Good morning, everyone. It's good to see you. Thank you so much for coming in to participate and listen to this panel discussion. This is part two of defining, identifying, and managing implicit bias in OEM. My name is Dr. Raul Mirza, and I have the distinct honor of serving as the moderator. The reason why I suggest this is because these four individuals next to me are going to share their experiences about bias in medicine, professional and personal, perhaps biases in their personal life in terms of what were their experiences, how they've dealt with them, perhaps what they've witnessed, perhaps how they may potentially have unintendedly have expressed them, and how they dealt with that. It's all this to suggest that this is going to be a potentially vulnerable discussion, one that is laden with a lot of courage, these individuals here. But I would be remiss if I didn't underscore the invitation to each and every one of you to also engage in the discussion and provide some information perhaps and demonstrate a little of your own vulnerability as to what have been your experiences in bias. I'd like to introduce our panel. All the way to your left, we have Dr. John Clark, we have Dr. Jill Rosenthal, we have Dr. David Cockrum, and we have Dr. Jeff Wiseman. Just as a reminder, in SwapCard, there is a product available to download. Of course, in the first presentation that was given in the last session, that is also available, which contains wonderful information, definitions about implicit and explicit bias that was presented by Dr. John Clark. This is also a nice, succinct card that illustrates some key definitions and some things to have under consideration how you deal with the notion of bias. With that, I want to start out with a couple questions. The first one is for any one of you who are first courageous to take it. How about sharing a microaggression that you experienced and sharing how you dealt with it? This could be in your professional work, it could be in your personal life, and perhaps also describing a little bit about the impact that it may have had on you that you may have not thought would have resulted. Hi everybody, thank you. I am a Jewish woman, and somebody ... Actually, this happened in a few different parts of my employment history, but there have been times when someone said something like this. He Jewed me. I don't want to get Jewed, and I'm like, what are you talking about? It's like taken advantage of financially, and you know how Jews are, you know how you people are. I was like, no, I don't. What do you mean? Just kind of challenging them a little bit to say, keep digging that hole, please. You're cheap. That's what I've come up with, you're cheap. Well, anyone who knows me knows that I probably should be cheaper than I am, especially my financial planner. I actually took great offense at this because, again, it was just defining a whole people, a whole religious group as this. That's what bothered me the most, and just explaining why I found it offensive. Actually, somebody at work who reports to me, literally referred to someone else we work with as, I just figured he Jewed the situation. I was like, you know I'm Jewish, and you know that's offensive, and she was like, no, what do you mean? How is that offensive? Again, this keeps happening, and I see it as an opportunity to educate. Do I end up thinking differently about them? You can't go back, the sign that you showed. I have to fight that all the time now, that when I'm dealing with this person, that I'm not like, oh, you're anti-Semitic. That's not good. Anyway. If I may, can I add on to that, or follow up on that? The recent 10 months has been extraordinarily difficult on the Israeli and Jewish communities. I'm very curious about if the current global circumstances has in any way impacted your work relationships, personal relationships, perhaps how, or even how you may communicate and or engage with others relative to how you may even perceive their thoughts on the matters. It has, and I have a very recent example of that. Because I sit on the board of directors of AECOM, and I don't want to politicize anything, the other day during the new fellows announcement, and I don't think you know this, there was a part of the script that in addition to acknowledging Asian American and Pacific Islander month, there was another line that I did not read, and I chose not to read it, that was about Jewish American heritage month, because I did not want to politicize what's in any way or have even the seeming conflict of not including everybody and knowing how emotional and how extraordinary the circumstances are right now, I actually chose not to recognize something Jewish when I spoke because I didn't, I don't know if that was right or wrong, but I felt it was right because I think that there is, personally I think all of the human loss and suffering that's occurring around the world is awful, period. So that's, thanks. Yeah, so when you did that, you know I was online and I actually saw the teleprompter, and I saw that you did that. And I was thinking that what you just said is probably why you did it, that you did not want to like, you know, bring that up, because it's such an issue for folks, so I was like, you know, I observed that because I was able to actually see it, yeah. But as far as microaggressions, I mean I did share about, you know, people assuming I'm not a physician, but I have a story. When I was 18 and I went to DMV to get my license, I remember, you know, going to the attendant and she asked, you know, for my information. She made conversations, she said, so are you going to college? And I said, yeah, I'm going to college. She says, where? And I said, Columbia. And she said, oh, football scholarship, right? So I say that because microaggressions are these little things that people say or do that, and sometimes it comes in the form of a compliment, but it's an underhanded compliment where it's actually an offense and it's based on, you know, whether it be gender, race, or some other factor, and it's subtle, right? But in that instance, I'm giving that example because I didn't do anything. So for me, I choose when to fight a battle. So I'm