"Hidden Costs: Unconscious Bias in the Healthcare Workforce"

Transcript

• 00:00Hey my name is Pamela Koons.
• 00:02I'm a GI medical oncologist and
• 00:04I'm the vice chief of diversity,
• 00:06equity and inclusion for this
• 00:08section of medical oncology.
• 00:10It is my great pleasure to introduce
• 00:12Doctor ABBA Black who will be our speaker
• 00:16for today's Cancer Center grand rounds
• 00:18and I had the pleasure to get to know
• 00:21Doctor Black in the course of our.
• 00:23She's also a vice chief for the section of
• 00:26general internal Medicine for Diversity,
• 00:28Equity and inclusion.
• 00:29We have a wonderful committee that.
• 00:31We've gotten to know each other through that
• 00:34effort and but just by way of background,
• 00:36I'd like to share with all of you.
• 00:38I'm about Doctor Black,
• 00:40so she is an assistant professor
• 00:42and associate program director for
• 00:44Diversity and inclusion in the
• 00:46Department of Internal Medicine.
• 00:47She received her bachelors from Princeton
• 00:49and went on to graduate from medical
• 00:51school at the University of Rochester.
• 00:54She completed her residency at the Yale
• 00:56Primary Care Internal Medicine program,
• 00:59and she also served as chief resident.
• 01:01She currently works as a faculty
• 01:03member in the section of TGIM.
• 01:05Many of Doctor Black's career and
• 01:08research interests focus on enhancing
• 01:10workplace diversity and inclusion,
• 01:12including participating in
• 01:13minority recruitment efforts,
• 01:15facilitating workshops on bias
• 01:17of which I attended,
• 01:19one that was fantastic and researching the
• 01:21effects of race on minority physicians.
• 01:24Her clinical work is devoted
• 01:25to working with underserved,
• 01:26patient populations in the primary
• 01:28care setting and in her role
• 01:30as a clinician educator.
• 01:31She also works towards supporting residents
• 01:34who identify with minority affinity.
• 01:36Groups and developing curricula design
• 01:38to enhance cross cultural knowledge,
• 01:40skills and attitudes,
• 01:42and I have truly been so impressed
• 01:45with Doctor Black's efforts
• 01:48through these workshops that she's
• 01:50really developed and spearheaded.
• 01:52And I'm really think that we
• 01:53can all learn a great deal.
• 01:55So doctor black. Welcome and thank you.
• 01:59Thank you so much and that
• 02:01introduction is incredibly kind.
• 02:02I'm so thrilled to have the opportunity
• 02:03to come and chat with the group,
• 02:05so thank you all so much for having me.
• 02:06I'm going to go ahead and share my slides
• 02:08and then we'll go ahead and get started.
• 02:15OK great so I have no disclosures
• 02:17today and as far as the learning
• 02:19objectives for the next hour or so,
• 02:22I hope that we can touch
• 02:23upon three major points here.
• 02:25First, anytime I do a talk like this,
• 02:26you know, I hope that we begin to expand
• 02:29our scope in terms of what we understand
• 02:31to be unconscious bias and how it plays
• 02:33a role in our healthcare workforce.
• 02:34This is less a patient facing talk and
• 02:37more thinking about our own culture
• 02:39and our structure in terms of what it
• 02:41looks like for healthcare professionals.
• 02:43I also hope that some of what I share will.
• 02:45Enhanced awareness of personal blind spots,
• 02:48of which we have many myself
• 02:49very much included and lastly,
• 02:51thinking about some steps that
• 02:52we can take to promote equity,
• 02:54both in terms of our personal spheres of
• 02:56influence but also thinking more broadly
• 02:58in terms of institutions and organizations.
• 03:00So I hope to leave you with
• 03:02some inspiration in that regard.
• 03:04I will say just to put it out there
• 03:07in the beginning that you know.
• 03:08Of course,
• 03:08diversity inclusion is a very large
• 03:10umbrella term and there are many
• 03:12lived experiences and identities that
• 03:13are important in terms of what that.
• 03:15EI umbrella really looks like most
• 03:17of my work and initiatives have
• 03:19focused on race and ethnicity,
• 03:21so I just want to be clear about that.
• 03:23Beyond that,
• 03:23a lot of examples in the literature all
• 03:25site will be related to underrepresented
• 03:27groups in terms of race and ethnicity,
• 03:29but of course that's by no means a
• 03:32an attempt to minimize the various
• 03:34forms of diversity that in fact really
• 03:37make up that important Umbrella DEI.
• 03:41So first of all,
• 03:42talk about some background and
• 03:43hopefully some interesting
• 03:45contextualizing information for you all,
• 03:47and then we'll go into some of
• 03:48the work that's been done around
• 03:50workplace experiences of those
• 03:52underrepresented in medicine.
• 03:53We'll chat a little bit about why this is
• 03:54something that's important for all of us,
• 03:56regardless of how we spend
• 03:58our time and academia.
• 03:59And lastly,
• 03:59we'll end this promise with
• 04:01thinking a little bit more broadly
• 04:03around steps to move forward,
• 04:05and how we can actually take some of
• 04:07this work and and make it more concrete.
• 04:12I'm sure many of you are familiar
• 04:14with some of these common deiters
• 04:15I I do just want to spend a few
• 04:18minutes going over some some common
• 04:19terminology because I think it's
• 04:21important to develop a shared mental
• 04:23model and make sure that you all are
• 04:25clear about what I mean when I do
• 04:26use these terms throughout the talk.
• 04:28So implicit bias,
• 04:29also known as unconscious bias.
• 04:31One definition that I like is
• 04:33thinking about this term as
• 04:34relatively unconscious and relatively
• 04:36automatic features of prejudice,
• 04:38judgment and social behavior.
• 04:39So really. That predisposition,
• 04:41that mindset that's not intentional.
• 04:43That's not about, you know,
• 04:44thinking about any.
• 04:47Antagonistic views or feelings
• 04:49towards any particular group but
• 04:53nonetheless operate at a level that
• 04:55we're not fully aware of and then
• 04:57thinking about microaggressions,
• 04:58so implicit bias is the attitude
• 05:00or the the predisposition.
• 05:02Then microaggressions are really
• 05:03these behavior based manifestations
• 05:05of such and it's actually a
• 05:07really old term tester Pierce,
• 05:09an African American psychiatrist
• 05:10dubbed the term way back in the 1970s,
• 05:12which I was surprised to learn
• 05:14about because they feel like it's
• 05:16a term that's only more recently.
• 05:17Have come into academia as a more of
• 05:19a buzzword and something that people
• 05:21think about more often and initially.
• 05:23When he conceptualized with the term,
• 05:25he really was only thinking about
• 05:27it as applying to African American
• 05:29physicians and trying to describe
• 05:30some of their their experiences.
• 05:32However, since that time,
• 05:34we've really expanded microaggressions
• 05:36to be relevant to a whole host
• 05:38of identity groups that may be
• 05:40marginalized or underrepresented.
• 05:42And it's definition that I've written
• 05:44here brief everyday exchanges that
• 05:45sending meaning messages to people
• 05:47because of their group affiliation.
• 05:49I think really encapsulates that
• 05:51concept that these again are
• 05:53not obvious in your face.
• 05:55Hateful ways of of behaving towards people,
• 05:58but they nonetheless can make people
• 06:01feel otherwise outside of the mainstream,
• 06:03disrespected,
• 06:03or demeans.
• 06:04Even without that lack of of
• 06:07conscious intent.
• 06:11Importantly, you know when we both,
• 06:12when we think about implicit bias and
• 06:15then microaggressions as the outdrove,
• 06:17what binds it all together?
• 06:18Is that these really are
• 06:19things that are unconscious,
• 06:19subtle and and automatic.
• 06:21And so oftentimes people have consciously
• 06:24held egalitarian views in regards
• 06:26to any kind of people group, right?
• 06:29They and I think that would say
• 06:31that that's very much true of our
• 06:33culture here at Yale that people
• 06:34see themselves as those who really
• 06:37embody ideals of of justice of equity.
• 06:40For all people,
• 06:41so this is again not about casting
• 06:44labels on anyone talking about anyone
• 06:46who's explicitly racist or sexist,
• 06:48but nonetheless thinking about the ways
• 06:50in which those automatic connections
• 06:51that are happening inside each and
• 06:53every one of us, myself included,
• 06:55can can end up causing a lot of harm.
• 06:57And so micro the micro and micro
• 06:59question is not about the impact,
• 07:01you know.
• 07:01I think it's really important to
• 07:03separate intent versus impact.
