The AMA defines health equity as “optimal health for all.” The work of psychiatrist Stephanie Eng, MD, is a reminder that this means mental as well as physical health.

Dr. Eng, an assistant professor of psychiatry and an attending physician in a 22-bed inpatient acute psychosis unit at a behavioral health hospital in White Plains, New York, is also part of the third cohort of a program training physicians to be the next generation of health equity advocacy leaders.

These physicians are participating in the Medical Justice in Advocacy Fellowship, which is a collaborative initiative created by the AMA Center for Health Equity and the Satcher Health Leadership Institute at the Morehouse School of Medicine.

Fellows participate in a three-day, in-person learning intensive at the beginning of the fellowship and subsequently engage in monthly learning sessions with a multidisciplinary group of nationally renowned experts, scholars, researchers and current and former policymakers across all levels of government.

The fellowship is just one of the ways the AMA is working to advance health equity. The AMA Center for Health Equity works to embed health equity across the AMA organization so that health equity becomes part of the practice, process, action, innovation and organizational performance and outcomes. Explore further with the AMA’s 2024–2025 strategic plan to advance health equity.

During her residency training, Dr. Eng became interested in providing care to urban, underserved populations experiencing various systems of inequity that increased their psychiatric morbidity and mortality. Her research focuses on the effects of implicit bias on clinical decision-making. 

Stephanie Eng, MD

Dr. Eng also did fellowship in forensic psychiatry, and her previous research includes examining inequities in the use of chemical sedation and physical restraints and variations in the psychiatric medications that are available to be prescribed in U.S. prisons.

After meeting with members of Congress in February during the AMA National Advocacy Conference, Dr. Eng took time to speak with an AMA news writer about the Medical Justice in Advocacy Fellowship, her research, her psychiatry practice and her efforts to promote health equity.

AMA: What prompted your interest in the Medical Justice in Advocacy Fellowship?

Dr. Eng: As a psychiatrist, I've become aware that it's been challenging to care for our patients who come from difficult social situations.

They often have housing insecurity, food insecurity, and they don't have easy access to medical care. And so, I found that it was challenging on a day-to-day basis to care for patients, considering these larger structural inequities that were making it difficult to carry out good care during a clinical encounter.

When I became a forensic fellow, this became even more apparent to me because now I was caring for patients who were even more marginalized, who were in even more difficult social situations.

There were people who were justice-involved, and I was looking for a way to figure out how I can build an alliance with people who are doing similar things because some of these structural inequities—on a day-to-day basis—feel really burdensome and difficult to overcome.

I felt being allied with other people could help with that. And I also wanted to figure out if there were ways to advocate for patients outside of the clinical encounter, because there's only so much I can do for patients in the social situations that they come from when it's a 30-minute or one-hour appointment.

What are ways that I can advocate for a change outside of that? So I was looking for that when I applied to this fellowship.

AMA: Is there a skill that you have picked up or perhaps that you've honed since your Medical Justice in Advocacy Fellowship cohort began in September? 

Dr. Eng: One that comes to mind is the use of language, the power of language in medicine. How these narratives about patients exist in our medical system that perpetuate power and health inequities that are based on race, gender, class and other identity markers. As a psychiatrist, language is the primary tool I have to care for people.

So I've been practicing how to be more mindful about how I use language when I am talking to patients, but especially when talking to other physicians. 

As well as using good language, you also must avoid using language that's stigmatizing and villainizing, because that's the other side of psychiatry. It can be weaponized at times, to give people diagnoses that are alienating and that sometimes interfere with the care that people could benefit from. 

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AMA: What else have you done during the fellowship that you’ve found valuable?

Dr. Eng: Being an advocate for my patients. My experience with advocacy before this fellowship was limited to just advocating for people during our very short clinical encounter. And being in this fellowship has helped me learn how to do advocacy in bigger, broader ways. ... For example, thinking about how to do research that describes what I see in a small encounter, but in a larger, quantifiable way with data to support it and more compelling for people.