like, this is just an attendant. I want my driver's license. I'll never see her again. I'm going to go, right? So when it's something where, yes, this can be an ongoing issue, it's in the workplace, or something where I'm connected to it, that's when I'll address it. Because you can go crazy. Like if every little thing, you react to it, you actually could end up being stressed out. So you have to decide, okay, is this something worth getting into or not? If you don't mind my building that for one second. So I've changed how I introduce myself on the phone to doctor's offices. Like if I call and say, I used to say, hi, this is Dr. Jill Rosenthal. I'm calling to speak to Dr. Doss, whoever, and they would immediately call me Jill. And so I just left out my first name from now on. You know, it's just Dr. Rosenthal. And I don't think that they do that to men. But I don't know, because I've never introduced myself as Dr. Stephen Rosenthal. I don't know. That's right. That's right. So I refer to myself as a old pale male. I'm a white guy. Implicit bias doesn't seem like it should apply to me. Quick back story, those of you who were here at AOC last year may recall my presentation on LGBTQ. I'm a gay man. I spent almost my entire career in the Air Force in the closet, because I had to, because I don't ask, don't tell. And so I learned a lifestyle, just a thought process of just avoiding it. I'd get the microaggressions all the time, but of course I couldn't do anything. But after I left, or late in my Air Force career, I was able to come out. I got married to a wonderful man, and after the Air Force, I moved to Nebraska. Nebraska tends to be a little bit politically conservative, which is fine. I would do a lot of DOT exams, and the drivers that I did were not long haul drivers. They were local farmers. They would drive once a year, but they had to have the DOT. So I would see them year after year. And they would say things about, what's your wife do? They would constantly use the word wife. And I didn't correct them, because I've kind of calculated, kind of like you just said, I kind of calculated the situation and said, it's not worth the battle at this point. But there's always that little sharp barb that goes into your brain that's like, why can't you say that? One of the benefits that our hospital there gave us was a discounted membership to the local YMCA. And it was a family discount, so I went in and did the paperwork, and I said, name. I think the form said spouse, but anybody I spoke to, I was using the word husband. If I was presenting it, I would use the word husband. And one of the staff there who knew very well that we were married, because she was a senior staff and they had fought the gay issue a few years earlier, would never call us husbands. She would see us at Walmart and say, hey, how's your partner? And it's, again, that same thing where there was just that lack of embracing who we really are, because we do use the term husbands. We are both male partners in a marriage, and so we're husbands. So it's easy for me to miss a lot of bias that race and gender experiences, but it's still there as a gay person, those little bits and pieces that happen. Thank you for sharing that. I kind of follow up on the circumstance of the microaggression, as the three of you have described it. I imagine in some capacity at some point, in lieu of dealing with it in a veiled way as a measure of protecting yourself and maintaining respect that you receive, I'm curious about what tactic, if you have done this, had you taken to help inform an individual who may have displayed this type of behavior? And also something to think about in the response is, how is it that you overcome a feedback from that individual, whereas they may express, well, that was not my intention? And so they're unwilling to receive the feedback that their words may have affected you in a certain way. Well, I could go back to college when I was asked by, and I went to Duke University. I feel like pretty well-educated high school students should be coming in to Duke, and this young lady asked me where my horns were, since I'm Jewish. That was one where I got to inform her that Jews do not have horns, and if my hair was puffy it was just because I don't know how to do my hair. Another would be when, so that was informing her in how offensive that was, but also it was just ignorance. It was just ignorance and recognizing her ignorance. So another female and a male and I were giving a talk to a bunch of insurance agents. I work, I'm chief medical officer of an insurance company, and the other lady was nervous. She was very nervous to speak, and somebody who was pretty high up in the company, not with the company anymore, said, don't worry. They're just wondering what it's like to, and then said, F you. And we were like, what? I'm sorry. We have a lot of really important information to share. We've spent a lot of time researching this. This is data driven, and he's like, oh yeah, they just want to think about having sex with you. And I was completely taken aback. I did go to HR in that one. I went to our CEO and complained, and spent a lot of time in HR trying to work on some educational opportunities for lots of people based on this one person's disgusting comment. Yeah, I mean, it depends on the scenario. So sometimes I'll use wit and humor. So one would be, oh wow, you're smart for a black guy. My response is, well, you don't know many black guys because I'm one of the dumb ones. Because it diffuses the situation, but it points out how silly the person's comment was at the same time. But again, you have to judge the situation. So let's say it's a CEO of the company you work for. You now want to tread lightly. Because a lot of CEOs, they have an ego. People in leadership often do. So they may not take it the right way. So you have to really judge the situation and how you respond. And you have to say, well, is it really worth it to get into this particular battle? And does it actually affect me, this person's ignorance? Do they have an impact on my life or anything? Let's say it's a coworker that you don't really work closely with, and they make a comment. You could address