• 07:05People can have good intentions
• 07:06or neutral intentions,
• 07:07but nonetheless cause a lot of
• 07:09harm and and negative impact.
• 07:11So that's an important point to
• 07:12keep in mind as we we go through
• 07:15some discontent here.
• 07:16In terms of the literature
• 07:17on unconscious bias,
• 07:18you know a lot of what we know really
• 07:20comes from the social psychology
• 07:21literature and a lot of the studies
• 07:23support that unconscious bias
• 07:24is also going to very early age.
• 07:26You know, as early as age 5 or 7,
• 07:28they've done experiments where
• 07:29they've asked children to rate
• 07:31the pain score of individuals who
• 07:33experience a painful stimulus,
• 07:35such as getting one Ted or biting
• 07:37one's tongue right and and they what
• 07:40they find is that children will for
• 07:42very same stimulus children will
• 07:44actually say that an African American.
• 07:46Child experiences less pain
• 07:48compared to a white child.
• 07:50That,
• 07:50of course is highly through beneficiant.
• 07:52Knowing what we know about disparities
• 07:54in terms of adequately treating
• 07:56pain across race, ethnicity lines.
• 07:58The second point here is about
• 08:00thinking that unconscious bias also
• 08:02has real world effects on behavior.
• 08:05So sometimes people think if
• 08:06this is happening underneath the
• 08:08skull and it's just all this very
• 08:10abstract kind of processing,
• 08:12what does this actually mean?
• 08:13And I think it's important
• 08:15to note that there are some.
• 08:16Studies that show that in terms of,
• 08:19for example,
• 08:20a pro White implicit association,
• 08:22not explicit racism,
• 08:23but it's just an automatic kind of
• 08:25implicit bias that's happening that
• 08:27automatically favors white over black people.
• 08:30For example,
• 08:31if you take those healthcare providers
• 08:33who do have that pro white bias,
• 08:35as demonstrated on the
• 08:37implicit association test,
• 08:38those same providers will also
• 08:40have observable behavior such as
• 08:43decreased eye contact engaging,
• 08:45small, engaging in small talk.
• 08:47That's often with their
• 08:48patients who are black or brown,
• 08:50so just important to highlight
• 08:52that then sociation can't go into
• 08:54the decisions that we're making,
• 08:55which is of course very important
• 08:57when we think about HealthEquity
• 08:59from a broader standpoint.
• 09:00On a more hopeful note,
• 09:02there are some studies that do suggest
• 09:04that unconscious bias can be malleable,
• 09:06particularly if you spend a lot of
• 09:08time engaging with people around there
• 09:10by it and showing counter stereotypic
• 09:12images over prolonged period.
• 09:14You can actually attend any attenuate,
• 09:16to some degree.
• 09:17The level of implicit bias folks have,
• 09:19and one example of that was taking
• 09:22taking college students who had
• 09:25an implicit association of women
• 09:27having less high powered careers.
• 09:29This is a implicit bias.
• 09:31I have myself around women
• 09:33and and career and over time,
• 09:36if you if you expose those people
• 09:38to a number of different people who
• 09:41challenge the implicit association,
• 09:44those same college students were
• 09:46found to actually improve their scores
• 09:47on the Implicit Association test.
• 09:49So hopeful note in terms of what
• 09:51it we can actually do about some
• 09:53of our implicit association.
• 09:55I always like to point out,
• 09:56particularly to a group of health
• 09:58care providers that you know,
• 10:00the things that make implicit bias
• 10:01source are things that we have in
• 10:03spades in our profession, right?
• 10:04No matter what you do in in health care.
• 10:07More broadly,
• 10:07chances are you've experienced some
• 10:09elements of cognitive overload,
• 10:11sleep deprivation, and stress, right?
• 10:13So just kind of being extra aware
• 10:15that in our field those sort of quick
• 10:18fast brain impulses associations that
• 10:20are going on are much more likely to
• 10:23happen when we're not getting adequately.
• 10:25I could sleep,
• 10:26have high levels of stress,
• 10:27and constantly have a lot to
• 10:31deal with cognitively.
• 10:33Some of you have made me have
• 10:34seen this depiction before.
• 10:35I think it's important to highlight
• 10:37because I think it really helps to
• 10:39demonstrate what the goal is when
• 10:41we talk about these larger goals
• 10:43and aspirations for diversity,
• 10:45equity and inclusion work and on
• 10:47the left upper side of your screen,
• 10:49you'll see inequality.
• 10:50And I think that's a pretty intuitive
• 10:52term for most people that the
• 10:54tree is obviously slanted towards
• 10:55the left has a lot more fruit on
• 10:57the left and the right side.
• 10:58But clearly that person on
• 10:59the right has unequal access,
• 11:01and I think that that's pretty clear.
• 11:02No, no one wants that.
• 11:04And then moving along on
• 11:05the right upper side.
• 11:06Now we have this equality question
• 11:08mark and what that means is now
• 11:11you can evenly distributed tools
• 11:13and assistance as depicted here.
• 11:14Now both individuals have the
• 11:17same size and color ladder,
• 11:19so presumably you know you might
• 11:20think that that was the goal,
• 11:22and for a long time and DI work we
• 11:24we did talk a lot about equality
• 11:26and evenly distributing these
• 11:27tools and assistance.
• 11:28But as this graph is a nice job of showing
• 11:31the trees still slanted towards the left.
• 11:33And the apples are still
• 11:35congregated on that left side,
• 11:37and so even though you give both,
• 11:39you've given both people the same
• 11:40sized ladder that person on the
• 11:42right still doesn't have that
• 11:44same access to opportunities.
• 11:45And then we moved to the left bottom hand
• 11:49at the the EDI and this is the idea
• 11:52of customizing tools and assistance in
• 11:54order to address the existing inequality.
• 11:57So now, even though that tree is
• 11:59still planted, the person on the
• 12:00right has been given a taller ladder.
• 12:01So is in a better position to
• 12:04actually reap the fruit of the tree.
• 12:06But ultimately, and I think this is what
• 12:08we we all hope for in the ideal world.
• 12:10What we really have is justice and
• 12:12by now you probably picked up on the
• 12:13fact that the tree in fact represents
• 12:15the systems and the structures of
• 12:17our organizations and our societies.
• 12:18Right, and so now both people have the
• 12:21same size bladder and actually do for
• 12:23the first time have equal access and
• 12:25opportunity because the fruit has now
• 12:28been distributed towards throughout the
• 12:29tree and the the tree is actually upright.
• 12:33So thinking about what the larger vision I
• 12:35think is can be really important to censure
• 12:38us around what our goals are for DI work.
• 12:42So some contextualizing data as promised.
• 12:44The term underrepresented medicine is
• 12:45probably not a new term for most people,
• 12:48and the way that the AA and C defined
• 12:50this is as those racial ethnic
• 12:51populations that are underrepresented
• 12:53in the medical profession relative to
• 12:55their numbers in the general population.
• 12:57So for the purposes of terminology,
• 13:00what that really includes is Hispanic,
• 13:02Latin, African American,
• 13:03American Indian or Alaskan Native origin,
• 13:06as as is depicted by the the double AMC.
• 13:09But I will say here.
• 13:10So I think this is important.
• 13:11That race is a social construct, right?
• 13:14The way that we decide to create
• 13:16boundaries around different people groups
• 13:18is more reflection on society than it
• 13:21is necessarily around genetic similarity.
• 13:23And of course we can think of many races.
• 13:26For example,
• 13:26the Asian race that encompasses so
• 13:29many different kinds of cultures and
• 13:31people from multiple kinds of lineages.
• 13:33So the way that we think about
• 13:35race to begin with is problematic,
• 13:37and so I just want to say that even
• 13:39though you know there's an effort
• 13:41here to just designate.
• 13:42Those who are underrepresented.
• 13:43It's not a perfect thing, right?
• 13:45There's a lot of heterogeneity even
• 13:48within one racial group that them back
• 13:51to our our society's way of trying to
• 13:53to group people and homogenize them.
• 13:55But I will use that term underrepresented
• 13:58because it it is how we have tried
• 14:00to track how we're doing in terms
• 14:04of diversifying our our workforce.
• 14:06Now on the left side of your screen
• 14:07coming up here,
• 14:08you'll see a pie chart that represents
• 14:10the racial ethnic breakdown of the
• 14:12US population,
• 14:12and now you'll see a similar graph,
• 14:14this time on the right that's
• 14:16depicting the resource and breakdown
• 14:18of our physician workforce,
• 14:19and even though this data is a few years old,
• 14:22it actually hasn't changed
• 14:24significantly unfortunately,
• 14:25so,
• 14:25but I'll draw your attention to is
• 14:27that on the left you'll see that
• 14:30Hispanic or Latinx individuals comprise
• 14:32approximately 18% of our population.