And then also thinking about how physicians fit into advocating for patients at a policy level. How do we even go about talking to people who are involved in making our laws and our policies?

What can we do? What can we say to people, to our representatives or senators when we're trying to advocate for something? How do we present information in a palatable and succinct way? ...

As a psychiatrist, you can work in a lot of different types of settings. You can be outpatient, seeing people in the clinic who are more stable. You can be inpatient. That's what I do. So I’m seeing people who are acutely ill, requiring inpatient admission to the hospital. They can see a doctor every day. They can get their medications adjusted more rapidly. 

The hospital where I work is dedicated to patients who are acutely psychotic. What that means, on a day-to-day basis, is that I'm mostly seeing people who may be catatonic, which means that their psychosis has progressed to the extent that it's limiting their ability to speak or it's limiting their ability to move. I see a lot of people who are agitated.

Inpatient psychiatry has the most interface with the legal system. Patients have their due rights and I can't keep someone in the hospital for as much time as I want. We have to consider what patients want too. ..

So I'm interested in examining health inequities in jails and prisons essentially. There's a 1976 U.S. Supreme Court case, Estelle v. Gamble, that says that the deliberate indifference to serious medical needs of incarcerated people constitutes cruel and unusual punishment.

We don't have a good system to determine whether the quality of care in incarcerated settings meets the standard of medical care that's established by the Supreme Court because there's no continuous external oversight of jails and prisons in the country. They're all disjointed.

There's not a continuous medical record, for example. And so, I'm interested in looking at what are the psychiatric medications that are available to be prescribed in prisons across the country.

I'm looking into medication formularies, which is essentially just the list of medications that are available to be prescribed. Those are accessible by public record laws.

My hypothesis is that there is a wide variation of medications across different states. This includes ones with a strong evidence base to support their use. Clozapine, for example, that's our most effective antipsychotic for treatment-resistant psychosis. Is that something that's available on all medication formularies? Actually, no.

The decision of what medications are available in each institution does not fall on one person—or even a group of psychiatrists. People are doing the best they can with the resources they're given. And so, I imagine that even if an institution has a limited medication formulary, psychiatrists are trying to do the best they can to choose the best medications that they have available to treat patients.

AMA: Now, you have done some research on how implicit bias may be affecting clinical decision-making on the use of restraints. That’s an area where, it should be noted, the AMA has policy. Tell our readers about your research.

Dr. Eng: It's ongoing. When I was a resident, I was awarded $25,000 in federal funding by the American Psychiatric Association to look at whether there were any inequities in our use of chemical sedation and physical restraints to manage agitation in the emergency room.

I conceived this project in my first year of residency. I myself was in the emergency room and I noticed that I was making decisions based on my own implicit bias, instead of objective clinical data.

And I couldn't help but wonder if other people were doing similar things—especially in the emergency department. The ED is one of the most overburdened settings of health care. And we rely, in some ways, on these implicit, subconscious patterns of thinking to be able to take care of a lot of people that you don't know very well in a short period of time. 

I wondered if that came out, especially during high-pressure situations like managing agitation, especially in the middle of the night when you don't have all your mental capacity to override subconscious thinking patterns. You're not running at 100% and there's fewer staff during those times to assist you.

So I was given this grant and, essentially, we were able to look in the medical record and pull a cohort of people who were agitated over a certain period of time. And look at their sociodemographic information and some of the structural information or the larger contextual information such as—what time was this happening? At what time of the year was this happening? What gender are these people? What is their insurance? What's their age?

The research began in 2020 and is still ongoing, but one of the major things we found is—when controlling for agitation, there was more use of chemical sedation and physical restraints to manage men of color over the age of 50 who were uninsured or had Medicaid.

Around the same time, conversations about excessive use of force in the community, excessive policing were becoming part of the national discourse. And I couldn't help but wonder if the same things were happening in our own emergency rooms.