it. And you could just seriously say, look, that was offensive to me, and explain why. But don't do it when you're angry. The one thing I've learned is when you're angry, you're not thinking clearly. And sometimes certain things come out of your mouth that you can't go back. And you learn this when you're married. You learn that. I probably shouldn't say that right now, so I won't. But I'm thinking it. So yeah, it's kind of like that, where a lot of times people, again, this is implicit bias. So they're not aware. They're not even aware that it was offensive. You know, I wasn't trying to, you know. But when you point it out, a lot of times they'll now understand. Let me take a second. And just to piggyback a little bit on that, and my background, I'm standing in for Dr. Defoe, who's done a lot of grassroots organizing to protect physicians' rights and patient safety. And I'm an attorney and also a physician. And figuring out how to respond to these types of situations can be really challenging. Because as you noted in your example of a CEO, as physicians, we often find ourselves in vulnerable positions. Because when you're a medical student or resident, if you speak up, you may lose the opportunity to train. And some of these things in medicine, it's very different than other fields, because you may not be able to get back on a training pathway. And even when you're a physician, what really scares me, and where I have people calling and asking for legal advice, is the fact that, well, if you speak up, well, in today's day and age, if you're fired from a hospital or medical group, it might be reported to the National Practitioner's Database. You may not be able to continue to work or get other jobs. So it's really a scary world to live in. And every situation is unique in determining how to respond to things. But I really think it's just unfortunate that, as physicians, we've got that extra layer of worry that we have going on. And I just wish it wasn't so, and I wish there were better solutions. In the practice of medicine, and as we're cultivating our craft and understanding how certain demographic and genetic factors may influence disease, perhaps, it's been my experience that, oftentimes, certain communities are thought of having certain diseases at incidence greater or disproportionate to other populations. And so those statistics, in a way, become the horse, the common animal. It's not the zebra. And so, in many ways, I've witnessed where that seemingly objective information tends to shape, perhaps, our differential diagnoses. It tends to shape, perhaps, where we place the responsibility for the health outcome. And it may also shape on what clinical advice and education and guidance we give to these patients. And so I'm curious, in your training experiences, whether in med school or in residency or in practice, if you have ever caught yourself internally into a situation where you thought, I need to slow down because I need to look at the bigger picture and not focus, perhaps, on an intended bias. or where you may have witnessed this by another colleague. So I think I have done a disservice to my own gender when I was in clinical practice because I think there were times when some women would come in and I'm like, oh my gosh, they're just whining and complaining about this and that's so wrong, right? Like that's just so wrong. But I did, I did that, right? I fell party to the whole, they're just complaining they don't really have something significantly or meaningfully wrong, but that's not necessarily the case, of course. So when I was younger in practice, I definitely did that, which is shameful. And I think an issue would be compliance, you know, where you see patients who aren't taking the medication, aren't doing well, but they come in and they complain of the same symptoms. But, you know, over time you learn that, okay, you should dig a little deeper, right? Sometimes the circumstances, the certain scenarios or issues they're facing, and it's really not that they don't wanna be compliant, right? It's certain circumstances beyond their control. And this is where individualization comes into play. So a lot of the problems with bias is generalization, where you're, and that's why I have the issue with the people of color and, because it takes away the opportunity to now tailor and fully understand what that individual is going through versus the group. So I think a way you tackle this is always step back and say, okay, this is a person and an individual, not just like a white person or a black person, it's a person who has a story and a history. And you try to avoid the judgment because sometimes as physicians and as healthcare providers, because we understand the importance of compliance, like in our own life, we naturally do it. So it comes easy to us to be compliant and to follow medical recommendations, but you then have to step back and say, okay, if I wasn't trained and I didn't know better, would I also not be compliant? And then you have to ask yourself, well, what am I doing or what could I do better in order to motivate this person to be compliant? So I think a lot of times, if you shift the focus from the person is the problem to maybe I could do something to be the solution, then you could kind of work through it that way. No? So since Roald declared this a safe space, I was raised by, well, not raised by, but my grandparents lived in Texas and I was raised around them enough. The N-word was very free. It was their nature to refer to black people by the N-word. And so that kind of bears into you as a young person. I don't use that word now, but I still recognize that that's in the back of my brain. My grandmother, she would divide Mexicans into Mexicans and dirty Mexicans, and just those kinds of things. And then I go into training in Fort Worth, Texas, in John Peter Smith, which is an inner city type hospital. And the predominance of your patients in that kind of hospital is the socioeconomically deprived. Well, guess what? They tend to be black because that's what our socioeconomic system does. And so I have to make sure, I would find myself having to consciously say that what my grandparents taught me is not