• 14:34We want it comes.
• 14:36To the percentage of the physician workforce,
• 14:38there are only 5% similarly for
• 14:41African American individuals,
• 14:4313% of our population is only 4%
• 14:45of our of our our of our workforce.
• 14:50We also know that if you think
• 14:51about the various aspects of the
• 14:53you know academic trajectory,
• 14:54that that we all go through
• 14:56to to become a physician.
• 14:58Not only is there this drop off
• 14:59when it when we go from you,
• 15:01the overall population
• 15:02to practicing positions,
• 15:03but those steps in the middle
• 15:05to go to medical school then to
• 15:07pursue residency or fellowship.
• 15:08We're we're losing people along the way,
• 15:11right? And there's increased attrition rates.
• 15:13There's actually a paper that came
• 15:15out in the New England Journal of
• 15:17Medicine recently that was looking
• 15:18at the diversity of US training.
• 15:20Programs from 2011 to 2019 and in many
• 15:22cases the numbers have stayed the
• 15:24same in terms of the representation
• 15:27of underrepresented individuals
• 15:28and some specialties in some of the
• 15:31surgical specialties are actually
• 15:32a drop off in that in that period,
• 15:35which is disheartening considering
• 15:36that there's a lot more attention
• 15:38paid these days to the importance of
• 15:40diverse recruitment and retention.
• 15:41So something is happening along
• 15:44the trajectory that I think is
• 15:46important for us to pay attention to,
• 15:48and that brings us to this next topic.
• 15:50Found workplace experiences of
• 15:52those underrepresented in medicine.
• 15:55There are multiple studies and
• 15:56a lot of this work has been done
• 15:58by Yale Bone Marcelina Snitch,
• 15:59who many of you probably know in
• 16:01terms of her her work both locally
• 16:03and on the national stage,
• 16:05and the pursuit of equity and a lot
• 16:07of this work has consistently showed
• 16:10that physicians who are considered
• 16:12underrepresented in medicine have
• 16:14very adverse experiences in the
• 16:16healthcare workforce and site.
• 16:18Things such as lower career satisfaction,
• 16:20patrons refusing their care or
• 16:22feeling like there's racial bias
• 16:23in the academic environment.
• 16:25Not feeling supported or adequately
• 16:28recognized on, on and on and on.
• 16:31So what we were interested in,
• 16:32and we meaning a research team
• 16:33as part of a few years ago,
• 16:35was thinking about how underrepresented
• 16:38medicine residents experience their training.
• 16:41Because there was certainly some
• 16:42resource to help us understand those
• 16:45experiences at the faculty level,
• 16:47as well as some literature at
• 16:48the on the medical student side,
• 16:49but not a lot in terms of that grade zone,
• 16:52which we felt like was a really important
• 16:54part of training to understand it's
• 16:55a vulnerable time where people are,
• 16:57in some ways being kind of
• 17:00initiated into this new.
• 17:01Difficulty of their choice and and
• 17:03learning a lot about professional
• 17:05identity and what their place is within a
• 17:07larger institution and a larger profession.
• 17:09So we wanted to understand how black
• 17:12and brown residents really felt about
• 17:15their experiences and residency.
• 17:16So towards that end we conducted
• 17:18some semi structured interviews
• 17:20or used an interview guide.
• 17:21But also we're free to kind
• 17:23of deviate and probe
• 17:24on themes as they were identified
• 17:26by our our group of residents.
• 17:30We interviewed people who.
• 17:32Met the double AMC criteria for.
• 17:34Kind of represented medicine.
• 17:36Primarily African American people.
• 17:38And then we conducted interviews until
• 17:40we reach any kind of thematic saturation
• 17:42where we no longer felt like there
• 17:44were new things that were arising.
• 17:46And then we just took a look at our data.
• 17:48We had a group of 3/3 of us on the
• 17:51team who looked at the the subsequent
• 17:54interviews to really find recurrent
• 17:56themes that we could identify.
• 17:57The overarching narrative and this is a
• 18:00little bit of our our our interview guide,
• 18:02so a lot of it was fairly open ended.
• 18:05Asking people to share about
• 18:07their experiences,
• 18:08what they feel like it might be to
• 18:11be underrepresented in medicine and
• 18:13to give some examples of of how race
• 18:16was relevant to their experience.
• 18:18We ended up publishing this study
• 18:20back in 2018.
• 18:21I think it was and this was a kind
• 18:24of a sense of our our sample.
• 18:26So we talked to 27 residents who
• 18:29represented 21 different institutions,
• 18:3156% identified as female, 40%,
• 18:33forty, 4% identified as male.
• 18:36The majority, as I noted,
• 18:37were African American and we had
• 18:38a good group of of specialties
• 18:40represented to all medical specialties
• 18:43across the folks that we talked to.
• 18:45And for the next session here,
• 18:47I just want to talk a little bit
• 18:48about what we learned when we
• 18:50we spoke with these residents.
• 18:51Our team ultimately boiled it down
• 18:54to three teams that could really.
• 18:57Populate the experiences of these folks.
• 18:59The first was common racial bias.
• 19:01The second was role of race ambassador,
• 19:03which I'll explain and then thirdly,
• 19:06the pressure to cover racial identities
• 19:08will also go into in more detail.
• 19:11I think by far the most common
• 19:13theme was around bias,
• 19:14both implicit and explicit,
• 19:16but primarily implicit bias,
• 19:18and there are a few sub themes
• 19:19that kind of shed light on what
• 19:21that meant for these trainees.
• 19:23First was what we call the
• 19:24assumptions of lower status,
• 19:25whereby the black and brown residents
• 19:28were very frequently mistaken
• 19:30to be any member of the team,
• 19:32but the physician,
• 19:33so they were called food transport workers.
• 19:36You know, medical assistants,
• 19:38people who are supporting the team,
• 19:40people who have integral.
• 19:41Goals of course to the whole healthcare team,
• 19:45but despite attempts to really assert
• 19:47their identity into where you know,
• 19:50stethoscope around their neck badge
• 19:51with the MD label very prominent,
• 19:54it seems that patient families in some
• 19:58cases other members of the care team
• 20:00really had a hard time seeing me.
• 20:02Black and brown residents at
• 20:04physicians and as leaders of the team.
• 20:06And you seen that that those
• 20:08quotes there I've never been called
• 20:09transport so many times in my life.
• 20:11I've been confused for janitors,
• 20:13food service worker.
• 20:13Even when I go in a room,
• 20:15I introduce myself like always
• 20:17when I first walk in a room.
• 20:18Hello,
• 20:19I'm doctor so and so and it's like they
• 20:21don't hear that. So really the
• 20:23sense of cognitive dissonance,
• 20:24which was very disheartening for our
• 20:26residents and made them feel like they
• 20:28they didn't belong in the environment.
• 20:30Another form of implicit bias is
• 20:32what we termed alien ones on land,
• 20:34so these were generally people from
• 20:36Hispanic or Latin next background.
• 20:39Who had names that were not
• 20:42common Anglo-Saxon names in the
• 20:44States and so you know.
• 20:46People often from patients making comments.
• 20:49Hey, can I just call you Bob
• 20:51or saying things like wow,
• 20:53that last name is different?
• 20:54How do I say where is that from doing this?
• 20:56Your first language?
• 20:56Where are you from?
• 20:58And this resident who is actually
• 21:00Mexican American whose family had
• 21:02been in the US for four generations
• 21:03and was very proud of his culture.
• 21:05Also,
• 21:06you know very much identified as an American.
• 21:09And this is really sharing how
• 21:10they would not just access Texas
• 21:12when he says I'm from Texas,
• 21:14they always kind of following up with
• 21:16with more questions and making it
• 21:18seem like because he had a Hispanic
• 21:20last name he could not be American
• 21:22and in other forms of bias like that.
• 21:25We also saw what we called assumptions
• 21:28of similarities of similarity,
• 21:29and this was the idea that for many
• 21:31of our black and brown residents,
• 21:33they found that they were confused
• 21:35for other residents of the program
• 21:36who are also black and brown.
• 21:38Even if they didn't look very
• 21:41similar in this quote,
• 21:42this is on a surgical resident who
• 21:43says six of us are black women.
• 21:45They're constantly interchanging our names,
• 21:47constantly interchanging people
• 21:48that don't even look alike.
• 21:50People that it's like I was in your surgery.
• 21:52I was in your 8 hours surgery the other day.
