Born in a small town in India to physician parents, Deepshikha Ashana, MD, MBA, MS, naturally developed a love for medicine as a child. She also watched her mother — an obstetrician — walk a professional path that was fraught with gender-based discrimination; an experience that instilled in her the core personal value of equity.
“I love medicine,” said Dr. Ashana, assistant professor in the Division of Pulmonary, Allergy, and Critical Care Medicine since 2020, and a core faculty member of the Duke-Margolis Institute for Health Policy. “It can be a very noble profession. But we work within a system which has enacted many barriers to good health, and those barriers are not faced equally by all people. If you love medicine, there's no way that that cannot bother you.”
The inequity bothered Dr. Ashana to the point that she decided to study the ways in which unequal access to resources and opportunities in medicine can affect a person's life — particularly when they become critically ill.
Today, Dr. Ashana is focused on three areas of study: shared decision-making in the ICU, trauma-informed care in the ICU, and abortion bans and critical illness during pregnancy. She deliberately focuses on how clinicians and health systems contribute to disparities in serious illness care, because she hopes this will be a platform for introspection and advocacy for the ways that clinicians and health systems can change to better serve all patients.
“We meet people at the most vulnerable moments in their lives,” said Dr. Ashana, who has a dual appointment in the Department of Population Health. “They're so sick and a lot of them will go on to die. And we're interacting with their families in the midst of tremendous stress. Particularly in this setting, we really have to do our best to ensure that people are all treated the very best that they can be.”
Meeting Patients in the Moment
In a recent thematic analysis, she established that racial disparities do exist in critical care clinicians' approaches to shared decision-making, a preferred method for evaluating complex tradeoffs in caring for critically ill patients.
In comparing critical care clinicians' approaches to shared decision-making in 39 real-world conversations with Black and white caregivers of critically ill patients, she found that racial differences were most evident in clinician behaviors: providing limited emotional support to Black caregivers, failing to acknowledging trust and gratitude expressed by Black caregivers, sharing less medical information with Black caregivers, and less commonly validating Black caregivers' treatment preferences for their loved ones’ care.
The main thing clinicians can do is, she said, is invest in their relationships with the patient or family member, get to know them and their loved one in a personal way, and acknowledge how difficult decision making is for families. The evidence shows that although everyone is prone to racial bias, ‘individuation’ or knowing a person as an individual, their likes, dislikes, motivations, she added, can help to reduce the impact of that bias.”
“It's a huge responsibility - supporting families in that decision, giving them time and space to think, and really showing them emotional support. These are not cognitive decisions made in a vacuum; they are hugely emotional,” Dr. Ashana said. “It's a very difficult job also for the clinician. Clinicians are doing their very best. Our goal is not to criticize what the clinicians are doing wrong, but to simply identify what could be done differently. I hope this type of analysis is motivating because we all do this job to serve patients in the best way possible.”
Trauma-informed ICU Care
Almost all people have experienced at least one traumatic event in their lives but when they enter into another stressful situation — becoming seriously ill, for example — stress that is already carried within an individual can be reactivated and amplified.
The situation promoted Dr. Ashana, supported by funding from the Doris Duke Charitable Foundation Clinician-Scientist Development Award, to look at the prevalence of trauma among critically-ill patients and their families at Duke and the University of Pennsylvania.
She found that they experienced, on average, six traumatic events in their lives; and for each traumatic event experienced, the likelihood of experiencing conflict with the clinical team increased by 44%.
In a new study just submitted for publication, she concluded that about half of the 229 ICUs surveyed in the U.S. reported a lack of consistent institutional practices to support clinician mental health. These included easily-implementable and cost-effective measures, such as soliciting feedback about mental health and physical safety at work, providing education about what traumatic stress looks like in colleagues and patients or their families, creating structures for clinicians to provide peer support to each other, and connecting clinicians who are really struggling to mental health resources.
“If clinicians are not supported, then it's very hard for them to deliver compassionate, high-quality care to patients,” she said. “These are easily implementable things and they're not very costly.”
Obstetric Critical Care in the Wake of Dobbs
A third area of research for Dr. Ashana emerged following the 2022 U.S. Supreme Court’s Dobbs vs Jackson ruling — obstetric critical care. Her goal thus far has been to describe the effect of abortion bans on the incidence of serious illness among pregnant women.
She is collaborating with critical care physicians from the University of Miami and University of Texas, Southwestern on an analysis of Texas's abortion ban, using Texas state data to understand what the impact of that ban has been on the incidence of critical illness among pregnant women.
They have so far noted a significant increase in infections, a precursor to sepsis, among pregnant women following the ban's implementation, possibly attributable to increased pregnancies, lack of prenatal care, and the continuation of high-risk pregnancies.
The work that she has done to date at Duke underscores the importance of interdisciplinary collaboration and dedicated University resources in addressing the legacy of inequity and racism in the Southeast United States, said Dr. Ashana, who works closely with the Duke Social Science Research Institute and acknowledges mentors, Drs. Christopher Cox and Kimberly Johnson, among others, as being critical in shaping her thinking.
A Unique Place and Time
“I don't know that this work could have happened as well anywhere else,” she said. “The spirit of interdisciplinary collaboration is what a university is all about and it really came to bear in this work. We, at Duke, are in a unique place in the country. In the Southeastern United States, the legacy and ongoing impact of racism is palpable. I think Duke is acknowledging that and trying to respond to that in positive ways; by investing in this type of work, by investing in diverse investigators and faculty, by investing in the community.”
For a long time, she has internally wrestled with the question of whether science is meant to be advocacy.
“For me, personally, I feel very comfortable in saying that the answer is ‘yes.’ We shouldn't just publish the science and leave it at that,” she said. “When you're doing any sort of patient-facing science, especially social science, by its very nature it is advocacy. You do the work because you want to improve patients’ experiences and their health and that requires advocating for a change in the status quo.”
So, Dr. Ashana has been learning to embrace science as advocacy. Though she does not yet know how to do it perfectly yet, her hope is that all clinicians will become more comfortable with the concept, especially in these coming years.
“Becoming more facile with op-eds, engaging with legislators, building relationships with people who are experts like in our professional societies or at Duke Margolis. I think that’s going to be necessary,” she said.
She also wonders now if she will be able to continue her research due to federal funding cuts.
“This research for me and lots of other people is going to be very challenging in the next couple of years,” Dr. Ashana said. “I hope the University, donors, foundations can find new ways to support folks doing this type of work because health equity and advocacy are inseparable from health. We can’t be committed to one but not the other.”