Medical Schools as Racialized Organizations: A Roundtable Discussion with Dr. Marcella Nunez-Smith, MD, MPH, Dr. Victor Ray, and Max Jordan Nguemeni Tiako

December 16, 2020

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December 15, 2020

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00:00So welcome everybody,
00:01my name is Anna Reisman and I am
00:04the director of the Program for
00:07Humanities Medicine here at Yale School
00:10of Medicine and I'm professor of
00:13Internal Medicine and our topic today.
00:15As you know, is medical schools
00:18as racialized organizations,
00:19and tonight's roundtable features three
00:21amazing people who all bring really
00:24interesting perspectives to this concept.
00:26And I'm going to introduce the Speaker,
00:29so Doctor Victor Ray is our first.
00:33Panelist, he is joining us from Iowa where
00:36he is assistant professor of sociology,
00:39criminology and African American Studies.
00:41His research applies critical race theory
00:43to classic sociological questions,
00:45and he's currently working on
00:47two book manuscripts.
00:48One is a project focused on race,
00:51an organizational theory and an edited volume
00:53on race and social sociological theory.
00:56His work has been published widely,
00:58including in journals such as the
01:00American Sociological Review,
01:01American Behavioral Scientist,
01:02The Journal of Marriage and Family and many,
01:05many others.
01:06In addition to this research,
01:08he is also an active public
01:10scholar publishing in places
01:12such as the Washington Post.
01:14Harvard Business Review in Boston
01:16Review and his work has been
01:18funded by the Ford Foundation,
01:20the National Science Foundation,
01:22among others.
01:24Second,
01:24I'm thrilled that Doctor Marcella Nunez
01:26Smith is joining us tonight from New Haven.
01:29She is many things,
01:31including the associate Dean of HealthEquity
01:34Research at the Yale School of Medicine,
01:36Associate Professor of Medicine,
01:38public health and management,
01:39and director of the equity
01:41Research and Innovation Center,
01:43also called Eric in the office
01:46for HealthEquity Research.
01:47As many of you know from recent news,
01:50she is serving as Co chair on the Biden
01:52Harris transition COVID-19 Advisory
01:54Board and will serve as the chair
01:56of the COVID-19 Equity Task Force,
01:58and it gives me like this swell
02:00of pride to say that which I did.
02:03So she holds many other leadership
02:05positions here at Yell.
02:06I'll just mention a few associate
02:08director for Community outreach and
02:10engagement at the Old Cancer Center.
02:11Chief HealthEquity officer at Smilow
02:13Cancer Hospital core faculty in
02:15the National Clinician Scholars
02:16Program and director of the Pose in.
02:18Commonwealth Fund Fellowship
02:19in HealthEquity leadership.
02:21Her research focuses on promoting
02:22health and healthcare equity for
02:24structurally marginalized populations
02:25with an emphasis on supporting health care,
02:28workforce,
02:28diversity and development.
02:30Developing patient reported
02:31measurements of health care quality,
02:33and identifying regional strategies
02:34to reduce the global burden
02:36of non communicable diseases.
02:37She is also had a major role
02:40in the medical school and has
02:42advised and mentored many,
02:44many students and other trainees
02:46and this one quite a few, several.
02:49Has won several teaching awards.
02:52So welcome marcella.
02:53And finally,
02:53I'm very glad to introduce Max
02:56Jordan and Caminiti Acco who is in
02:58his final year or final less than a
03:01year of medical school here at Yale
03:03who joins us from New Haven as well.
03:06Over the last few years Max has
03:08written on racism in medical education
03:10in a variety of national and local
03:13outlets, including the Washington
03:14Post and Inside Higher Ed.
03:16He hosts a podcast called Flip The Script,
03:19which focuses on health in equities,
03:21and Max was recently named as a Forbes 2021.
03:2430 Under 30 awardee.
03:27I just want to add I'm very grateful
03:29to Max for proposing this topic,
03:31which is something he thought about himself
03:33and written about and given a number
03:35of talks on as well an for suggesting
03:37inviting victory and Marcella Mia Smith.
03:40Max has been an eager humanities
03:41and medicine participant and
03:42contributor over the years.
03:44He's been here at the Med school.
03:46He's brought a lot to the program and
03:48I'm grateful to have this opportunity to
03:50invite him to moderate this discussion,
03:52which will go until about 6:00
03:54and around six.
03:55I'll come back in and will moderate the Q&A.
03:57And we welcome your questions to any
03:59or all of our three participants.
04:01So thank you all for being here tonight
04:03and I'll turn things over to Max.
04:06Thanks Doctor easement for having
04:07us just to clarify, will go
04:09until seven at 6 or 7 right now.
04:13Well, thank you all so much for
04:15joining us with this conversation.
04:17I am really thrilled to be in conversation
04:20with Doctor Ray and Doctor Neil Smith.
04:22I met Doctor Ray on Twitter just because
04:25he posts about super exciting work
04:27that has been doing about racism and
04:30Doctor Nina Smith has been my academic
04:32advisor in medical school for the last.
04:34You know, 4 1/2 years.
04:36At this point I just want to put it out
04:39there before we get started that, you know.
04:42The theory of racialized organization
04:44is applicable to many different
04:46aspects of organizations.
04:47But for tonight's conversation
04:48we're going to specifically talk
04:50about medical education, right?
04:52So this is applicable to
04:54have the hospital works.
04:55How medical school works,
04:57even how medical schools might
04:58treat staff who are not Chinese.
05:00But we're going to focus on
05:04medical education tonight.
05:05And so in together started,
05:07I'm going to ask a few questions
05:10to our panelists.
05:11So Doctor, Ray, what does this mean?
05:14Racialize organization?
05:16Especially for people who
05:18are not sociologists.
05:21OK, when I say organizations are racialized,
05:24I mean that they typically distribute
05:27resources along racial lines in ways
05:30that enhanced the agency of dominant
05:32racial groups and sort of lessen the
05:35agency of subordinate racial groups.
05:37So I think that a lot of research
05:39looks at organizations is race
05:42neutral until proven otherwise?
05:44And I actually think we should
05:47invert that thinking right?
05:48We should go into research.
05:50Assuming that schools,
05:52workplaces, churches,
05:53medical schools are either
05:55implicitly or explicitly using
05:57racial criteria to make decisions,
05:59and so I think I think this is
06:02a more honest way of looking at
06:06organizations throughout US history.
06:08But I also think that if
06:11you look at organizations,
06:13most organizations remain highly
06:15segregated both between organizations
06:17or also within organizations as
06:20one moves up and down hierarchies.