applied. As you just said, John, I have to remember this as a person. Gender may be important to their medical condition. Their color of their skin or their cultural background is not really. It's just something I've had to constantly work on because of that background that came from my childhood. Very good. I'm gonna pivot a little bit. And so this may be something that many of us can relate to. And I think what I'm about to say has always been interdigitated within our practice and how we provide services to individuals who are seeking such. But I think the politics surrounding COVID certainly had an impact on how our patients were willing to receive their care, willing to be educated potentially, or even accept the fact that their ailment was indeed COVID. And some patients, very few, I would say, have very strong convictions about the circumstances surrounding what was their current health situation. But that's not exclusively left to COVID as well. That this applies in a variety of conditions expressed by a variety of individuals who have their own personal beliefs which stem for whatever reason. So my question specifically is in a circumstance where misinformation and dearth of evidence really has compelled an individual towards one way of thinking, how have you been able to overcome that while still being able to provide care and overcome that while providing care to a patient? And has that influenced how you've provided care to that patient? Yeah, and I'll address COVID specifically and the vaccine. So as a black person in America, you're used to never being first, right? So I think a big mistake when people tried to roll out the vaccine was saying, we're gonna give it to black people first. We're gonna give it to the underserved. So people didn't trust that, right? If this vaccine is so good, they're gonna give it to white people first, right? That's how it goes in America, right? And that's just, and I was thinking the same thing too. I was like, what's going on? We're never first, something's up. So I think with these things when, you know, it could be misinformation, you have to acknowledge the validity of the person's concern, right? Because yes, historically in America, we've been experimented on. Historically, we're never first, right? So you have to kind of dig into that and explain, right, and give people, right? And again, this is not just about the vaccine. Like I have my own views about the vaccine, but it's to anything. So if you're trying to overcome someone's belief, yeah, it's the anchoring bias, right? And again, with confirmation bias, you know, certain things you say might confirm it. And confirmation bias for a lot of black people was, yeah, see, they wanna give us the vaccine first because that's part of the experiment, right? So, you know, I think acknowledging people's experience and their reality and the history. And I go back to the example of that, the person on the cruise ship, right? Who made assumptions, made statements. And I was thinking that that cruise line, right, had they trained their workers to do that, to say, you know, if you have customers that may be black American, these are some things that you don't say and teach them history, right? Teach the history of what they go through and why. And so as you apply that to healthcare, you know, if you're serving a population, it's important to understand their history as to why, because of that history, they formulated certain beliefs that may make them resistant to what you're trying to offer them. Did you wanna comment on that? So in my role at the insurance company and trying to educate our own employees, I'm involved in our group health plan as well. I just would echo what you said, which is to listen to the people's concerns, right? I think we all do this. You don't necessarily have to agree with it, but you have to listen to the concerns and then consider what fallacy might exist, what ignorance might exist, where can I make an impact, where can I teach, educate, saying on top of the literature, evaluating the literature to make sure that it's accurate and done well, but to just educate with empathy. You have me thinking about your line of work in particular. And so in part, you're receiving health information and making administrative decisions about, in some cases, access to care, equipment, et cetera. Perhaps the validity of claims being brought forward. And I'm curious if you have any experience with language that is used within the electronic health record in a medical encounter about a patient and how that language may have influenced a medical opine, not necessarily yours. I'm wondering if you can address an example of that in any capacity and perhaps how that may have been dealt with or how that may have impacted your response in the practice. Well, I'm sure that we've seen a lot of that in terms of like some of the examples you gave in your earlier talk with the quotes of, you know, the patient failed this treatment or they claim that their pain is 10 out of 10. I mean, that happens all the time. There's mention of race, but I'd like to think that we do, and I can't speak for any other company, but is go to the facts of the case. You know, 65-year-old person with this complaint issue. These are the symptoms, these physical exam findings. Now, we look at, our team of physicians and nurses look at all of the data and put it together in our own heads to say, does this make sense? Do they have the right diagnosis? Do we have the right doctors? Do we have access to care? Now, access to care in comp is often state dictated, right? Like geo-access in California is very specific. In Florida, it's not as specific as California, but I mean, you want to have access to physicians wherever you write business in comp. But I'd like to think that on our side of it, that, and I think we promote this, and Rupa, correct me, please, please. I think this is a safe space, but that we look at the individual patients and identify the diagnosis, potentially the root cause, and then the treatment option should be the same no matter the patient, right? It's about the condition and getting them back to their communities, their work, all of that. I do know