold, people of color catch pneumonia. And so is this disproportionately affecting people of color?
Felicity Enders: Yes. So there is work called the weathering hypothesis, which basically says that in aggregate, when you look by race, part of what you’re seeing for the differences in health are the differences in accelerated biological aging that are brought about by additional stress that we see by race, but is really due to factors in someone’s life caused by societal issues that differ by race.
Lee Hawkins: And we talked earlier about the Adverse Childhood Experiences Study, which shows that if a person has had four or five adverse childhood experiences over time, it can actually shorten life expectancy by 20 years and increase the likelihood that they could have cancer, diabetes or heart disease. And so when I hear you speaking, it really makes me wonder if doctors even have this kind of conversation that would need to be had to identify the potential people who are at risk.
And you asked me to talk about my experience with my dad, which was one in which I spoke at his funeral about the long term effect of Jim Crow that ultimately, I believe, played a role in his death because of the chronic stress over the years. And when that speech was given, the doctor who treated him and decided not to identify some blockages that were in his arteries by testing him with the stress test was in the audience. And we actually met at the end and one of the questions I asked was: did you talk to him about his childhood?
Felicity Enders: That is so powerful. You’re absolutely right. So you’re seeing in real time that that stress of Jim Crow and other factors that continued to this day really do have an impact on health. And you saw that ub your gut reaction. But I think what you’re pointing out is that the doctor didn’t know your father well enough t identify those stressors as potential impacts to follow up on in terms of assessing his potential for heart damage. That’s a really big deal. But imagine that that doctor had had just a simple survey that he filled out at some point that said this man has had a lot of exposure to stress over his lifetime. He’s therefore at risk for accelerated biological aging. And therefore, we should think about doing extra testing for the following X, Y and Z. And we don’t totally know what those are yet, but heart damage is certainly one of them. That would change how she thinks about treating him and testing him and looking for problems. That’s exactly where we want to go with this.
Lee Hawkins: Wow. So this really has potentially sweeping implications for marginalized people, right? Because if we can get this right, then we could start to do a better job of diagnosis and prevention.
Felicity Enders: Absolutely. And it also has the potential to help overcome unconscious bias in health care workers. Health care workers are people too Unconscious biases is something that we all carry from having been in this society for our whole lives. It’s coming from the society. It’s not intentional. It actually is unconscious. But when you have unconscious bias towards a particular group and you are stressed and pressed for time, you’re much more likely to have different behavior towards that group and perhaps minimize their risk. And health care workers are always stressed and pressed for time.
And so imagine if they had something that was cuing them: Wait a minute. This person is really at risk. Let’s think about this differently. That might help overcome that unconscious bias.
Lee Hawkins: But it actually requires an industry shift, even at the training level from the beginning.
Felicity Enders: Yes. So there is extensive research now showing misconceptions among medical students as well as among regular people in the lay public about people’s ability to withstand pain and have other factors within medicine that differ by the race of the patient. So there was a study showing that medical students thought that Black patients had thicker skin, would not be able to feel pain, and that’s a major misconception that really does need to be addressed, and people are working on that in medical school training now to really try and overcome those misconceptions early on. But it takes a lot of repetition because it’s something that people are coming in with. They’re not being taught that in medical school, certainly. But you’re trying to overcome something that they have had unconscious knowledge of that was mistaken.
Lee Hawkins: And it’s important to know how that manifests actually in the treatment room, because that means that there’s a higher likelihood that the person who needs pain medication is not going to be prescribed it. Because of this unconscious bias that this health care worker has internalized.
Felicity Enders: Absolutely. So pain may get ignored. People may actually have totally different treatment plans and that can really impact health outcomes. So it’s not just pain, it’s actually people dying sooner. In part because of treatment, as well as other factors like accelerated aging.
Lee Hawkins: Or people reaching the conclusion that, well, maybe this person really isn’t as sick as they say they are.
Felicity Enders: Yes, absolutely.
Lee Hawkins: All of this is really interesting. How did you even get into biostatistics and when you got into it, did you expect that you would be able to have such an impact on diversity, inclusion?
Felicity Enders: That’s a great question. I did not know I was going to go into biostatistics, and I certainly didn’t know where we would end up in diversity, equity and inclusion. So I would say my background is really framed by my parents. I’m biracial, my mother is Black. My father is white. My mother’s family for many generations has really pushed education – that you need to get as much education in whatever field you’re going to go into as far as you can, because that’s what opens doors.