06:22If you look at the job distribution
06:25within a lot of organizations,
06:28people of color remained sort
06:30of clustered near the bottom.
06:32Broadly speaking,
06:33black and Latino people are
06:35less likely to be hired.
06:37They move up through the workplaces more
06:40slowly than equally qualified white folks.
06:43So in the paper outlining my theory,
06:46I argue that organizations do this
06:48through a number of mechanisms.
06:50One thing that organizations do.
06:53Is there help make legitimate the kinds
06:55of inequality's and distributions
06:57of resources that they facilitate?
07:00I think I argue that whiteness is
07:03an unstated credential in a lot of
07:06organizations that both eases passage
07:08into the organization through hiring
07:10or getting admitted to school,
07:13and also eases ones movement up
07:15the hierarchy of an organization.
07:18I argue that organizations often Di
07:20couple sort of formal commitments
07:23to equality and diversity.
07:25From actual practice,
07:26and so I think that I say all this
07:29to argue that when people talk
07:31about structural racism,
07:32one of the things that I think they're
07:35talking about his organizations,
07:36and that we should think of organizations,
07:39is a kind of racial structure.
07:41And by that I mean that sort
07:44of cultural ideas about race.
07:47Like who?
07:47Who we expect the ferns from who we
07:51should defer to in an organization.
07:54Are are connected to social and
07:57material resources through the kinds
07:59of procedures organizations carry out.
08:04Thank you for that explanation.
08:06Doctor Nina Smith.
08:07When you hear that phrase medical
08:09schools as racialized organisations,
08:11what does that mean to you?
08:16Well, first let me say you know,
08:19thank you so much Max an Anna into
08:23the program for putting on this
08:25panel and for inviting me to come.
08:28And it's a great pleasure to meet you,
08:32Victor, if I might,
08:33and I really want to thank you for this
08:37anchoring framework for our conversation,
08:39because, you know, it is.
08:41It is worth that moment of pause to
08:45unpack because so many of these terms.
08:48Have become quite common in our 2020
08:51lexecon where people some newer to concepts.
08:54I mean we have this collective
08:56witnessing this year of the
08:58effects of structural racism,
09:00and I think this intentionality to drill
09:03down on exactly what are we talking about?
09:06How does that operate in organization,
09:09which is, quite frankly how so many of us.
09:14We spend our time right.
09:16Is moving in consciously and unconsciously,
09:18in and out of organizations.
09:20And so this question of thinking as you
09:24lay it out, sort of medical schools.
09:28As racialized organizations you know the.
09:32So you know to bear with me for
09:34a second because, you know,
09:35one of the great interest of mine
09:37academically and personally is
09:39around workforce diversity, right?
09:40And so to even talk to representation,
09:42you alluded to this a little bit in saying,
09:45kind of where the clusters are,
09:47and if you're looking at folks of color,
09:49and so whether we ask a question
09:51of kind of promotion and movement
09:53through academic medicine,
09:54so we think about faculty and
09:56leadership in academic institutions,
09:58we see that phenomenon.
09:59We've seen it for.
10:00All time essentially have sort of the
10:03clustering at entry level positions.
10:06Really minimal,
10:07limited representation,
10:08higher levels of rank and then if we
10:12look at things such as chair or ordenes
10:15for example very limited representation.
10:18But you know this, this history of
10:21of racialized medical education,
10:23at least some of the roots.
10:25I think we would have to trace back to.
10:30This the Flexner report, right?
10:32And sort of the the 1910?
10:36Sort of monograph that ended
10:38up closing essentially right.
10:40This is a very abbreviated version
10:42of what took place,
10:44but ended up closing so many of the
10:47schools that were training physicians
10:49that particularly physicians of color
10:52and schools, are training women.
10:56And so it is not perhaps a
10:58difficult stretch to sort of.
11:00Think of how we're situated now
11:02in terms of medical education.
11:04How do we come to have the
11:06medical schools that we have now?
11:08Really only a remake of small
11:11number of minority serving medical
11:12schools that are open today,
11:14that the contrast from the very
11:16kind of beginning of the last
11:18century set us up for racialized
11:21medical education in it's very sort
11:23of just it's very design.
11:27Absolutely thank you for that explanation.
11:30Dr. A1 of your one of the tenants in
11:32the theory of racialized organizations
11:35is that they grant more or less agency
11:38to a two members based on rates.
11:41Can you explain a little bit how you
11:43know this extension of agency happens?
11:46You know, with a few examples
11:48or or maybe just one.
11:51Oh yeah, sure. I think that this
11:53is an abstract point that I think
11:56has a really clear explanation, so.
11:58If we think about organizations are key
12:02to social mobility and if we think about,
12:06for instance, that the Flexner report
12:08closing schools means that it made
12:11it less likely that black folks and
12:14folks of color more broadly and women
12:16who were interested in the career
12:19could actualize their future right?
12:21So sociologists are like obsessed with
12:24this debate between structure and agency,
12:26and I think with that case
12:28you see really clear example.
12:31Of a social structure of the medical
12:34schools closing and it in it,
12:36in that act,
12:37foreclosing opportunities not just
12:39for the folks who were excluded from
12:42the school and the opportunity to move
12:44up and get the education they wanted.
12:47But we can also think of sort of the
12:49ripple effects of health that had
12:52broadly for historically underrepresented
12:53or underserved communities.
12:55Not having access to health care because
12:58of the people who were trained where.
13:01Likely to go serve those communities right?
13:04And so I think when we think about
13:08segregation and when we think
13:10about actually the concept of race.
13:13Historically,
13:14the concept of race arose to constrain
13:17the agency of nonwhite groups.
13:19And we can think about how organizational
13:22segregation both between organizations
13:24with you know predominantly organizations
13:27that serve predominantly people of color,
13:29typically being under resourced relative
13:32to historically white organizations.
13:34Um and internal segregation were
13:36literally designed to limit the future
13:39chances of people of color, right?
13:41Like the reason segregated schools are
13:44bad is not just that it's separate,
13:47it's that those are.
13:49It's inherently unequal,
13:50meaning that those children are denied,
13:53like access to a full range of human choices.
13:59Yeah, and Doctor Nina Smith
14:01how would you say you know
14:04when you look at medical education?
14:07How would you say that if it is a case
14:10and I think it is that not different
14:13Members or different students from
14:16different groups are granted agency
14:18in sort of differential manners.
14:26Yeah so.
14:31This is good stuff, right?
