Photo: Dr. Alejandra Casillas is doing research at the intersection of disparities and health communication among underserved populations. (UCLA Health photo)
As the world moves further into the digital age of information, who will help those that lack access to essential technologies like internet, cell phones and computers, from falling behind?
One person answering that call is Alejandra Casillas, MD, MSHS, an assistant professor in residence in the Division of General Internal Medicine and Health Services Research, Department of Medicine, at the David Geffen School of Medicine at UCLA and primary care physician at UCLA.
When she isn’t caring for patients and teaching, Dr. Casillas is doing research at the intersection of disparities and health communication among underserved populations.
In 2016, she learned that the Los Angeles County Department of Health Services (LAC DHS) had begun transferring patient records to an electronic health record system, as mandated by the Affordable Care Act in 2014.
“I thought to myself, how is this going to work for a population that is largely low income and underinsured, many from immigrant backgrounds with English not their primary language?” she recalls. “How is the integration of digital health tools going to affect these populations? It felt like it was something we needed to explore.”
Dr. Casillas says, at the time, she felt like she had more questions than answers. “What happens when we keep moving technology forward, but we never pause to make sure that all populations are on board?” she says. “For example, we need patient portals that are available in multiple languages.”
Dr. Casillas partnered with Dr. Anshu Abhat, the LAC DHS medical director for patient digital health engagement, and was glad to see that they were exploring ways to operationalize digital health tools for non-English speakers – but there was little to no formal research or criteria on how to do it.
“We had big gaps in the research, so I cold-called the only person I saw writing papers in this area,” she says of Courtney Lyles, PhD, an associate professor in the UCSF Division of General Internal Medicine at Zuckerberg San Francisco General Hospital.
Dr. Casillas tells us that their ideas for digital research in the safety net were sometimes met with pushback. For example, “people would tell us that these patients don’t use the computer, that they prefer to talk to someone in person,” she recalls. “Some of that is true, but many diverse patients want to use (digital health services), so we need to make them culturally tailored and multilingual.”
Then COVID-19 happened.
“It was a wakeup call to the country and to health systems about how we think about access to care, and now digital access to care,” she says. “When we implement digital health tools and communication, we need to start with an equity lens; otherwise, we leave behind patients who are already underserved.”
In addition to work at the patient and health system levels, this multifactorial problem requires all communities to have equitable access to broadband internet, Dr. Casillas says.
“The pandemic showed us that addressing the digital divide will require local, state and federal governments to improve the infrastructure,” she says. “This is the new way that our society functions, and it plays into their access to health care, and also many other social services.”
She says though not every clinical scenario is appropriate for telemedicine, health care systems should learn now to integrate it to best augment care.
Seeking a better life
Helping to inform this work were Dr. Casillas’ own experiences navigating structural systems such as education, health care and insurance for her parents, who immigrated from Mexico.
At 18, her father arrived in the U.S., seeking a better life.
“He told me that he had to hide under a highway for multiple days waiting for the right time to cross the border, and he survived off cold tortillas,” she says. “I can’t even imagine for myself, even as a 40-year-old woman, having to go through something like that. Hearing that story is very impactful.”
Dr. Casillas says both her parents came from low-resourced families. “My mom always wanted to go to high school, but they just didn’t have the money,” she says. “My mom and dad are some of the smartest people I know. They just figure things out.”
Both her parents worked in manual labor jobs, work that Dr. Casillas says has been physically hard on them.
“Early on, I witnessed all the struggles of them trying to make a life – from making medical appointments and signing us up for school, the stigma that came with being undocumented and fearing deportation. It was a lot of stress for our family,” she recalls.
The stress and burden that people with undocumented status carry within themselves overlaps with health outcomes, she says.
Dr. Casillas says she can recognize that stress in her patients because of what her family went through.
“I see the relationship to the social determinants of health – the burdens that people have to deal with,” she says. “I witnessed all these moments trying to navigate health care for my younger siblings when they got sick, having to translate for my parents in the emergency room.”
Dr. Casillas says that professionals in the health care system “were there to help us,” and those early experiences sat deeply with her. She ended up viewing medicine as “a very tangible way” to help people like herself and her family.
Passing it on
During her academic career and medical training, Dr. Casillas forged a path that focused on mitigating health disparities. Because of this, and because she was a first-generation college graduate and doctor, medical students actively sought her out for mentorship.
“I remember talking to one of my medical students who was also First-Gen and she said to me, ‘Wouldn't it be nice to JUST be a medical student?’”
That statement referred to the weight and burden of being first-generation, she says, i.e., “in addition to all the challenges of being a student, helping and advocating for family members, and having to compartmentalize.”
At same time, in 2017, the First-Gen movement at the university level was kicking off. The University of California developed campus initiatives to improve the experience of first-generation college students.
“We thought, why can't we have a First-Gen (organization), here at the med school?” Dr. Casillas says. She and some members of the student affairs office organized a last-minute meeting to gauge interest, although they didn’t expect many students would show up due to its timing – during the week of Thanksgiving.
About 100 students attended.
“All of a sudden, it became like a town hall,” Dr. Casillas says. “It was one of the most powerful experiences of students standing up together and connecting with each other.”
She says being able to verbalize their first-generation experiences in life and in medicine, and get validation, brought an otherwise “invisible” community to existence.
Soon after that meeting, the First-Gen DGSOM student group developed a charter.
For the past five years, the group has hosted a welcome dinner for DGSOM First-Gen students and community at the beginning of the academic year. They also have a “First-Gen Families program,” with each “family” comprised of 10-12 individuals from all levels, faculty, staff and trainees, to engage in informal intergenerational mentorship. More than 200 DGSOM community members currently participate in First-Gen Families.
First-Gen student leaders created a pin for students to wear on their white coats to show other First-Gen students, staff and patients that their identity is to be celebrated, Dr. Casillas says. “It’s an empowering way for them to show that this journey isn’t in isolation.”
Dr. Casillas refers to herself as the product of the village that’s helped her get to where she is.
“I worked really hard to get here. But, I look back and realize that so many people have given me an extra hand and opened doors for me,” she says. “All these little moments, they make a difference.”
She says at UCLA, others can continue to make a difference for colleagues and patients alike.
“Given our resources, expertise and location, UCLA Health is on a path towards elevating patient-centered care for our most underserved populations,” she says. “In Los Angeles, we are privileged to take care of one of the most racially and ethnically diverse patient communities in the world. It's a calling and an opportunity that should not be squandered.”