that one of the, probably the places that we could do better is around obesity, especially with like work-related knee issues or ankle issues or low back, and really paying attention to the work that they're doing and not just saying, well, but they're obese. And so of course they have knee pain and they, of course they, like that would probably be something that we can do better. So we've spent some time talking about, you know, experiences with the physician, the physician-patient relationship, provider-patient relationship. And what we really haven't talked about yet is the professional to professional engagement. And specifically, it could be individuals who are your peers, your clinical peers. These could be individuals who are your department chiefs or your directors or your chief medical officer, or an individual of authority over your program or your clinic. And so I'm curious about any experiences you may have had with a peer in this space. And how did you overcome? And in overcoming, what was your reaction and how may have that changed as the situation evolved? So there have been a few instances at work where someone will say, I'll deal with this, you just sit there and look pretty, which is not great. There, I remember, I am in menopause, we're gonna normalize that word, by the way. And so I am often taking my sweater off, my sweater on, off, on. And somebody with whom I work very closely, he turned to me, he said, I'll give you 100 bucks if you keep going. And I was taking off my sweater in a meeting. Again, I was speechless at the time and then I told him later how I was offended by it. But did I tell somebody who was two levels above me who had said that you just sit there and look pretty comment? I did not, I didn't. I didn't feel safe to. But also at work, I have the extreme honor of working with Rupali Das, who started the Jedi Committee at WOMA, which inspired me to do an action item at AECOM to create the Jedi Committee, which we are now about to enter our second year and Dr. Clark is taking over as chair. So that's a great thing to come out of work and my peers. Yeah, so I mean, yeah, I don't really have a situation but I'll share something, a colleague. So this was a black female physician and the challenge that she was having was that the staff would call her by her first name, right? And this was in a health clinic where it serves students as it was a university setting. And she said, even the students would call her by her first name, right? And she would notice the staff would refer to the other physicians, you know, by that little doctor, you know, in the last name. So when I spoke to her, I said, look, and this goes back to what I talked about with prototype bias. I said, wear your white lab coat. And I said, once you do that, there'll be no questions about who you are. People won't ask and they'll likely stop referring to you by your first name. And she did that and it worked, right? So, and again, I've had situations, you know, I've even gone to HR in certain scenarios, right? And when it was critical, when it's something, you know, I had a situation where the administrator, you know, was taking things away from my department and I felt there was a racial undertone to that. So I went to HR to address it, right? So you have to know which battles to pick and how to do it. Because going to HR is a big deal because now, right, when all the dust settles, you still have to work with that person and you might become a problem for HR where they view you as someone who complains you're a troublemaker, right? So sometimes going to HR can work against you, right? And especially, you know, I've seen people, I know someone who she actually made a claim with the EEOC, right? And I told her before she did it, I said, look, you know, tread lightly because, you know, in talking with EEOC people, what they say is what organizations do is if you lodge a complaint, risk management comes in and their goal is to preserve the organization. And guess who they have you talking to, right? When you go talk and file those complaints as risk management, but they care about preserving the organization. And they know if they make a finding that you actually have a claim, it results in your organization getting a suit. So EEOC, when I've talked to folks that work, they say unless you have a recording or you have witnesses that are willing to come forward, which, you know, people don't come forward, right? They'll, you know, hype you up, but then they're not coming forward. What happens is, you know, you may put your claim in, but then the organization starts to try to find legitimate reasons to terminate you. So you start getting bad evaluations. They start picking, you know, and I say, if you lodge a complaint, you better cross the T's and dot the I's, but start looking for another job because when the dust settles, you're a troublemaker, right? And those cases become public record. So you might get blacklisted where you can't even get another job because who wants to hire a troublemaker? And even that term blacklisted, right? That's biased language, right? Like white lie, right? Good lie is white, black, you know, but that's a whole other discussion. But yeah, it's a real challenge for folks who are going through these things because you can't fight the machine, right, and they find a lot of ways. No one's a perfect worker, so they always can find things to put into your evaluation, and a lot of times it boils down to subjective things, right, where if you're a really good worker, you know, a good clinician, and technically, right, they'll start finding personality things. They don't get along. You know, there's conflicts. They don't have good, you know, emotional intelligence, and the soft skills is what they'll use, right, especially if, yes, you're perceived as a troublemaker. So what I would say is if anyone's in situations like that, you know, I would start looking for another job before you take on, you know, take on an organization. And, you know, one story that I was asked to share from someone in just as far as, you know, just peer to peer, there was a female physician that was hired to be a medical director for a larger