14:33I mean to sort of take this moment
14:35to pause and think this through,
14:38sort of how we come to be in this place
14:40today where we're having this conversation,
14:43at least here in the panel where we are
14:46walking in with some shared perspective.
14:48Potentially that leads you.
14:50You know Max to say to kind of to conclude
14:54even in the question right in to say hey,
14:57this is where we are in a
14:59place where where other ring.
15:01Is a very real phenomena and at least for me,
15:05sort of personally moving.
15:07As you know, someone who hasn't
15:09identifies as a person of color through
15:12largely white dominant institutions.
15:14In my training, you know,
15:16I am perhaps quick dish to share
15:19a perspective that that says yes,
15:22Agency is not equally distributed
15:24across our students mean.
15:25Even if you stop for a second
15:30and think about.
15:31The the process of of what we
15:34see in ones curriculum right?
15:36I mean,
15:37this is perhaps beyond the extent
15:39of time that we have tonight
15:42and maybe further in the Q&A,
15:44but there is from the very
15:47beginning of medical school.
15:48I think ones recognition,
15:50particularly when one is identify strongly
15:53with the subordinate group right to use
15:56victors language that you are not right.
15:58This is not built for you
16:01this this institution.
16:02Really was not designed for you
16:04right down to the curriculum,
16:07sort of who you see and what is valued
16:10at elevated and how taught and how
16:13disgusting what discourse is like.
16:15Signals very strongly.
16:18It in terms of kind of where who?
16:21Who and for who and for whom,
16:23right?
16:23The institution was was built
16:25and where the power is.
16:30Yeah, absolutely. In my next
16:34question for Doctor Ray,
16:36you know the the second and third
16:38tenants of this theory seemed
16:41pretty self explanatory, right?
16:43That whiteness is a credential and that
16:46resources are distributed in unequal manners,
16:49or again along racial lines.
16:51You know whiteness as a credential
16:54sort of reminds me of this
16:57tenant of critical race theory
16:59called or whiteness as property.
17:02It's a little bit more about,
17:04you know the connection
17:05between between the two.
17:08Yeah, sure, um.
17:10So whiteness as property is afraid
17:12it's a title of a sort of classic
17:16critical race theory piece from Journal,
17:19Harris and Harvard, Harvard Law Review.
17:21I believe it was published in those P.
17:25She argues that white racial identity
17:28was constructed against or sort of
17:31in relation to forms of racialized
17:33exclusion in property from black folks
17:36and Native Americans, right? So?
17:38The expropriation of Native American lands,
17:41the continual breaking of contracts
17:42in the form of treaties with Native
17:45Americans that allowed the theft of
17:47that land and the literal property of
17:50black folks who were enslaved right?
17:52And that one of the things that
17:55was enshrined in US law,
17:56was white folks being sort
17:58of exempt from that.
18:00So she ties this to classical
18:02notions of property being,
18:04you know, all of a persons rights.
18:06What people what is alienable to a person?
18:10And I draw on this to make
18:122 points about credentials,
18:14which is like sort of a key idea
18:17in organizational theory about
18:19what is illegitimate means for
18:21moving folks up hierarchies,
18:23getting into school,
18:24and one of them is that many of
18:26the so-called like race neutral
18:28organizational procedures that we
18:30have for getting into medical school,
18:33getting into Graduate School essay Tees,
18:35GRA these EM Cats.
18:36They are actually sort of like
18:39encoded in those measures.
18:41Is a history of racialized
18:43exclusion racialized segregation
18:44racialized access to resources.
18:45So when we look at those measures
18:48and people are like it's an
18:50objective measure of outcome,
18:52I look at that measure and say actually,
18:55it's a measure of cumulative advantages
18:58that have historically been racialized
19:00and are captured partially in that measure,
19:03right?
19:03So organizations have adopted these
19:05so-called neutral measures that
19:07kind of launder racial domination
19:09or the history of domination.
19:11That's embedded in those measures.
19:13Second,
19:13there's a whole history of field
19:16experiments in the social science,
19:18and actually some in the Medical
19:20Sciences that in these field
19:22experiments send equally matched,
19:24like black folks and white folks out
19:27to do things like apply for jobs,
19:30apply for housing,
19:31trying rented apartment try
19:33and try and buy cars,
19:35and what these experiments often find,
19:37even if they say, for instance,
19:40user racialized name.
19:41In match everything else on the
19:43resume is that race tends to Trump
19:46the formal credentials right?
19:48And so that's why I say that actually
19:51whiteness is often kind of a hidden,
19:53unspoken credential that helps folks
19:55get into organizations and move.
19:57But once there, in.
20:02That's heavy. And so Doctor Nina Smith,
20:07in the context of medical education,
20:09again right beyond the sort of
20:12signals that you described earlier.
20:14That sort of, you know,
20:16send a message to minority
20:19minoritized medical students
20:20that they might not you know,
20:23belong as part of either the organisations
20:26or the sort of system of training.
20:29How else my whiteness grant sort
20:32of an edge to two trainees.
20:35The progress through medical
20:36education compared to their
20:37minoritized counterparts in water.
20:39Some long term repercussions.
20:40You can think of an I know
20:42you started earlier.
20:43You know,
20:44sort of thinking about talking
20:46about like promotion,
20:47but you know if you could expand.
20:50No, I'm sorry. I'm really grateful for
20:52you to bring up for the audit study
20:55designed to come into play here, right?
20:57Because there's so many insights
20:58that we have from that right?
21:00This exact idea of the side-by-side
21:02resume or CV and you, you know,
21:04sort of change a name and kind of who
21:06moves forward and we over and over and
21:09over have done various versions of audit
21:11studies in medical education, right?
21:13Trying to understand kind of who gets in.
21:16We have this.
21:17This is an evidence base.
21:18I think that's really important
21:20for listeners to know.
21:21That even as we talk here today,
21:24we're not really speculating that
21:25there isn't evidence based already.
21:27That shows that within medical
21:29education within medical school,
21:30when you do these experiments as they were,
21:33we will.
21:34We will see the patterns
21:35of bias persistent exist.
21:37So whether we're looking at entry
21:39as we were talking about or you
21:41know things like advancement.
21:43So, so within academic medicine,
21:45let me drill down.
21:46On one example there where so much of,
21:49let's say, once you know progression,
21:51progress through has to do with
21:54things like mentoring and we see
21:56that when you do the same audit
21:58study in terms of people doing
22:01outreach to get mentoring for their
22:03scholarship for their professional
22:04development and advancement,
22:05we find the same phenomenon right that
22:08the side-by-side identical sort of CV
22:11this tracks for for gender for rates for.