• 21:54Your eight hour surgery.
• 21:55And you do not know my name.
• 21:57So again,
• 21:57another theme that really made folks
• 21:59feel like they did not belong at the
• 22:02institution that people around many
• 22:04cases were even sometimes you know the
• 22:07program leader who program director
• 22:09who was engaged engaging this kind
• 22:12of behavior to not know the names
• 22:14and really added to that sense of isolation.
• 22:17And I might commonly there
• 22:19were forms of explicit bias.
• 22:20For example this resident who said
• 22:22someone like who had a patient statement.
• 22:25Excuse me,
• 22:25Someone Like You should go
• 22:26back to where you came from.
• 22:28You people come and you take our
• 22:29places and you take our jobs and
• 22:31you don't even have citizenship
• 22:33and you don't even speak English,
• 22:34so you know clearly nothing,
• 22:36nothing implicit or unconscious about this,
• 22:38just hateful language.
• 22:39And the resident described having to
• 22:42continue on to go through their day
• 22:44despite having an encounter like this,
• 22:46which was.
• 22:48Work very challenging.
• 22:49We also found that despite the
• 22:52relative frequency of these episodes,
• 22:54very few residents actually did
• 22:56anything to share this with their
• 22:58program or to arc it up the chain,
• 23:01and oftentimes they either would
• 23:02kind of go home and perhaps talk to
• 23:04a partner or friend about what was
• 23:07going on, or have an internal support
• 23:09system among other residents who
• 23:12identified as underrepresented.
• 23:13And when we asked why there is no follow
• 23:15up and why they didn't share that these
• 23:17kinds of incidents with program leadership.
• 23:19A lot of it came down through
• 23:21these three reasons.
• 23:22One was fear of repercussions
• 23:24and just the fear that there is
• 23:26a tuition was very hierarchical.
• 23:28One in turn, said when you're
• 23:29at a certain level of training.
• 23:31You don't have clouds really stick out
• 23:33your neck and say you're totally out of line.
• 23:35There's also some skepticism that
• 23:37speaking up would actually lead
• 23:39to any kind of measurable change.
• 23:41Someone said I brought up in the
• 23:42past and just kind of puts aside.
• 23:44So sort of the mindset of why bother
• 23:47and then time and energy expenditure,
• 23:49which I found really moving.
• 23:50This idea,
• 23:51that residency in general requires
• 23:52a lot of emotional bandwidth and
• 23:54so to kind of fit with the program.
• 23:56Director,
• 23:57director talk to someone and
• 23:59ombudsman about what's going on.
• 24:01Just it just felt like an
• 24:04additional expenditure of emotional
• 24:05energy as well as time,
• 24:07and I think the resident put it
• 24:09very well in this last quote.
• 24:10That's the hottest piece of currency
• 24:12that I own in residency is my time.
• 24:14I don't want to spend it reliving something.
• 24:19Our second theme was around the World
• 24:21Race ambassador and some of you may be
• 24:24familiar with the term minority tax,
• 24:26which is is this idea that,
• 24:27particularly in academic settings,
• 24:29what can happen is that for folks
• 24:32who are racially underrepresented,
• 24:34there's an increased burden to do
• 24:36things like join a diversity Committee,
• 24:38help recruit and retain certain
• 24:41individuals from diverse backgrounds,
• 24:43mentor and advise students
• 24:44or trainees of color.
• 24:46So all these sort of added tasks, or.
• 24:49Our efforts that historically
• 24:51haven't been compensated have
• 24:52that haven't come with time,
• 24:55collective time or compensation, right?
• 24:57And so thinking about how that task can
• 25:00actually downstream really affect things
• 25:02like promotion and and recognition.
• 25:05And what we thought was interesting
• 25:07is that while that that phenomenon
• 25:09has been well described in the
• 25:11literature for faculty members,
• 25:13we actually thought that the
• 25:14residents themselves were vocalizing
• 25:16a lot of these same themes.
• 25:17We talked to residents who are, you know.
• 25:19Entirely developing and running a
• 25:21HealthEquity curriculum at their institution.
• 25:24Because there was no faculty member
• 25:26who felt comfortable with that
• 25:27material who are leading diversity
• 25:29committees who are felt like they
• 25:31had increased responsibilities to
• 25:33educate their peers around diversity,
• 25:34equity, and inclusion.
• 25:35So a lot of work that was being done that
• 25:38again wasn't given time or or compensation,
• 25:41and one resident put it this way.
• 25:42The black people are asked to
• 25:44to fix the black black problem,
• 25:46but we also noticed was that
• 25:48there was really a lack of.
• 25:49The long term plan when it came to DI work,
• 25:53and in many cases we felt that there
• 25:55was this institutional abdication
• 25:57of responsibility when it came
• 25:59to having a strategic plan or
• 26:02vision for improving the issues,
• 26:04and it was made it very vulnerable
• 26:06because in many cases there would
• 26:07be one attending or one resident
• 26:09who was really passionate about
• 26:10the work and who would be doing it.
• 26:12Then when that person would leave,
• 26:14as you can see in that second quote,
• 26:16a black attendant who was very involved
• 26:18in recruitment left to another.
• 26:19Is the 2000 and since he's left
• 26:21without that voice on the table,
• 26:23there's few and everything sort
• 26:25of falls apart,
• 26:26so not not very sustainable in
• 26:29terms of prioritizing DI work.
• 26:31And then it's glass beam.
• 26:32Thirdly, is around pressure to cover.
• 26:34And this is a term that was
• 26:37conceptualized by Kenji Yoshino.
• 26:39That legal scholar and he talked
• 26:42about covering as this attempt to
• 26:45play down identities that are outside
• 26:47the mainstream in order to blend in.
• 26:50And we definitely found that theme
• 26:51with the residents that we spoke
• 26:53to where they felt like predicting
• 26:55when it came to external factors
• 26:56such as hair or clothing or speech.
• 26:58There's this attempt to to be
• 27:00very mindful of how they were.
• 27:03With that team,
• 27:04and oftentimes that hypervigilance
• 27:06was related to experiences that
• 27:08they had in that first quote.
• 27:10This is a biracial resident who
• 27:12one parent is black and one parent
• 27:15is white and he wears his natural
• 27:17hair in an Afro and oftentimes pulled in
• 27:20a ponytail and he had one of his clinic
• 27:22attendings come up to him and say, you know,
• 27:24there's people who you're going to see
• 27:26in clinic who probably would not feel
• 27:28comfortable with your hair being like that.
• 27:31And you know if you found it shocking.
• 27:33That someone would say that to him,
• 27:34but didn't really know what to do about
• 27:36it and ended up just kind of changing
• 27:38his hairstyle and not letting anyone
• 27:40else in the program know about this
• 27:42comment and the hypervigilance that
• 27:44resulted was often around feeling like
• 27:46a race representative that any action,
• 27:48good or bad, would would somehow cause
• 27:51others in the program to extrapolate that
• 27:54as a characteristic of the entire race,
• 27:57and this was particularly predominant
• 27:59in low diversity environments where
• 28:01there were very few residents of color.
• 28:03Institution and one resident told
• 28:04us just want to make sure that what
• 28:07you're doing is top notch because
• 28:08they may use your mistakes and then
• 28:10kind of pair that with your race,
• 28:12which of course it was not
• 28:15a comfortable feeling.
• 28:17Outside some of this quality of that,
• 28:18I also just wanted to spend a few minutes
• 28:20talking about bias and professional
• 28:22opportunities and advancement on some
• 28:23of you may be familiar with this study
• 28:26about resourcing bias and also maybe
• 28:27the Alpha Honor Society selection that
• 28:29made a big splash when it came out
• 28:31a few years ago was led up by a team
• 28:33here at Yale and the bottom line is
• 28:35that both black and Asian students were
• 28:37less likely to be inducted into Alpha
• 28:39Omega Alpha even after controlling
• 28:41for what you might think of as those
• 28:43common offenders that might play a role.
• 28:45As you can see there.
• 28:46And it's like I said,
• 28:47really need waves and actually
• 28:49caused several medical schools to
• 28:52temporarily or permanently suspend,
• 28:54affirming to alpha Honor Society
• 28:56selections and to take a look at
• 28:58their internal process to understand
• 29:00what was driving those inequities.
• 29:03There's also some literature around racial,
• 29:05ethnic,
• 29:05and gender bias and medical
• 29:07student evaluation,
• 29:08so I'm sure a lot of you remember the
• 29:11MPE that large kind of Dean's letter
• 29:13that that contains a lot of language.