My father’s family and his generation, almost everyone grew up within about two blocks of one another in a very small town. A lot of them went on and did get significant education, but there wasn’t that same impetus that you have to do that. Now because of my mother’s family, I had an advantage that I just assumed that I would be going to college. And that gives you a big advantage. Any time you’re not sure that you’re going to do something. Sometimes you close the door for yourself. And so that door I just assumed I would be doing and that that’s a big advantage. But I didn’t have that same assumption when it came to graduate school. So I was not a straight-A student in college.
And because of that, I didn’t apply to Ph.D. programs when I thought that that’s probably what I wanted to do. Instead, I applied to a master of public health program with the intent that I would do that and then do well enough that I could get into a Ph.D. program. So I did close that first door for myself, but I did the Master of Public Health Program and I was intending to do a Ph.D. in epidemiology, and I was pretty excited about that. But along the way, I had become an engaged student in that master of public health program. Now, I was not an engaged student in college. I was not the person asking questions, I was not the person talking to professors. But I was in the master’s degree (program). And because I was an engaged student, I was the one I was asking questions all the time. Sometimes people would pass me notes to ask me to ask a question because they were afraid to ask a question about that.
It was quite something. I had changed my persona and I was getting to know the professors, my statistics. Professor Scott Zeiger was amazing and I would be emailing him while I was working on a homework assignment and saying: Hey, I got stuck at this spot. What should I think about next? And this would be happening at like three in the morning because I was in graduate school and I was awake at three in the morning, unlike now, and he would email back, I don’t know why he was awake at three in the morning. That’s a separate question. But because I was an engaged student when I asked him for a letter of recommendation for a Ph.D. in epidemiology, he said, Sure, but would you consider a Ph.D. in biostatistics? So he opened the door in part because I was that engaged student, and that really led me along a path.
Lee Hawkins: So how did you get to that point? Did you actually know that you were going to be doing the Ph.D. in epidemiology?
Felicity Enders: Absolutely not. So I knew by the time I was in college that I liked science. I kind of liked math, but I couldn’t see how we were going to apply it. And so I didn’t actually go very far in math. But I was testing the waters with different things in science, and that did not show me what I wanted to do.
Instead, it showed me what I didn’t like. I tried this thing, didn’t like it did another summer thing didn’t like that either. That winds up narrowing the window of what I was doing, and that led me towards a general realm of epidemiology, statistics, research that was very important. And I think people come in thinking that someone like me knew what they were going to do all along. Absolutely did not know.
Lee Hawkins: What kid is sitting at home right now saying: I want to be a biostatistician. I mean, it isn’t something that people generally think about or maybe it is.
Felicity Enders: No, it’s not generally known. So that’s a problem. We teach people skills, but we don’t teach people what career opportunities there are. There are no AP statistics courses, advanced placement statistics courses in some high schools. But that’s not biostatistics. And it doesn’t show you the wealth of what you can do with biostatistics. You’re really just doing tests. You’re not doing research. So if I were advising someone, I would say, first, keep going in math. It’s important to keep going in math. I actually didn’t go far enough. I had to take a summer course at a community college before that Ph.D. program to get that last course that I hadn’t done. But also statistics is not just math, it’s also logic.
And biostatistics involves a lot of learning about research. We really don’t do a good job of teaching people about research and what happens in research in school. And so you have to look for other opportunities. There are now a lot of internship programs that are available for people to do in summers in a gap year. And it used to be that those internships programs were almost all unpaid.
Fortunately, people have now realized that that is a huge barrier to bringing people into the field. And this is across all of research. And so because of that, many, many of those internships now are paid and available. And actually, at Mayo, we have summer internships. If you just look up Mayo Clinic summer internship, you’ll find a whole bunch of programs, many of which are paid.
And that can provide an opportunity to learn about research, which can involve learning what you don’t like as well, to narrow that field and figure out which aspect of research you do like.
Lee Hawkins: What was the career you thought you were getting into and what did it turn out to be?
Felicity Enders: By the time I was finished with the Ph.D., I knew that I loved teaching statistics to people who were not going to be statisticians. And that’s a skill, because there’s actually research showing that a lot of statistics teachers teach statistics like they were taught meaning like you’re teaching someone who’s going to be a statistician, and you have to teach differently to teach someone who’s not going to be a statistician to use these tools and I really took off in statistics education.
I taught at Mayo for many, many years, primarily teaching physicians, also numerous graduate students. But after I became a professor of statistics, it became clear to me that there were very few people who were at that level, not just at Mayo, but at almost any institution across the country who were Black or minority, and that there was a serious gap going on, not just in statistics, but across all of academic medicine.