22:13Lots of things,
22:14right?
22:14You changed,
22:15you changed the sort of identity variable
22:18and then suddenly people are are not
22:20interested in mentoring or sort of pull back.
22:22And so we sort of just replicate
22:25over and over again.
22:26Seeing this, we we see the patterns
22:28in terms of awards and recognitions.
22:31This is not something that is unique.
22:33No one medical school can
22:35really claim ownership of this.
22:36This is pervasive, right?
22:38And so whether we're talking
22:39about school level awards,
22:41we're talking about things like promotion.
22:43That which you know,
22:44tie into progression.
22:46So earlier on we were talking
22:48with the clustering sort of.
22:49Where do people cluster in an organization
22:52and you know all of this is wrapped
22:55up and I am so grateful for this.
22:57For this interrogation of objectivity,
22:59which is really plagued,
23:00us right quite severely when we
23:03start saying we need to be blind,
23:05we should blind things.
23:06We should only look at GPA here.
23:09We should only look at scores right?
23:11And this becomes an issue.
23:13So whether it's about NIH award receipt,
23:15which we've seen.
23:16Differences there,
23:17which again have to do with how
23:19we've racialized scientific value
23:20right in terms of scholarship.
23:22Primarily So what is important
23:24to study what's not right?
23:25These kind of value that then get re
23:28ified in the way that we score grants?
23:30And then who gets grants and who doesn't.
23:33But if you don't get a grant you
23:35don't promote if you don't promote,
23:37you can't be.
23:38You know in leadership positions in in
23:41a medical school so.
23:42It is so these are.
23:44This is the conversation
23:45about structures right?
23:46And how you know,
23:48kind of who who is in a
23:50position to benefit and who
23:52is at a disadvantage from the
23:54sort of the status quo of some
23:57of these structures which
23:58really reflect inherent value.
24:03Doctor Abe when organisations engage
24:05an sort of like PR campaigns right
24:07about as passing certain values.
24:09You know I'm going to use
24:11the NFL as an example.
24:13During this summer.
24:14All of a sudden they were down with
24:17Black Lives Matter and yet right there
24:20on the play by a different set of rules.
24:23You know, within, you know,
24:25within their sort of like everyday practices.
24:29People call that decoupling and
24:30one of the tenets of the theory is
24:33basically this sort of like decoupling
24:34of rules in a racialized manner.
24:37I could use it a little bit more about that.
24:40Yeah, sure, so the coupling is,
24:43you know, an idea in sociology and
24:45organizational theory about sort of
24:47the gap between an organization.
24:49Stated commitments to things
24:50like diversity or inclusivity,
24:52and then what happens in actual practice,
24:54and so, like a lot of times
24:57this is talked about as.
25:00Is it Kering because their external
25:02constituency who pushes on an
25:04organization but with that but with
25:06that external constituency is asking
25:08for is oftentimes like at odds with
25:10the organizations core functions right?
25:12And so like if you think about the
25:14NFL in your example of the NFL is
25:17not a racial justice organization.
25:19They are sporting organization to
25:21bind like design to like commodify
25:23peoples bodies and make as much
25:25money off of that as they can write.
25:28And so when there's this gap.
25:30They often have this sort of like PR,
25:33you know. Are all. We believe in diversity.
25:37Black Lives Matter,
25:38and then when you look at sort
25:41of the daily practices,
25:42those things don't really happen.
25:44I think a lot of organizations
25:47like medical schools,
25:48colleges,
25:48corporations think diversity policy
25:50is a great example of this.
25:52So we've had diversity policies
25:54in place since I sort of think
25:57I'm pronouncing this right.
25:58The Bakke decision in like 1978
26:01and they have done very little
26:04overall to alter the sort of.
26:06Overall,
26:07distribution of racialized
26:08power in organizations.
26:09In all that time,
26:11although many corporations have adopted them,
26:13and I think another example of this
26:16is my colleagues allenberry Robert
26:18Nelson and Laura Beth Nielsen have
26:21this book on sort of racing align
26:24anti discrimination policy and they
26:26show that folks who have claims of
26:29racial discrimination in organizations
26:31who actually like follow the rules
26:33and go to PR actually end up.
26:36They claim the folks who do this
26:38claim in worse position than if
26:41they have never reported it.
26:42So the very mechanisms designed
26:44to supposedly help folks end up
26:46stigmatising them and hurting them right?
26:48And so making the discrimination
26:50worse than if they didn't report it or
26:53left the organization in the 1st place.
26:55I could. I'll leave it there.
26:57I could talk more about this, but yeah.
27:01Yeah totally doctor Nina Smith and I
27:04think Doctor Ray you could probably
27:06you can relate to this as well.
27:08I think I feel like every every
27:10black person has been told before.
27:13You have to be twice as good to have it.
27:16You know to have half as much or something
27:19along those lines and I think typically
27:22that you know it applies to the sort of
27:25like the rules that we have to play by.
27:28And there's sort of this
27:30parallelism right between rules.
27:31We are, we expect or expectations
27:33would put up on ourselves because
27:36of the environment that we're
27:38navigating and and sort of.
27:40Just supposing that 2D coupling makes it.
27:43It really helps us understand
27:45why we quote unquote,
27:46have to be twice as good and so Doctor
27:48Nina Smith like Asier, Advisee.
27:50I've come to you and been like
27:52I've been told I have to play
27:55by a different set of rules.
27:57And like a come to complain because
27:59I felt like rules were applied to
28:01me in the different in a different
28:04manner and I'm just curious, you know,
28:07as a mentor, as someone who is navigated,
28:10you know academia through,
28:11you know several ranks. How do you?
28:13How do you help Chinese right?
28:16Like navigate this this reality of
28:18just the rules not always being
28:20applied the same way.
28:24So, um.
28:27Yeah, you know I would yes so
28:30I would say that this this is.
28:33When you when you came to me right now,
28:37that's not uncommon, right?
28:38So this is a very.
28:40This is a very common reality
28:43in my experience, right?
28:44In my 20 years in academic
28:47medicine that oftentimes folks
28:48from my minoritized groups will,
28:50will will come with a version of the
28:53rules are being applied differently,
28:55and you know, as in your case,
28:58in many cases that has been
29:01explicitly stated right and so.
29:03This is often very.
29:06An acknowledged or underappreciated
29:08because we have both this
29:11reality of the decoupling, right?
29:13So the sort of the cognitive dissonance
29:16that that one has to sort of live with,
29:20right?