• 29:15To summarize,
• 29:16the medical students performance as they
• 29:18go on to their next step of training.
• 29:21Terms of the racial bias.
• 29:22What they found is that, again,
• 29:23even after controlling for step one,
• 29:25scores or leadership experiences,
• 29:27community outreach experiences and so forth.
• 29:31White applicants were more likely
• 29:32to be described with those standout
• 29:34keywords that reviewers are often
• 29:36looking for at the other.
• 29:37On the other side of the application,
• 29:40words like exceptional, best,
• 29:41outstanding and black applicants were
• 29:44really describe more muted language.
• 29:46This resident was competent,
• 29:48for example,
• 29:48and then the gender piece interesting.
• 29:52Not surprising,
• 29:52but I think women were more likely
• 29:54to be described with nurturing
• 29:56words like carrying empathetic,
• 29:58commented on their organizational
• 30:00skills instead of using again those
• 30:03standout keywords that really tend
• 30:05to make an impact in terms of
• 30:08who's reviewing that application.
• 30:09What we also know is that when we
• 30:11take a look at the distribution of US
• 30:14medical faculty by race and ethnicity.
• 30:16Now if you look at the the X axis
• 30:18here we have the different groups.
• 30:20Here, white, African American, Asian,
• 30:21Hispanic, gladness and then the
• 30:23blue stand for assistant professor,
• 30:25associate professors in orange
• 30:27and then Gray full professor and.
• 30:30What I want to draw your attention
• 30:33to is that even for Asian groups who
• 30:36are not underrepresented in medicine
• 30:38on any racial group besides white
• 30:41faculty members really have this
• 30:43same pattern where the majority
• 30:44of the physicians are clumped in
• 30:46the assistant professor category.
• 30:48But then that level of diversity
• 30:50really trails off as you move up
• 30:52to to associate and full professor,
• 30:54and there's an interesting study done
• 30:56about 10 years ago by Marcel Nunez Smith,
• 30:58looking at that variation and promotion.
• 31:01On and the bottom line is that most
• 31:04institutions displayed lower rates
• 31:06of promotion for black and Hispanic
• 31:09faculty despite controlling for
• 31:11characteristics that you might think of
• 31:13as germane to how that decision is made.
• 31:15Interestingly,
• 31:16there are 13% of institutions do not
• 31:18promote any Hispanic faculty over
• 31:20the course of this study period,
• 31:22almost a quarter to promote any
• 31:24black faculty at all.
• 31:25But there was this third,
• 31:27the third of their sample size,
• 31:28that those somewhat equal rates of promotion,
• 31:31which I think is encouraging.
• 31:32In terms of thinking about what the best
• 31:34practices might be that are associated there.
• 31:37The next election will we'll talk about
• 31:39is the case for why this all matters.
• 31:41Highest relevant to us as
• 31:44healthcare professionals.
• 31:45You know.
• 31:45I think a lot of the the case for this
• 31:48really comes from the business literature
• 31:50and certainly in academia as well.
• 31:52There's a great study in the 1990s from Anne
• 31:56McLeod around diversity and and creativity,
• 31:59and there's this experiment
• 32:00that was done there.
• 32:01135 paid volunteers.
• 32:02They're all college students I believe,
• 32:04and they're randomly assigned to two
• 32:06groups and have this brainstorming
• 32:08task to solve the torus problem,
• 32:10and essentially they were.
• 32:12Has to come up with as many ideas as
• 32:15possible to improve American tourism,
• 32:16and then blinded judges assess the
• 32:18performance based on the feasibility
• 32:20of the ideas and also the effectiveness
• 32:22and what they found is that for the
• 32:24groups that were made up of people from
• 32:27a variety of different backgrounds,
• 32:28they had ideas that were much more
• 32:31feasible and more effective compared
• 32:33to those groups that were homogeneous,
• 32:34and this is often thought of as a
• 32:36landmark study to think about why
• 32:38diversity is important in terms of
• 32:39creative thought and giving an organization.
• 32:42Really,
• 32:42you get vantage.
• 32:45From the business side of things,
• 32:46I think also certainly applies to
• 32:48our our medical organization,
• 32:50thinking about how diversity leads
• 32:51to a competitive advantage when
• 32:53you have a heterogeneous group,
• 32:55better market performance,
• 32:56increased productivity,
• 32:57higher return on equity.
• 32:58All these things have been associated
• 33:00with organizations that are not made
• 33:02of people who have the same lived
• 33:05experiences or the same identity group.
• 33:07So something that's important,
• 33:08I think, thinking about it from an
• 33:11organizational optimization point in
• 33:13addition to of course the the moral.
• 33:15Argument that I hope we we all care about.
• 33:18In terms of HealthEquity, you know,
• 33:20I think this is an important point,
• 33:22although it's important
• 33:22to be careful about it,
• 33:24the method certainly shouldn't be that
• 33:26people of color should only be treated
• 33:29by physicians who are also of color.
• 33:31But it is true that the
• 33:32literature supports that race.
• 33:34Concordant care improves access,
• 33:35so particularly for providers
• 33:37who are black and brown,
• 33:40they often will go practice in areas
• 33:42where there are a higher number of
• 33:44underrepresented individuals who we all
• 33:46know unfortunately experienced worse.
• 33:48Outcomes in our country.
• 33:49So in terms of thinking
• 33:50about Medicaid patients,
• 33:52uninsured patients patients who are high
• 33:54utilizers of accused health services,
• 33:56and the Ed and in urgent care
• 33:59centers and patients who self report
• 34:02as fair or poor health status.
• 34:04Providers of color much more likely
• 34:06to work with that that group.
• 34:08So again,
• 34:08I say with a grain of salt because I
• 34:11again don't want to send the message
• 34:13that our solution is to make sure that
• 34:15providers and physicians all have the same.
• 34:18I'm sorry providers and
• 34:19patients have the same race,
• 34:20but I do think it's important to
• 34:23note that diversifying our health
• 34:25care workforce is likely to make
• 34:27inroads in terms of this HealthEquity
• 34:29issue that we we constantly face.
• 34:31So for the remainder here,
• 34:32then I hope to leave a good amount
• 34:34of time for for questions here.
• 34:35At the end is thinking about how we
• 34:37can move forward and some of the work
• 34:39that I've been doing and the DI space
• 34:41and other things to think about is
• 34:43as you chew on some of what we've
• 34:46been talking about during this talk.
• 34:48So I think something that's become
• 34:49very clear to me in the time
• 34:51that I've been doing this work is
• 34:53how important it is to protect
• 34:54time for DI leadership efforts.
• 34:56As you saw in the data that I showed,
• 34:58it unfortunately has become way too common.
• 35:01For folks to think of TDI leadership as
• 35:04an extracurricular activity that that
• 35:06doesn't get much recognition or much support,
• 35:08and I think there's really something
• 35:11about giving that protected time
• 35:13and that funding to make sure
• 35:15that the message is being sent,
• 35:17that DI is something that's prioritized in
• 35:19the department and the larger institution,
• 35:22whatever the the sphere of
• 35:24influence might be.
• 35:25And I feel really fortunate that
• 35:27I have had time and support to
• 35:29do the work that I do.
• 35:30So if Pam mentioned at the beginning
• 35:32I have a few roles in DI leadership.
• 35:35One is as the associate program
• 35:37director for DI and Yale Primary Care,
• 35:40and then the vice chief
• 35:41for DUI in the section
• 35:43General Medicine and then as
• 35:44as most of you probably know,
• 35:46that hitting Hanal left us this spring
• 35:48to become the the Dean of Diversity,
• 35:50equity and belonging at Penn State.
• 35:52This is such a wonderful opportunity for her.
• 35:55And in in that transition,
• 35:57I'm now helping with the DI by chief
• 36:00development across different sections
• 36:02and partnering with bonding kamdar,
• 36:04who's taking on other engineer
• 36:07responsibilities on an on an interim basis.
• 36:10And I made this a sort of a Venn
• 36:12diagram because I I just wanted to
• 36:13note that I think it's so important
• 36:15for diversity and equity and inclusion
• 36:17work that it doesn't happen in silos,
• 36:19and I think there are many ways in which
• 36:22all these roles help to inform each other.
• 36:24You know, certainly.
• 36:25Both the app role and the Vice Chief and
• 36:28GIM role are under the larger GI M section,
• 36:32right?
• 36:32And so our trainees are very integral.
• 36:35Part of how we function overall,
• 36:36the section of general medicine and
• 36:38doing the work in terms of thinking
• 36:41about how we help develop our our
• 36:43DI Vice chief across the Department
• 36:45of Medicine is also going to have
• 36:48downstream effects in terms of what's
• 36:50happening in the individual section.
