"Hidden Costs: Unconscious Bias in the Healthcare Workforce"

June 24, 2022

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Yale Cancer Center Grand Rounds | June 21, 2022

Presentation by: Dr. Aba Black

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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.