29:21Which is being part of organizations
29:23that have sort of explicit statements
29:26about things like inclusion or or diversity,
29:29or the value thereof.
29:31But the the messaging is quite
29:34counter to that in terms of ones.
29:37Live daily experience and so you
29:39know the the uh, there it is true.
29:42Once again this is not speculation, right?
29:45We already know this is what the
29:47evidence based shows us is that
29:49there are different rules that the
29:52standards are applied differently.
29:54So you know,
29:55even from work we did very early
29:57on looking at the experiences
29:58of physicians of of African.
30:00Sent sort of navigating these spaces.
30:03You know people use language like
30:05being kind of always on right?
30:08I mean this sort of hyper.
30:11This hyper state of kind of being really
30:13aware that one can simultaneously be
30:16invisible because these organizations
30:18make people invisible but at
30:21the same time be hyper visible,
30:23right?
30:23When it's time for critique or
30:25or other or otherwise dismissive
30:27or marginalizing behavior,
30:29one becomes very hyper hyper visible.
30:32And so it is.
30:33It is that navigation that
30:35I think is very hard.
30:36What I think is most what I
30:38think is most real and important,
30:40and it's it's it's better to ask
30:42mentees and mentors that question.
30:44But you know what I think is
30:46really important is to validate
30:47that because it is true, right?
30:49I mean so many people just end up
30:51feeling like you know that they are in
30:54some sort of altered reality or universe,
30:56right?
30:56And so there are so many people who
30:58come with a deep questioning right
31:00around not just belonging this.
31:02Which of course, right,
31:03but also their own ability to kind
31:06of understand social interaction
31:07cues their place right.
31:09And so I think it is.
31:11It is an important first step
31:13to acknowledge like this is what
31:15organizations racialize organizations
31:16produced by default, right?
31:18Is going to be that degree of
31:20cognitive dissonance for people who
31:22are moving through the organization for
31:24whom the organization was not built.
31:29Yeah, that what you just described.
31:31I remember literally coming to you and
31:33saying I feel like I'm going crazy, right?
31:36Like is this stuff for real and this
31:39is in terms of interactions with
31:41peers and and again when I was on
31:44the words so acknowledging that and
31:46I mean you literally said, right,
31:48it's true you will burn out if
31:50you keep sort of like thinking or
31:52thinking that it's not real or that
31:55there's something wrong with you.
31:57So I totally I.
31:59Appreciate your your emphasizing
32:01of the need for us to acknowledge
32:04that from the get go.
32:06Now Doctor Ray in your theory in
32:08the paper that describes a theory
32:11you've identified sources of change
32:13based on historical lessons that
32:16apply to racialized organizations.
32:19Can you expound on some of those?
32:23Yeah I can. I just want to go back
32:26for a second to this sense of not
32:28real like that creates like anxiety
32:31and real health outcomes right?
32:33This questioning like am I crazy or did I did
32:36what I think just happened just happen right?
32:39And so I want it again with the evidence
32:42based like it's not just like documented but
32:46there's also negative sort of long-term.
32:49Health implications from being always
32:51on right from B from having to have
32:54this sort of hyper aware state.
32:56Still I want to say that organizations
32:59have changed for historically
33:00for a number of reasons,
33:02and so I think about this in terms
33:05of like opening up avenues for more
33:07agency for marginalized groups, right?
33:10So if racialized organizations limit agency,
33:12then we need to think about
33:14ways that they they have it,
33:17and I think the biggest one is.
33:19Um? Social movements, right?
33:23So we know that historically,
33:25movements for economic and racial
33:27justice have often relied on the
33:30manipulation of organizational resources
33:32and how people think about them, right?
33:35So we think about the iconic movements
33:38of the Civil Rights movement,
33:41the Montgomery Bus boycott, right,
33:43integrating segregated spaces,
33:44all of those used organizational resources,
33:47sort of against the widely held
33:50cultural thinking about.
33:52How black folks should behave or be
33:54treated within those spaces, right?
33:56So that's one way,
33:58and then I think it's important to
34:00think about how the victories of those
34:03movements get institutionalized in the law.
34:05So you know,
34:06Fair Housing Act,
34:07anti discrimination law which then
34:09binds other organizations and and you
34:11know organizations aren't static.
34:13So a lot of them have found ways around,
34:16right?
34:17We've already been talking about
34:19the ways they found sort of like
34:21move around or find new ways to
34:23reproduce these kinds of inequality's.
34:26But social movements,
34:27can you know filter up to the level of
34:30the state and bind other organizations in
34:32ways that open up avenues for greater agency.
34:35And I think you know the response to
34:38George Floyd's murder this summer,
34:39and we've seen how organizations
34:41have reacted.
34:42Some of that might be PR.
34:44I'm also hopeful that those movements
34:46will push organizations to do better,
34:48but I think it's too early to tell and
34:51see how long those movements carry out.
34:54The other thing is,
34:56I think.
34:57Movement actors moving into
34:58organizations can help.
34:59So things like if we think about the
35:02history of African American studies
35:05departments or even having as as you
35:08two are pointing out having a mentor
35:10who is a person of color who can
35:13share or understand some of the same
35:16experiences and help navigate can help.
35:18But you know,
35:20I am a sociologist,
35:21so like collective action is always going
35:24to be more important than individual.
35:26Actions,
35:27although individuals are important,
35:28and then I think it's important to think of
35:32like large like things like immigration.
35:35Major demographic shifts,
35:36but I also think things like
35:38niche marketing campaigns,
35:40so organizations recognizing.
35:41Oh, if I target this particular
35:44community and bring some folks in,
35:46I might have the opportunity
35:48to make more money. Ultimately,
35:50I think once that money flees,
35:52the organization is going to like give
35:55up their commitments in many cases.
35:57But I do think historically there
35:59are examples of that happening
36:01and now just that's that's enough.
36:05Yeah, thank you so much for
36:08that very thorough explanation.
36:09I think I would think of them as like
36:13external and internal sources of pressure.
36:16Basically on the organization and so
36:18in the context of medical schools
36:21and medical education in General,
36:23Doctor Near Smith.
36:24I'd like to ask you what have you
36:28and others identified as you know,
36:31as evidence based sources of change,
36:33both internal and external.
36:35To how we we improve in academic medicine.
36:38Because, you know,
36:39there's been so much inertia over.
36:41I don't know.
36:42Like over the decades.
36:45Yeah, and longer so you know,
36:47yeah I would, I.
36:50So I would say yeah, we can use that.
36:53The frame for external internal so
36:55you know I started with with kind of
36:58a Flexner and some of the results,
37:00particularly when we talk about.