And that I had unknowingly found some tools that helped me along the way, and I learned that I was able to share some of those tools. So part of what I now try and train people about is what’s called hidden curriculum. So that is what an institution needs you to know in order to succeed, but doesn’t usually teach you because no one thinks about teaching you, you know – how do you talk to someone or know you really shouldn’t talk to that person or anything else (like that)? That’s not part of our academic training and that hidden curriculum we can teach to trainees and students. And it really helps people succeed. And there’s actually more pieces of it for someone who’s diverse to learn because you’re learning more things when you’re from a different background.
But we can also use that to train people who are on the faculty, who may be majority folks who didn’t have to go through some of these same hoops. We can teach them to mentor people who are diverse more successfully by learning what folks may be facing.
Lee Hawkins: How many women are in this field? Is it it gender diverse?
Felicity Enders: In biostatistics? It used to be almost entirely men. Biostatistics have shifted much more to be roughly equal. Theoretical statistics at an academic institution still tends to be much more men than women. It’s an interesting question. I’m not sure why there’s the difference between those two, but biostatistics has undergone a transition. But across academic medicine, because there is a transition, you see differences in who is in the field at different levels.
And because of that, there can be mentoring gaps and that someone who’s the senior person who needs to mentor someone who’s junior may be very different from them and therefore may have faced different challenges. And so across the area, we want to teach people how to successfully mentor folks who are different.
Lee Hawkins: And when you mentor researchers and actually train them around this, obviously you have your experience that you’re bringing in to from the world outside and you’re aware and you’re cognizant of all of these problems we’re talking about in terms of the data. Is this something that you’re actually teaching people as well? And your colleagues who are teaching are they doing the same?
Felicity Enders: There is there is a push to try and include issues of disparity across research training and medical training. That being said, I think it’s different when you have personally experienced it. I give talks on this topic all the time. I think that because there are so few folks who are at this level who have personally experienced it, we need to find ways to spread that experience around better, right?
Lee Hawkins: Because otherwise it becomes you doing the training. You can’t train everybody. Right?
Felicity Enders: I wasn’t going to say that. But yes.
Lee Hawkins: They call that the diversity tags.
Felicity Enders: Absolutely.
Lee Hawkins: And unconscious bias. This is a huge thing that affects almost everyone. As a matter of fact, you said everyone has it. I have it. And you talked about a test that you took that exposed that. Tell me about that.
Felicity Enders: This was very upsetting. The test you’re talking about is the Harvard Implicit Association test. It’s not a perfect test, but it’s the only objective measure we have of when you have a bias that you’re not aware of. Because asking someone isn’t going be enough if they’re not aware of it. The idea is the association between a type of person and positive or negatively framed words where if you have bias towards women being in careers, then you are more quick to associate home life with women and more quick to associate careers with men.
I carried that bias. I was not aware that I carried that bias. I found it out when I was around mid-career as a woman, and that was pretty upsetting. I also had a bias towards Black people and I’m Black and we all carry a lot of these biases because we’re growing up in this country. And so taking the tests – there’s actually many of them for different specific biases – taking the tests gives you an idea of the bias that you probably carry. And that’s very important to make you aware. It’s hard to change the internal bias – we’ve had in our whole lives – but you can change your behavior by knowing about that bias. And so by learning about that, you can change your behavior and change the impact that you may have on others. So I’ve been working on that. I really encourage others to work on that. I think we all have to keep learning. There’s so much to do in this space.
Lee Hawkins: And so how can people get into biostatistics?
Felicity Enders: First, pretend you were in my mother’s family. Get all the education you can. Presume that the doors are going to open and just drive forward. And then you don’t have to know what you want to do. You can learn what you want to do by learning what you don’t want to do.
It’s okay to have those negative experiences. They teach you something and as it’s happening, it feels terrible. I hated that. I must be terrible at this. You’re not terrible. That just wasn’t for you. And you move on and you try the next thing And then last be that engaged student, the one who’s asking the questions, the one who is emailing the professor. Because then people notice you and you get a lot more out of the class. So go forth and figure out what in research you want to do, you can do anything.
Lee Hawkins: Dr. Felicity Enders, thank you so much.
Felicity Enders: Thank you for having me. Lee, this was fantastic.
Lee Hawkins: And this has been in the Mayo Clinic’s Rise for Equity podcast. I’m Lee Hawkins. We’ll see you next time.