organization, and, you know, once they got there, they were basically not treated as a supervisor because they were female. And even though they had that title, they had that position, they were treated just as rank and file. And when they brought that up to the leadership of that medical organization, the response was to, as you noted, to kind of turn it around and say, well, we were actually concerned about the fact that your clinic's not busy enough, even though they had no control over who was coming to the clinic and booking it. And the end result was they put them on a performance plan for their clinic not being busy enough, and then let them go, even though other clinics have the same exact volume in that organization. And it's just, you know, it's unfortunate. And just having to strategically plan how you come forward and how you do things. And if it may be that you need to, you know, head out and go somewhere else to prevent further problems. And it's just trying to be strategic. And I always think it's important to talk to your peers. Don't make a plan and go forward until you've kind of analyzed the entire situation. Talk to your colleagues. There's always mentors out there. And I just think that's just so critical because you don't want those missteps because, you know, as noted, it's really unfortunate with the internet these days. If somebody makes a complaint or files a lawsuit, and then all of a sudden that can follow them when people Google them, even if they're in the right. And that's what really gets to me, is you see these kind of horror stories where someone came forward and made a complaint and they were just horribly wronged, but then other employers are scared to take them on even knowing that fact. So, you know, I think it's important to just, you know, talk to your peers and get mentors and find paths forward. I firmly believe there are paths forward, but, you know, it's just a, you know, a minefield sometimes. I really appreciate it. Oh, go ahead. I think someone has a question. Can you guys talk about what's a good technique if I'm an observer of bias? Because I believe that if somebody else says something, that that's probably more effective than the bias-y saying something. And are there any techniques that we could use to do that without creating war? And I'll just restate that question. So the question was, if you are an observer of someone who is demonstrating bias, how do you respond to that as the observer? What is a good technique? So about four or five months ago, Medicine Grand Rounds at Dartmouth, somebody presented on microaggressions. Unfortunately, I could not be there. So I asked Amy Kassing, MIPA, to attend, and I then had her do a abbreviated version to our department. Amy, can you recall any of the techniques for addressing the microaggressions? Sure. Can you go to the other microphone? Thank you. I like to put my staff on the spot. So the presentation was in particular to medical residents that came on and how to interact with patients who had direct bias. And so it was working with the team, whether it was the nurses, the supervising physicians. And if something happened during an evaluation of a patient and the supervising physician noticed something, they pulled the student or the resident out of the room and said to them, this felt uncomfortable to me. I don't know if it feels uncomfortable to you, but can we talk about this? And so they would do a debriefing afterwards. And then it was an offer of, would you like to go back into the room? They made an excuse of, we have to check lab, we'll come back into the room. So they were able to remove from the situation and then offer, would you like to come back into this evaluation? Would you like to take a break? And then if they chose to or not to, when the patient evaluation continued, they would bring that up to the patient. I'm not sure if you know that what you said was offensive. And it was a conversation that was limited to, we are here to take care of your health. If we can proceed with that, we can proceed with your visit. And then afterwards, it was another debrief with the student as far as, or the resident as far as, how did that feel? Are you okay? Is there anything else we can offer to you? Did they talk about if the person who's the superior in the hierarchy though was the aggressor? So if the student is witnessing it or the resident is, how did they advise how they should bring it up to the attending? And what if the patient's the aggressor? Well, that was the main presentation was when it's patient-directed bias against a medical professional. They didn't really get into what happens when it's someone of a superior rank than you in the hospital. But that's a good point, yeah. We've got a hand over here. So I'm sorry to continue. Here, one sec, one sec. Thank you. Hi, I'm part of the, I'm a third-year medical student and I'm part of the team at Dartmouth that's doing the training. So I have a skills card here on allyship. I can read a few examples if that's helpful. So with a patient, something like reframing as the skill. So saying, I'd like to focus on your health needs now or talking with the team member saying, is there another way we can look at this? And reframing is one way. Or some other options are educating and affirm. So we're really fortunate to have X person on our team and they're highly trained medical professional and should be treated with respect. Something like, so there are a lot of different options but depending on what was happening at the time, you could empathize, say I'd love to hear more about your experiences of bias when speaking with the person who was experiencing the harm. You would say, I would love to hear more about your experiences with bias if you feel comfortable sharing them. So there are a few different options as an ally. So you can either speak, kind of pull the other person aside and speak with them or if it's the patient and you need to continue with the visit, there are some ways to kind of redirect. So some examples. Thank you. So along those lines, just a quick survey, how many of the female providers in this room have been referred to as nurse? Yeah, and that's something that