37:03Issues of diversity and
37:05representation in the profession.
37:06Also very much to Victor's point.
37:07When we start talking about health equities
37:10right and how do we kind of connect all
37:12of those those dots and what that means.
37:15I want to sort of maybe circle back because
37:17one of the things that comes to mind is,
37:20you know, the.
37:22AA MC Justice, which is the Association
37:25of American Medical Colleges.
37:27So here we come into externalities
37:30and external organizations and kind
37:33of groups that have both sort of
37:36governance like actual actual sort of.
37:39Influence through things like accreditation
37:41and metrics and other things,
37:43but also sort of the the power to push
37:45because of sort of collective movement
37:48from this kind of membership structure.
37:50So you have the double AMC coming
37:53out and saying we are renaming
37:55the Flexner Award right,
37:57which is one of their most prestigious
37:59awards that they've given historically
38:01for lifelong educators, right?
38:02So this has happened.
38:04I think in the past week or two
38:06where they sort of come out and
38:09made this declarative statement.
38:11That you know we are renaming.
38:13So you know,
38:14I think we we certainly have time
38:17to unpack sinus symbolism and
38:19symbolic events and activities versus
38:22sort of deeper structural ones,
38:24but I do think that they're worth having
38:28those conversations at the same time,
38:30right?
38:31I know from me that that that
38:34signaled quite a lot, right?
38:36And I think that was very important
38:39in sort of this recognition
38:41of what really every year.
38:43And this isn't to take.
38:45Oh, I mean,
38:46you know there are other great things
38:48the way our medical structure is designed,
38:51you know,
38:51has to do with a lot that came out of that.
38:55And so you know I can have a more
38:57nuanced conversation about Flexner.
38:59But certainly every time there
39:01would be the Flexner Award,
39:02I would have a reaction,
39:04right?
39:04Because I understood at a different level,
39:07kind of what that meant for the
39:09opportunities to victors point
39:10opportunities and aspirations of
39:11generations of young, black, Brown women.
39:13Who wanted to come into the
39:15profession and were denied, right,
39:17systematically denied entry.
39:18And then there are repercussions for
39:20communities where other where people
39:21wouldn't would not come to serve them.
39:23I mean, even within the Flexner report,
39:25it was said we should keep a few of the
39:28schools open that are minority serving,
39:30so that so that the the black doctors
39:33could take care of black patients and
39:35keep sort of syphilis and other diseases.
39:37Kind of in those communities
39:39and away from us,
39:40and so kind of the entire
39:42construction was one that was.
39:44That was damaging.
39:45Kind of every time to here would
39:48be damaging in that way,
39:49so I think there is a role for those.
39:53For those issues of sort of symbolic right,
39:57but I think that there are repercussions.
40:01And at the same time when you think
40:03about bodies like Liaison Committee on
40:05Medical Education, right or AC GME,
40:08which accredits residency programs
40:09and there are real opportunities in
40:12those programs and structures too.
40:14To incentivize,
40:15shall we say institutions in the
40:16policies that we know are going
40:18to make transformative change.
40:20So if I talk too long,
40:21I get very animated when I talk about that.
40:28Not too long at all.
40:31Yeah, you know it's funny I
40:33I was just thinking about the
40:35double AMC renaming this award,
40:37but I think something that was
40:39really interesting to me was that
40:41when they renamed their award and
40:43when they were asked you know what
40:46was the motivation behind it.
40:47It wasn't so much because of the
40:49legacy of the Flexner report itself.
40:52When when the CEO of the double
40:54AMC response to this question,
40:56but but rather because of the
40:59views that Flexner himself held.
41:01An honestly to me that was like a little
41:04bit of a disappointment because it
41:06sort of speaks to how much you know.
41:09We sort of value as a society
41:12as a system in general,
41:14like how racist is that one person
41:16an like that's what we're going
41:18to harp on as opposed to what?
41:21What are the consequences?
41:22I mean, of course,
41:24those two things are related, right?
41:26But but I would have loved
41:28for that answer just to say.
41:31Yes,
41:31like Flexner was incredibly racist
41:33and he held these terrible views but
41:35also in the report that he produced.
41:38And I and I suspect that part of the
41:41sort of like dancing around on the
41:43impact of the of the Flexner report.
41:46Even from a chief diversity officer,
41:48is probably tide to the fact
41:50that the Flexner report you know,
41:52despite its incredibly negative impact
41:54on like black Medical education,
41:56is still held as like the,
41:58you know,
41:59the bellwether of like what today's
42:01medical education is and like.
42:02I don't think medical education
42:05in general is like ready to yield
42:08of like what we feel the benefits
42:10of the Flexner report where
42:13despite the negative impact.
42:15So I'm just to sort of like
42:17wrap our conversations up.
42:18I have a few things I want to share.
42:21A funny enough you sort of
42:23got ahead of me there,
42:25but I want to read this like this,
42:27like short paragraph from the Flexner report.
42:30And for context, everyone who's listening.
42:31You know,
42:32the Flexner report was over 300 pages long,
42:35and there are exactly 2
42:36pages that's reserved.
42:37You know that's about black people.
42:41And in its chapter I think it's Chapter
42:4314 is titled the Medical Education of the.
42:47Anne Anne.
42:48This is where the part that is really
42:51interesting to me starts it goes.
42:54The physical well being of the is
42:57not only of moment to the himself.
43:0110 million of them live in close
43:03contact with 60 million whites.
43:06Not only does the himself suffer
43:08from hookworm and tuberculosis,
43:10he communicates them to his white
43:12neighbors precisely as the ignorant.
43:15An unfortunate white contaminates him.
43:18Self protection not less than the humanity,
43:22offers weighty console in this matter.
43:25Self interest SEC philanthropy the
43:27must be educated not only for his sake,
43:31but for hours.
43:32He is, as far as human I can see,
43:36a permanent factor in the nation.
43:39He has his rights and yuan value
43:42as an individual,
43:44but he has, besides the tremendous importance
43:47that belongs to a potential source.
43:50Of infection and contagion.
43:53The pioneer work of in educating the race,
43:56you know, and to practice
43:59fundamental hygienic principles
44:00must be done largely by the doctor.
44:03Anthony grow nurse.
44:04It is important that they both be sensibly
44:07and effectively trained at the level at
44:10which their services are not important.
44:13The is perhaps more easily taken in then
44:17the white Ann as his means of extricating
44:21himself from a blunder are limited.
44:24It is all the more cruel tributes.