• 36:52In terms of thinking about the
• 36:54DI by T development,
• 36:55I think we've really had this kind
• 36:58of try part vision and I think in
• 37:00any did such a wonderful job in
• 37:03terms of developing infrastructure
• 37:05for DIF administration,
• 37:06because a few years ago certainly
• 37:08I came to residency here,
• 37:10so I've been here for about 9
• 37:11years and when I first came,
• 37:13there really wasn't much in the way
• 37:16of leadership positions or people
• 37:18who were really taking their time
• 37:19and energy to work on various DI.
• 37:22To do and so even having a DI
• 37:24vice chief in each section in
• 37:26the Department of Medicine,
• 37:27is just such a wonderful development.
• 37:29And I'm really so grateful to have the
• 37:31support of the department in that.
• 37:33I think in terms of the things
• 37:35that we've been focusing on,
• 37:36team building has been a huge component
• 37:38of the work that we're trying to do
• 37:40because it's been very clear that there's
• 37:42been a little bit of TDI work done in,
• 37:45you know,
• 37:45one section, perhaps,
• 37:46but then no one else in the
• 37:48department may know about it.
• 37:49And there may be multiple people who
• 37:50are working towards the same goal.
• 37:52But even reinventing the wheel because
• 37:55it's it's unclear who's doing what,
• 37:57and so you know part of it is developing
• 37:59a really good team model so that we
• 38:01can support one another and collaborate
• 38:03and make sure that we're really
• 38:05effective in the work that we're doing.
• 38:08Secondly,
• 38:08is the goal of the I
• 38:10knowledge and skill building,
• 38:11and there's a ton of passion
• 38:13or group for social justice,
• 38:14and it's such a wonderful group
• 38:16to be part of.
• 38:17And so a lot of what we're
• 38:18thinking about now is how do
• 38:20we just hone our skills to make
• 38:22us more effective?
• 38:23And DI leaders and understand the
• 38:25strengths that people are bringing to
• 38:27enhance the content that we can can then
• 38:30bring back to our individual sections,
• 38:32and then a huge piece as well
• 38:34has been leadership development
• 38:35and I'm really grateful to be
• 38:37partnering with Doug McKinley.
• 38:38Approved announced external consultant
• 38:40who comes in and works with us to help
• 38:44us understand our leadership styles.
• 38:45To understand how to be more
• 38:47effective and the work that we do is
• 38:50to really kind of hardness our our
• 38:52individual personalities to make sure
• 38:54that we are going into this work.
• 38:56To really make sure that we are
• 38:58thinking of ourselves as just as
• 39:00worthy as other vice chiefs and
• 39:02affection and getting that kind of
• 39:04voice to to make us effective leader.
• 39:06So it's it's been fun to have him work.
• 39:08Alongside as we're sort of doing a
• 39:11DI content piece to also think about,
• 39:14how do I understand myself as a leader?
• 39:16And what does that mean in terms of how
• 39:17I want to optimize the work that I'm doing?
• 39:23And then in terms of Vice chief
• 39:24role as the sector general medicine,
• 39:25specifically, this is a year,
• 39:28a role I've had for about a year now,
• 39:30and so really the focus that I've
• 39:32been having this first year plus
• 39:34has been around education and
• 39:36doing a lot of faculty development.
• 39:38Something that I'm really excited about
• 39:40that are our section has committed
• 39:43to is having an annual DI themed
• 39:45retreat which we had in February was
• 39:47our first one since the pandemic,
• 39:49so it was virtual,
• 39:50but at least we were able to to
• 39:52go through the content.
• 39:53We did things like have a virtual
• 39:56privilege walk, talk about what,
• 39:57what privilege means in terms of what
• 40:00it looks like for our lived experiences,
• 40:02doing some small group activities,
• 40:04and having external speaker come in and
• 40:07talk about resistance and advocacy.
• 40:09So really great ways to keep
• 40:11the conversation going.
• 40:12Think sometimes in the I can feel like
• 40:14a you know one off kind of thing where,
• 40:16uh, someone has a training but we don't
• 40:18want it to be a check with the kind
• 40:20of initiative we really want to think
• 40:21about how to create it to be a thread.
• 40:23Neurocrine theme that comes
• 40:25into people's minds.
• 40:26I've also enjoyed being the director
• 40:28of the race bikes and advocacy and
• 40:30medicine distinction pathway and
• 40:32working alongside a great group
• 40:34of faculty and resident coli.
• 40:36And these are for residents in any of
• 40:38our three internal medicine programs,
• 40:40so the traditional internal medicine program,
• 40:42the primary care program that I
• 40:44work primarily in and then the
• 40:46medicine pediatric program,
• 40:47so it's open to all all residents
• 40:49in any of those three tracks,
• 40:51and the idea is for it to be a deeper dive.
• 40:53To some of these social justice kinds
• 40:56of issues for people who want to
• 40:58engage more so they attend various
• 41:00forms of interactive didactic.
• 41:03In order to at the end of their
• 41:05tenure as a resident,
• 41:06they kind of graduate with distinction
• 41:09in this particular field,
• 41:11and it's similar to the way that
• 41:12we think about distinction,
• 41:13pathways and other aspects.
• 41:15So we have investigations pathway.
• 41:18We have a clinical educator pathway.
• 41:21We have a global health and equity pathway.
• 41:23So really great as the most recent
• 41:26of these distinction pathways.
• 41:27To really elevate the importance
• 41:29of thinking about things along
• 41:31the lines of race and bias.
• 41:32On a large piece of that too,
• 41:34is thinking about how we can provide
• 41:36mentorship and professional develop
• 41:37opportunities for for these residents.
• 41:39Because a fair number of them are are
• 41:42underrepresented in medicine themselves.
• 41:43Looking forward,
• 41:44I think somebody would love to
• 41:46focus on in the Vice chief role in
• 41:47the next year or two is thinking
• 41:49about recruitment and retention.
• 41:50I think we've certainly made some inroads
• 41:52in terms of diversifying our trainees,
• 41:55so it's kind of work to do there.
• 41:57But you know the the faculty level
• 41:59as I showed you in some earlier data,
• 42:02tends to be a really.
• 42:04A really challenging.
• 42:06Uh, kind of trend to shift,
• 42:08and so you know, thinking about what
• 42:10it looks like to to make sure that
• 42:13we're positioning ourselves in a
• 42:14position to diversify our faculty,
• 42:16and even to think about the experiences
• 42:19of those who are underrepresented
• 42:21in medicine to make sure that we're
• 42:24addressing any potential barriers.
• 42:26And then as a PD for DI and
• 42:28the primary care residency,
• 42:30I have a number of roles,
• 42:31some of which are traditional
• 42:33APD rolls administratively,
• 42:34but also in education recruitment.
• 42:36Thinking about climate,
• 42:37I have a curriculum with the residents
• 42:39that runs three years in our ambulatory
• 42:42didactic curriculum where we dive
• 42:43into a lot of different interactive
• 42:45small group activities to help them
• 42:47understand the experiences of other
• 42:49people in the training program who
• 42:50may or may or not look like them.
• 42:52And we always have incredibly rich
• 42:54conversations to think about our
• 42:56own identities and what that means.
• 42:57Not only personally,
• 42:58but professionally.
• 42:59What that means when we
• 43:00interact with patients,
• 43:01so that's always a really fun
• 43:03thing to work on.
• 43:05I'm grateful that we've done quite
• 43:06well when it comes to recruiting
• 43:08a diverse group of residents
• 43:10in our primary care program,
• 43:11and that's been a really integral
• 43:13part of our our ethos.
• 43:14As a program with something
• 43:16that we very much prioritize.
• 43:18And of course, it's not just recruitment.
• 43:19Also,
• 43:20the retention and making sure that the
• 43:22climate that these trainees are in
• 43:24one is one that actually encourages
• 43:26other folks to come and feel at home
• 43:28here and experience that sense of belonging.
• 43:30And I,
• 43:31I really enjoy that
• 43:32mentoring and advising peace,
• 43:33and that helping to advocate for people.
• 43:35That's me so that they
• 43:37do feel like they belong.
• 43:39So as I wrap up here in the next few minutes,
• 43:42the thing about institutional next steps,
• 43:44you know,
• 43:44I think I always like to
• 43:46emphasize that each of us,
• 43:47whatever our particular rules might be,
• 43:49there's something that we can do
• 43:51as a as a next step in terms of
• 43:53adding our voice to this long term
• 43:56road to equity and to justice,
• 43:59and I think something that's very
• 44:00clear to me is that institutions
• 44:02and sections and departments we all
• 44:04have to take ownership of diversity.