men can't relate to because we walk in and we're the doctor. It just still baffles me though and that's one of the microaggressions I remember that was in that course was the patient calling the very experienced female attending the nurse and having to be corrected that women can practice medicine. Well, even if we say doctor, they still think we're nurse. Yeah, so I'm Anna Nobis, I'm medical director at Vanderbilt and my husband is also a physician, so we're both Dr. Nobis and we would go to the childcare center to pick up our kids and they would know that and they would always say, oh, hi, Anna, hi, Dr. Nobis. You know, but what I wanted to say is, yeah, at Vanderbilt, there is now an institutional policy. It was called the refusal to treat policy, I think, but now it's called mutual respect. So it's an institution-wide policy that if a patient makes a racist comment or anything like that, that it's not tolerated. It's if they say, I don't want that provider because she's Hispanic, the supervisors will come and support the provider. The patient is not accommodated unless there is some medical necessity for the accommodation and we have all kinds of training about microaggressions and there has been, there's a lot of papers about being the bystander and so we encourage people, instead of being a bystander, to be an upstander and just like you said, you have to gauge the situation. If the patient obviously is not in the right state of mind or it could potentially turn violent, that may not be the moment, but if it is something that's not quite as acute, yes, you pull the medical student out, the resident out, you debrief and then you do follow up if that's what they want you to do so just a small example. We have, at Vanderbilt, we have medical students from Meharry, which is a historically black medical school and I'm a portfolio coach so I don't get to work with them on the rounds but I get to check in on their progress for the medical students and she's African American and she was on a pediatrics rotation and she introduced herself but she had her Vanderbilt School of Medicine badge so she just said her name and they were like, oh, so are you visiting from Meharry? You know, and so she talked to me about that because she's like, that just makes me feel like an other, like they don't, they can't assume that I'm a Vanderbilt University medical student, you know? So she didn't feel comfortable talking to the attending in that moment because of that power dynamic but we, you know, the medical students have different coaches and mentors and people that they can talk to because they know that the institution feels really strongly about not letting people, not letting their staff and med students get mistreated. So, thank you. Thank you, Dr. Narbis. Got another question, yep. I'm gonna play Oprah, 1980s Oprah. Hello, I'm Dr. Abuaba from Beaufort Naval Hospital. The challenge arises and this was to date myself eons ago when the ones who are supposed to protect the medical students or the residents are the ones that really fear. And so, situations long time ago arose where the professors were not, didn't treat people like me well. And there was an occasion or more than one occasion when I would be the first year resident went in with a medical student who is Caucasian and it was like I was not there. And so, or there would be comments like, you know, you're a very good doctor but you just don't know how to play the game. And I'm like, what game are we talking about? So, these are the kinds of things that, and the state will remain. Well, I could tell you the state, Connecticut, but the university will remain nameless. But the things, the harm that comes from that of othering people, and it is a poet, Virgil, says myself no stranger to misfortune. I have learned to relieve the suffering of others. So, if we think in terms of how we are treated, you know, how we treat people, we have to think carefully about that because it destroys the self-confidence. And the most important thing is to remember that if that self-confidence is destroyed, it can be, it can impact you for a very long time. So, think carefully. Think twice before you speak. Think three times before you act. And if we try to abide by that, we will become the better angels of our natures as physicians and as human beings, you know, in general. Very well said. Thank you, Dr. Aboyama. So. Well, you know what? We had another hand. Do we have a hand? Okay. I just have a very quick comment. I wanted, I was curious, because I'm sure, like, we're all the buyer here, right? Like, we've all experienced probably at some level microaggressions and all this. And as we become more senior and older and maybe we have positions. So, what do you think the role of sponsorship? Because for me, I don't feel like I could have been where I am right now without sponsorship and mentorship. So, what do you see that role and how can you, because, you know, the issue is, like, if you're the only female and, or you're the only minority, you already have so much you're tasked with. So, but then it's still your job to sponsor others. So, how do you see that role of sponsorship for, you know, the future and to make things kind of better, hopefully, over time? Yeah, I mean, it definitely plays a role. So, I went to medical school at Mount Sinai and I remember it was me and four other black males who were in my class. And the senior students, one day, sat us down and said, this is the deal, right? And it helped us. It said, look, you're black. You gotta show up early, leave late, right? You're gonna work extra hard, right? But in the long run, it's gonna help you because the more you work, the better you'll get, right? So, my outlook from that, and they told me, speak up on rotations because if you don't, they're gonna think you're dumb and you don't know anything. That's why you're not talking. They're not gonna assume it's because you're quiet. So, you have to be aggressive, right? So, we were taught, and it does work. Like, I wouldn't have known, right? Those little things. So, that's a great point, but I think it's for us. I don't think the system has any internal design that will make it happen, right? So, it's