44:26His ignorance through any sort of pretense.
44:28And while top sanitary and
44:31will be immensely useful,
44:33an essentially untrained wearing
44:36an MD is dangerous.
44:38I'm going to skip past the part
44:41where he talks about surgery,
44:43but basically what I when I read
44:45this an I think about some of the
44:47experiences and discussions that that
44:49I've had in medical school with friends,
44:52colleagues, and with you.
44:53You know, back then,
44:55the the Flexner's vision was that
44:58black people in medicine were meant to.
45:01And as much as he claimed that philanthropy
45:04matters and that self interest comes second,
45:07like Ohio Noble.
45:08But ultimately the role of the black
45:11physician in infectious mind in
45:131910s was to protect white people
45:15right from infectious black people.
45:18So we where we had tuberculosis,
45:20and we,
45:21and so black people had to be sort of.
45:26You know, treat it.
45:28This emphasis on the sanitary
45:30and at the time I truly feel we
45:33continue to sort of like experience,
45:36the lingering consequences of that
45:38you and I have discussed this before.
45:41I think there's good evidence that
45:44the majority of black and native
45:46students come into medical school,
45:49wanting to serve underserved communities,
45:51but I think that wish of wanting
45:53to serve the underserved often
45:55get sort of like misinterpreted.
45:58As necessarily like I don't know,
46:00wanting to work in the next year,
46:03see or wanting to go into primary care,
46:06and so when you look at specialties today,
46:09medical specialties and how the
46:11system values or undervalues
46:12certain specialties versus others,
46:14some somehow as it happens,
46:16black and native students go into
46:18primary care at the highest rates.
46:21And when I think about 1910 and today,
46:24primary care is the equivalent of
46:26who the sanitary and was back then.
46:29And there's nothing wrong with primary care.
46:32It's a phenomenal field.
46:34You you, you're a generalist, right?
46:36But also you know the cognitive
46:38work of primary care is undervalued
46:40through our value system compared to,
46:43say surgeons and ophthalmologists
46:44and plastics.
46:45Are you know you name the sort of
46:48like more procedural specialty.
46:50What's even more interesting to
46:52me is that when you look at the
46:55forms that medical students you
46:57know fill out those questionnaires
46:59from WMC Black and native medical
47:02students expressed the least interest
47:04compared to white Hispanic,
47:05and Asian medical students.
47:07Express release interest in primary
47:08care and primary care related specialty,
47:11and yet somehow,
47:12by the time we graduate,
47:14Black and native students go
47:16into primary care at rates higher
47:18than anyone else, right? And so.
47:22The big question, and you know that?
47:25I mean, that's like a care
47:26one award to be investigated.
47:28Probably we talked about this before
47:30is what is, you know, like, how is it?
47:33How does this happen in medical school that?
47:37You know people come in wanting
47:39to do neurosurgery.
47:40Orthopedic surgery, you name it.
47:41An ultimately through the black
47:43box that medical education is that
47:45black and native medical students
47:47end up going into primary care when
47:49they they are the least likely to
47:51express interest in primary care.
47:53And there are several mechanisms that
47:55we you know we can discuss at length,
47:58but I want for the for the medical
48:00educators and for people who are
48:03in leadership generally in medicine
48:04and who might be listening to us.
48:07Now or later to take that into consideration,
48:10right?
48:10Like what is it that where is
48:13medical school or medical education
48:15missing the mark such that the
48:18wishes of medical students at entry
48:20basically end up not being met an.
48:24Of course.
48:26People change interests as they navigate
48:28medical school and mentorship matters.
48:30And in a lot of things happen right.
48:33But all of those things are racialized
48:36and I just want us to sit with that.
48:40I don't know if either of you
48:42have a comment about that,
48:43but in about 9 minutes we will
48:45take questions from the audience.
48:48I have a. I have a quick comment about that.
48:51Something similar happens in sociology
48:53programs where students of color come
48:56in so often times like not wanting
48:58to study race and there will be like
49:00people were just like, oh, you're here,
49:03you're here to do race, right? Anet.
49:05Actually through a number of mechanisms
49:07or lack of mentorship steering,
49:09they end up studying race.
49:11I was also thinking of the audit
49:13studies that I was talking about
49:15in the housing audit studies.
49:17There's a mechanism column steering.
49:19In which they'll show black
49:21or Latino families.
49:22They'll say I want this
49:24apartment and 18 will be like.
49:26Well, what about these ones over
49:28here in the segregated neighborhood,
49:30right in the black neighborhood?
49:32And so I wonder if there's an
49:35analogous organizational mechanism.
49:36It's tearing these folks into
49:37certain certain careers in line with.
49:40Well, I mean, I'm pretty sure there is,
49:43but I don't.
49:44I don't
49:44know. Yeah, maybe Marcella can say some of
49:47us, Siri? Yeah, that's exactly,
49:49that's exactly correct.
49:50Analogy right is sort of
49:51the steering phenomena.
49:52I think in medicine we
49:54have a few things right.
49:55So I think what we do we do have steering.
49:58And again, there's evidence for that, right?
50:00So we already.
50:01Can I have that that evidence based excuse
50:05me that shows that students particularly
50:08color seem too much talking all day.
50:11Are steered right, but also we're
50:13back to some of these objective.
50:16The objectification of these
50:18measure measures and metrics, right?
50:20And so for a lot of things,
50:22we end up both with students feeling.
50:27Potentially unwelcome and
50:28right in certain specialties,
50:30maybe specialties where there already is.
50:32Limited representation and then on top of
50:34that we begin sort of gymnastics around.
50:37Is somebody qualified right to get into
50:40a particular specialty so we are kind
50:43of we stand alone in our the way we
50:46organize graduate medical education,
50:48right?
50:48It's pretty unique where we have
50:50here this system that is really
50:53dictated by student choice.
50:55Don't throw tomatoes,
50:56right?
50:56But sort of dictated by student
50:59choice and then and then.
51:00And a system where kind of different where
51:03specialties begin to tear themselves.
51:05Right by saying this one is harder
51:07to get into them as other one
51:10be there for more prestigious,
51:12therefore sort of reflecting
51:13graders value somehow right tide
51:15up a lot with reimbursements.
51:17So we have a very complicated system
51:19and structure that's also sort of
51:22inherently set up for this right?
51:24As opposed to maybe other systems where.
51:26We begin with what we need societally, right?
51:29Like how?
51:30How many?
51:30How many primary care doctor do we need?
51:33How many plastic surgeons do we need?
51:35And we kind of begin from that
51:37process as opposed to beginning
51:39with this notion of student choice.