• 44:06You know,
• 44:06it can't be this thing where it's relegated.
• 44:09The only people who have official
• 44:11DI position because diversity
• 44:13as we talked about is something
• 44:15that really benefits everyone.
• 44:17It's not just for underrepresented
• 44:18groups and so everyone has to be
• 44:21a part of the the the effort to
• 44:23really make sure that we're meeting
• 44:26the challenges and improving
• 44:28ourselves consistently.
• 44:29I think in a lot of ways that we
• 44:31talk about institutional standard
• 44:32of excellence and in many things
• 44:34like patients safety and quality,
• 44:36we really need to have a a similar mindset.
• 44:39A similar framework.
• 44:40When it comes to the EI.
• 44:42I also think that some of that
• 44:44racial burden that we talked about
• 44:46where there's that that tax to
• 44:49underrepresented individuals can be
• 44:51minimized. If there's more resources and
• 44:53support to diversity initiatives and making
• 44:55sure that people who may not feel like
• 44:58they themselves have personally been the
• 45:00recipients or bias for microaggressions.
• 45:02They also of course have a very important
• 45:05role to play in all of this too.
• 45:07As an organization, I think some of the
• 45:09things that come to mind is importance
• 45:12of mandatory unconscious bias training.
• 45:14Paris, Florence,
• 45:14who recently came to speak with our
• 45:17Vice Chief DI Vice Chief Group,
• 45:19is the inaugural director of DI Training
• 45:22and development underneath Darren
• 45:24Lattimore and Darren Lattimore's,
• 45:26office of Diversity and inclusion
• 45:28at the Med School,
• 45:29and I think that's going to be really great.
• 45:30It's not mandatory yet,
• 45:32but I do think sometimes when these
• 45:34DI circles we kind of get to the this
• 45:36concept of preaching to the choir.
• 45:38The people who show up and engage in the
• 45:40topic are people who already bought in.
• 45:43So thinking about what it looks
• 45:44like to implement structures so
• 45:46that everyone can can engage in
• 45:48these issues and ultimately helps
• 45:50to cultivate our environment.
• 45:51I think open forum to discuss these
• 45:53topics are really important sometimes
• 45:54with our residents will do town halls
• 45:57where we just have people reflect
• 45:58on what's going on in the world.
• 46:00Things would have happened in their own
• 46:02lives because it was clear to me in the
• 46:04the study we did with those residents.
• 46:06Oftentimes there aren't adequate venues.
• 46:08For people to process their
• 46:10feelings and their experiences,
• 46:12I also think it's incredibly important
• 46:14to survey our trainees about their
• 46:16experiences because oftentimes they're
• 46:18not coming forward unless being asked,
• 46:21and so I think that needs to become
• 46:22a regular part of our culture.
• 46:24We talked about a strategic
• 46:25plan to increase diversity.
• 46:26I think that's part of hiring those roles
• 46:29so people can build out those plans.
• 46:31Mentorship of underrepresented groups
• 46:32not only a faculty who look like them,
• 46:35but people who can be really informative.
• 46:38Allies and support folks who else to achieve
• 46:41their personal bests and then making sure,
• 46:44as I mentioned,
• 46:45that we support colleagues who do
• 46:47engage in diversity work and do
• 46:48in a way that's not going to be a
• 46:51detriment to their career advancement.
• 46:53On an individual level,
• 46:54I think there are a number of
• 46:56practices that we can also engage in.
• 46:57I think having awareness of our
• 46:59personal biases is something
• 47:01that's extremely important.
• 47:02I mentioned in the Implicit
• 47:04Association test earlier,
• 47:05which I'm sure some of you
• 47:06have have done in the past.
• 47:08I think it's it's not a perfect test,
• 47:10but it's a good way to think about some
• 47:12of that unconscious bias that might
• 47:14be lurking underneath the service,
• 47:15and I think that awareness was really
• 47:18important first step and then helping
• 47:20to make sure that we're changing
• 47:22our behavior when it comes to.
• 47:24Evaluations is something I hear
• 47:26a lot from the trainees who come
• 47:28and talk to me and debrief as as
• 47:31not always feeling like the
• 47:33the feedback they get is is as
• 47:35fair and equitable as it could be,
• 47:37and wondering, you know,
• 47:38they do something or say something.
• 47:40Is it perceived in the same way as
• 47:42another trainee who does the same
• 47:43thing who looks differently from
• 47:45them and part of the majority?
• 47:47And because of the data that we we do
• 47:49know that shows those those differences
• 47:51and how we're evaluating trainees,
• 47:53I think it's really important.
• 47:54When we are on the side of evaluating
• 47:57someone else to be clear about
• 47:59what the performance metrics are
• 48:01to be really specific in terms of
• 48:03behavior based language and and not
• 48:05just say things like oh this person
• 48:07was a good fit or you know this
• 48:09person did a good job like what?
• 48:10Why are we?
• 48:11Why are we saying someone does
• 48:13well or doesn't do well?
• 48:14Mindfulness is an interesting
• 48:15point at actually read a study
• 48:18about how mindfulness can help
• 48:19to disrupt some of the fast brain
• 48:21connections that we that we make and
• 48:23so engaging in mindfulness can do.
• 48:26Some ways help to attenuate
• 48:27that implicit bias,
• 48:28which is really important in the
• 48:30complex cognitive environment that
• 48:31we all live and work in and then
• 48:33thinking about how you can stand the
• 48:36diversity work in your department.
• 48:37I know from Pam that there's some
• 48:39great things that are that are
• 48:40happening already and maybe if if
• 48:42you've been on the sidelines and
• 48:43you don't feel like the expert.
• 48:45The room is 5.
• 48:46Still something that you can contribute,
• 48:48and doing that having that effort
• 48:50of increasing your personal growth
• 48:52and stepping out of your comfort
• 48:55zone and joining in the work
• 48:57can only yield good things.
• 48:59The last thought here,
• 49:00you know,
• 49:00I really think a lot of the what I talked
• 49:02about today is ultimately a Wellness issue.
• 49:04I think representation and experience
• 49:06are very much interdependent.
• 49:07You know,
• 49:08for making all these efforts
• 49:09to recruit and retain people,
• 49:11but we're not doing the the work that
• 49:13we need to do to create a kind of
• 49:16climate where people feel welcome.
• 49:18Then of course,
• 49:18it's it's not going to be successful.
• 49:20So we really need to think about
• 49:22those efforts as very much linked.
• 49:24I would also encourage you before
• 49:25we get to the questions here,
• 49:26just to take a moment of silent
• 49:28reflection and think about how
• 49:29you can do something differently.
• 49:31Moving forward,
• 49:32you know maybe it's a simple step
• 49:34like a book you want to read,
• 49:35or a colleague you want to talk
• 49:37to about their experience joining
• 49:38us Diversity Committee.
• 49:40You know, doing something different,
• 49:42but I think there's constantly
• 49:44something to do in this larger journey
• 49:46towards justice and we we all can
• 49:49make those decisions to to move forward.
• 49:52A few resources,
• 49:53but I'll leave you with some
• 49:54books that I've read that I think
• 49:56are give a nice lens to thinking
• 49:58about some of these issues.
• 50:00The double AMC that second
• 50:01bullet bear has great portal
• 50:03on physician workforce data,
• 50:04so if you are interested in
• 50:05some of those trends or wanted
• 50:07to look up how the healthcare
• 50:08profession is doing in terms of
• 50:10diversity and inclusion efforts,
• 50:11there's some really great
• 50:13resources there as well.
• 50:15And with that I will stop sharing my screen.
• 50:19I think you found my free time and
• 50:21I'm happy to take any questions.
• 50:25Thank you so much,
• 50:27that was wonderful to hear a little
• 50:30bit more about your research and some
• 50:31action items that I think we can all take.
• 50:33So what I thought I would do is turn.
• 50:36There's actually a great first
• 50:37question we can take from the chat,
• 50:39so this is the question is what
• 50:42is the approach to addressing
• 50:44patients bias and aggression?
• 50:46It seems we have strong efforts in place
• 50:48in regards to faculty development,
• 50:50but how do we approach patients?
• 50:52It's difficult to speak back to
• 50:53patients and that's a great question.
• 50:55And in fact,
• 50:56I'll just editorialize a little bit I.
• 50:58I have personally found and observed
• 51:01that we've seen more patient bad
• 51:03behavior in the era of COVID,
• 51:06and I think it's it's a struggle.
• 51:09I'd love to hear your thoughts on this.