kind of like us to say, okay, I'm gonna help these younger folks that are coming up. Yeah, when I was in med school during my surgery, I did an orthopedic surgery rotation. I actually thought I wanted to be an orthopedic surgeon, and I'm grateful for this experience that I'm about to share with you because it ultimately allowed me to be in this field that I'm so passionate about. I call myself a Work Comp Achmed nerd, which I am. But I was in the OR with the surgeon, and he had me hand boring the space for the graft for the ACL repair that we were doing. And he literally said, if you were a guy, I would have given you this, and he pulls out an electric drill, and he proceeds to just do it. I was like sweating. And the fact, if it had been any student that he did that to, that would have been okay. But because he said, but if you had been a guy, I would have given you this as if I couldn't handle a drill, right? And so I was angry. I said, I do not want to be treated like this. I looked somewhere else for a different field of medicine to practice in. So I'm grateful for that, but that was a real thing. So what I tell students whom I mentor, sorry, my mom's an English teacher. I had to get the who and whom right, is that stand up for yourself. If you want to be an orthopedic surgeon, don't let that one jerk decide for you what you want to be, what you're going to be, and find a different person to work under perhaps. But don't let events like that necessarily derail you from what your dream is, your passion is within medicine. And also, I've worked with a bunch of mentees. I always learn more from them than I think I share with them. So I encourage everybody to be a mentor. Very good. I do have one question. Did you want to make a statement, comment? I was just going to add a quick follow-up that I think that point to always be mentoring and always be able to help people is just incredibly important because whoever you are, at some stage of your career, you may need help, a helping hand. And things happen for a variety of reasons. It could be discrimination. It could be that there's a health issue in your family and you have to take time off work. Things happen. And I'll just say, I think it's always important to be there as a mentor to others and to help others because you never know what they're going through and helping somebody to get back on track with their careers, particularly in medicine, which can be very challenging because if you detour a little bit, it's just exceptionally hard for us to get back into things. So I think that's just very important to just always be mentoring, always be helping. And it really helps yourself because you're building your network, your friend group. So I just think that's really important. One more question. I think one other thing we always have to do when we talk about this is to acknowledge how far we have come. From my medical school class that had two women, no African-Americans, no Asians, to where we are now. I think we sometimes lose track of the fact that we are accomplishing something and that we have a lot still to do, but let's not say, oh my God, there's been a failure. And so, you know. But we still have, you know, short white women in the. That's okay. I do. That's why we're healed. I do have one final question for the group and I know we're at time. And some of you may not have realized, but ACOM has a Jedi committee. And we also hear sometimes that Jedi, the notion of Jedi, its application, its basis for having recognition of Jedi has in some capacity had a negative connotation. And so what I'd like to know from the group is why does ACOM have a Jedi committee? What is its importance and what is its value to the organization? Yeah, you know, ACOM recognizes that, you know, the work we do as occupational medicine physicians impacts a lot of people because we deal with workforces. You know, a lot of people work. So it's important to recognize that, you know, in the settings we are in, and a lot of us hold leadership positions because of the nature of Ahmed and understanding justice, equity, diversity, inclusion is key to actually achieving success. You know, organizations, a lot of companies, you know, have DEI because they recognize them. You know, this was a big topic when I was in business school that the value of DEI does affect the bottom line. Like companies recognize that if you have a diversity of thought, where you're having people with different perspectives, you actually earn more, right? You make more profit because if you're creating a product or you're creating a customer service experience, and you have customers from a certain demographic, but you don't take into account what appeals to them, you now can lose that demographic. So ACOM, you know, recognizes that it is necessary for us as the providers. We often work for companies to understand because you, believe it or not, if you're not on board with that, right, you may not fit into the company. They may look at you like, okay, you know, DEI is something that we value and throughout the organization. And I think we also recognize that we needed to remove some barriers to access to leadership positions, to committee involvement so that our committees, our leaders, more accurately reflected the diversity of our membership. Can I just say, because of the JEDI committee, Charlie Peckman and Aaron Ransford are the ACOM staff who support the JEDI committee and they do an incredible job keeping us moving forward. So I just wanted to publicly thank them. No, absolutely. And actually that's a great segue. I want to thank each of you for sharing your insights and being willing to be vulnerable and having that courageous discussion and expressing your thoughts and your feelings and your experiences. That's been really helpful. And I think that many of us have been able to glean something valuable here today and have learned something that perhaps we haven't given light to or have recognized. And so well done. Thank you.

bias in medicine

implicit bias

microaggressions

gender bias

racial bias

speaking up against bias

diversity and equity

sponsorship in diversity

Jedi committees

addressing bias in medicine