• 51:12Yeah, this is such an important
• 51:14question and it's something that I
• 51:16love to talk to people about as well,
• 51:18because, you know, some of you might
• 51:19be familiar with the term of bystander
• 51:21response training, or more recently,
• 51:23we call it upstander response training
• 51:25because we want to make it more proactive,
• 51:27but there is really such an important
• 51:29role when it is the patient who is being
• 51:32something inappropriate and I've had,
• 51:33you know, in our program as a graduate
• 51:35of our our Yale Primary care program
• 51:37who was actually called the N word
• 51:39on our inpatient General Medical
• 51:41service by a patient.
• 51:42And literally,
• 51:43no one in the room said anything,
• 51:45even though there are about five or
• 51:47six other health care professionals
• 51:48in the room at the time.
• 51:50So I think this is critical in terms of,
• 51:52you know,
• 51:52can really make or break anyone's experience.
• 51:54But of course,
• 51:55our trainees are are more vulnerable.
• 51:57I think my personal feeling on
• 51:59this is that it's very important
• 52:01to be direct with patients.
• 52:03I think you can be both direct
• 52:05and respectful. Oftentimes.
• 52:06What I'll do is I'll employ
• 52:08strategies that encourage the person
• 52:10who made a comment to reflect.
• 52:12So I'll say something.
• 52:13For example,
• 52:14you know what did you mean by that,
• 52:15or what made you say that,
• 52:17and I think that signals that what
• 52:19was said is not OK and put that
• 52:22person in the position of explaining
• 52:24why they made it a made a comment.
• 52:26I think ideally you know it
• 52:28can lead to a teachable moment.
• 52:30Sometimes you know you can have a
• 52:31strategy where you acknowledge that the
• 52:33person may not have had bad intent,
• 52:35but there's still a bad impact,
• 52:37and so you know.
• 52:38I mean, I know you may not have meant harm,
• 52:39or you may not have realized
• 52:41that your words were offensive,
• 52:42but that was actually really hurtful to me.
• 52:44Or really.
• 52:44Bothersome to me,
• 52:45and here's why I'm hoping to engage.
• 52:48There are many other states you've got,
• 52:50I'll leave it at that.
• 52:50I think sometimes if a patient's
• 52:54particularly antagonistic,
• 52:55something something I'll do if
• 52:56they don't seem open to education
• 52:58is just remind them of our sort
• 53:01of institutional values.
• 53:02Saying something like an institution like,
• 53:04yeah, it's very important.
• 53:05We all embody this these ideas
• 53:07of respect and accountability and
• 53:09compassion our team is treating you that way.
• 53:11We very much expect those same
• 53:13kinds of values and return.
• 53:14So please respect every member of our
• 53:16team and then transition to talking
• 53:18about you know the blood pressure
• 53:19or whatever the situation might be.
• 53:23Thank you, I'd love to turn
• 53:25to Doctor Barbara Burtness,
• 53:26who's serving as our interim associate
• 53:28director for DI for the Cancer Center.
• 53:30So Barbara and I partner on a
• 53:31lot of these efforts so Barbara,
• 53:33any comments or questions.
• 53:35First of all, I want to thank you for
• 53:37for coming and and sharing with us.
• 53:40And for the work that you do,
• 53:42what I particularly loved was.
• 53:47You you know your your message that
• 53:50implicit bias is not cast in stone,
• 53:52that that this is something that over
• 53:56time you can see progress on you know.
• 53:59Obviously you brought forward a an
• 54:01example with college students in
• 54:02the same way it gets harder to learn
• 54:04a new language when you get older.
• 54:06It's probably harder to let go of
• 54:09of these habits that that people
• 54:11have had over the years.
• 54:13But I wanted to and and I
• 54:16loved your emphasis on.
• 54:20Repeated exposure to counter
• 54:24stereotypic examples.
• 54:26And obviously representation
• 54:28is is part of that.
• 54:32You know the the fact that that
• 54:34we're able to use Cancer Center
• 54:36grand rounds on on DI topics,
• 54:38I think is is one of the reasons we
• 54:41we like to do this, but I I guess I.
• 54:45As much as I like that I I still see
• 54:48it as very difficult, and you know,
• 54:50I I struggle with issues like to
• 54:54what extent can you require people
• 54:57to do implicit bias training?
• 55:00What's the the backlash and the
• 55:03resentment that that creates.
• 55:05And you know,
• 55:06I just took a quick look at who the
• 55:09attendees are for for today's grand rounds.
• 55:12And it's it's a lot of people who
• 55:14already work on on these issues.
• 55:16So apart from working on our artwork,
• 55:20working on who we invite is speakers.
• 55:23Do you have any concrete strategies
• 55:25for for kind of?
• 55:27Breaking across to to groups where these
• 55:30biases are are more solidified I guess.
• 55:35Yeah, I mean it's I.
• 55:37I completely that completely resonates
• 55:38with me because it's tough and I,
• 55:40you know, as many of these
• 55:41workshops as the first that I do it.
• 55:42Oftentimes the people in the audience are
• 55:44people who are already very much bought in,
• 55:46and so we have the same, you know,
• 55:48problem in general medicine.
• 55:50I think there are few things right, I think.
• 55:53Even though it can be a little
• 55:55uncomfortable to mandate training,
• 55:56I I do think you know
• 55:58there is precedent for it.
• 55:59You know, we all have to undergo
• 56:01sexual harassment training.
• 56:02We all have to go, you know,
• 56:04go through training on you know how to
• 56:07decrease certain infections in the hospital
• 56:09and and know the response to a code.
• 56:11And you know all those kinds of
• 56:13things that we're required to do.
• 56:14So.
• 56:14I do think there's a way in which
• 56:16the the training that we decide
• 56:18are mandatory for any employee
• 56:20can send a message about what we
• 56:21think is really important. Umm?
• 56:23That aside, you know I think this,
• 56:27like larger question is,
• 56:28how do you engage individuals who who
• 56:30who may not be particularly excited
• 56:32about doing the equity and inclusion?
• 56:33One size that I often use
• 56:35with the residence is.
• 56:37Trying to engage in as many small
• 56:39group activities as possible because
• 56:41I find that for people who may be a
• 56:44little bit resistant to the topic,
• 56:46it's a lot easier for them to
• 56:48learn if they hear their peer talk
• 56:50about something that happened to
• 56:52them personally because they care
• 56:54about their peer right and so.
• 56:56Oftentimes in my the curriculum I
• 56:57mentioned that I do feel primary care
• 56:59residents very little of it is didactic.
• 57:01You know, I'm not here.
• 57:03I don't deliver grand rounds.
• 57:04The residents I'm not talking for an hour,
• 57:06but I'm doing is.
• 57:07I'm creating structured opportunities
• 57:08for them to reflect and then share.
• 57:10So, for example,
• 57:11you know we'll do an activity where we
• 57:14write down our name on a piece of paper,
• 57:16and then we think about 7 identities.
• 57:19That means something to us that
• 57:20can be raised, gender, ability,
• 57:21religion, whatever.
• 57:22Defined it for an individual and
• 57:24I just asked two simple questions.
• 57:26One is described,
• 57:28you know,
• 57:29a time that you were proud to be
• 57:30part of one of these identities and
• 57:31describe the time that it was painful
• 57:33for you to be part of these identities.
• 57:34So I'm always amazed by the
• 57:36richness of the conversation that
• 57:38comes from such a simple activity.
• 57:40And I've witnessed,
• 57:41like people sort of light bulbs
• 57:42go off when you know someone,
• 57:44for example,
• 57:45shares a painful time when they
• 57:47were members of certain community,
• 57:49and what that means and what you
• 57:50know the things that they have
• 57:51to think about is it creates an
• 57:53opportunity for someone to be
• 57:54in someone else's shoes,
• 57:55and I think that's a the more
• 57:58accessible way to engage in DI issues.
• 58:01For someone who you know
• 58:02is not going to attend
• 58:03the grand rounds or something on the topic.
• 58:068 Ava, thank you. We are at time.
• 58:09So I we could go on probably for
• 58:10a while longer with questions,
• 58:12but I'm certainly leaving feeling inspired,
• 58:16motivated and really hopeful about this
• 58:18work that can be hard and slow going.
• 58:22So thank you for sharing
• 58:23kind of your vision with us,
• 58:25and I'm I'm sure I I certainly learned a
• 58:27lot and I'm sure our audience did too.
• 58:29So thank you so much for joining us.
• 58:32Great, thank you so much
• 58:34for having the opportunity.
• 58:35Thank you. Have a great afternoon everyone.
• 58:39Aye.