51:41That is actually very driven by sponsorship,
51:44right?
51:44So the idea of student choice ends up being.
51:47Are there people more senior in that
51:49field who will sort of vouch for you?
51:52Open the door for you partnered with
51:54sort of over investment in objective.
51:56Measures that we talked about at
51:58the top right that begin to that
52:00aren't objective in in the least when
52:02we talk about things like scores,
52:04and you know the board scores
52:07or something so.
52:08I think we do have a lot of
52:10work to do to understand that,
52:12but but from where I sit in my perspective,
52:15that's all legacy of Flexner in in the
52:17way that it's come through the generations,
52:20right?
52:20And again,
52:20I'm happy to have with anybody at any point,
52:23because scholars in this space
52:25know that we have to have a more
52:27complete discussion of Flexner,
52:28some access point,
52:29kind of modern medical education, etc.
52:31But this is one of the ways in
52:33which that manifest, right?
52:35That notion?
52:35And that's why even as a
52:37workforce diversity researcher I.
52:39I cringe when people start talking
52:41bout concordance right?
52:42And that we can have a more
52:44nuanced conversation about
52:45that as well, because I feel like we
52:48have at some levels we let concordance
52:50creep in as the appropriate sort of
52:52modern expression of that legacy, right?
52:55You know, definitely, and it's just,
52:57uh, we have to have just a more
53:00thoughtful conversation about that.
53:15I think you are muted Max.
53:17I don't if you try.
53:22OK sorry I was having a
53:24little bit of tech difficulty.
53:25I'm trying to share once just
53:27one slide if you will bear with
53:30me because you made a point.
53:32OK, so I can't tell if
53:34everyone can see this slide,
53:36but you made a point about scores
53:39and I just want to show everyone
53:42if you're able to see how you know
53:45how tightly correlated you know
53:48specialties you know specialties
53:50specifically earning potential
53:51are with step one scores an you
53:54know family medicine is here
53:57and orthopedic and neurosurgeon
53:59plastic surgery are up here but
54:00but you know it really speaks to.
54:03How much value is assigned
54:05to each individual specialty,
54:07but also how much value is assigned
54:10to students based on based on like
54:13how they perform on, you know,
54:16individual, standardized,
54:17standardized tests and it's in or we I guess.
54:22And then just sort of replicate itself.
54:24But but but really,
54:25the first time I saw this this this
54:27graph you know I was like mind blown.
54:30I mean there are square of 0.66
54:32is pretty good.
54:33So anyways I just wanted to
54:35share this with you all.
54:36I'm gonna stop sharing and I think
54:38we can go ahead and start taking
54:40questions from our audience now.
54:44OK, thanks so much,
54:45so I'm going to just start right at the
54:49top with the questions and this is this.
54:52These first 2 questions are directed both
54:55to Doctor Ray and Doctor Nunez Smith.
54:57So how to medical schools?
54:59Weaponized mission statements
55:01of diversity and inclusion when
55:03minoritized individuals raise a
55:05complaint with the organization
55:06itself and the follow up to that is,
55:09is that weapon weaponization also
55:10part of the decoupling process
55:12that Doctor Ray has articulated?
55:22Yes please.
55:25Oh, I mean, as far as
55:27medical schools specifically,
55:28you do, you want to start or?
55:31I mean, I guess I can talk in general.
55:34OK, so I don't.
55:35I'm not going to speak about
55:36medical schools specifically and
55:38I would say I'm not sure about
55:40diversity and inclusion statements.
55:42But I will say that.
55:46The the research Doctor Ellen Barry's
55:48research that I've mentioned before does
55:50talk about anti discrimination policy,
55:53sort of being weaponized against
55:55people who access it and I think
55:58so in my theory I'm trying to
56:00talk about like general processes
56:02that I have seen or I think are
56:06occurring across a whole bunch of
56:08different kinds of organizations.
56:10But you know how that is carried out in
56:13any given organization is kind of an.
56:16Open question and it needs
56:18empirical verification.
56:19I will say in my dissertation
56:21research on the military,
56:23I found this happening with people who came
56:26forward with complaints of sexual assault.
56:28People who came forward with complaints
56:31of PTSD and with people who came forward
56:34with complaints of racial discrimination.
56:36And I said that I thought it was a
56:39general process and that actually
56:41the programs in and of themselves
56:44were part of the kind of PR.
56:47Process that they allowed people to say,
56:49look we're doing something like we
56:51have these mental health programs,
56:52but when you talk to people a lot
56:54of the folks in my dissertation
56:57were like I wouldn't even.
56:59Go to the mental health.
57:02Folks in the military they were
57:04leaving the organization if they could.
57:06If they were stationed in the US,
57:08they were going to get help for
57:10mental health issues related to
57:12deployment in the community because
57:13they were worried about how it would
57:15harm their careers in the military.
57:20Yes, I would just go back, go ahead. I
57:24was just gonna say it.
57:26Yeah, first of all,
57:27how there are few medical schools
57:29that actually quote unquote.
57:30Have diversity like you know such
57:32explicit diversity mission statements,
57:33I think fits you the latest
57:35remodels research showed, right.
57:37The medical schools that actually
57:38had the sort of like most meaningful
57:41an like walking the walk mission
57:43statements where the HBC use and
57:45the state schools that were that
57:46sort of had to be accountable to
57:49the to the state because they
57:51are funded by the state, right?
57:53So? So I think you know,
57:55even talking about diversity
57:57statements is is a huge step
57:59in medical school right now.
58:00But go ahead or so.
58:02Yeah, no. So, so first,
58:04I'm really grateful for you to
58:05bring up fits and fits you,
58:07Mullin and all of his work
58:09and his contributions.
58:10And he actually founded Beyond Flexner,
58:12which is an organization we really
58:14focused and committed to workforce.
58:16Diversity and social mission,
58:17which is what you were just
58:19talking bout backs right?
58:21So fits his work was around doing
58:23social mission ranking and we
58:24actually saw in that kind of early
58:27Seminole work an inverse correlation.
58:29Between sort of social mission
58:30and perhaps some of these other
58:33artifacts of prestige things like
58:35US news and World Report rankings.
58:37NIH dollars, right?
58:38So it was a complete inverse proportion,
58:41and so on.
58:42The social mission metrics HBC?
58:44Use msis,
58:45state schools like scored much
58:47better and then large NIH research
58:49institutions were on the bottom
58:51in terms of social mission,
58:53which was a composite of things
58:56like how many students go out and.
58:59And do primary care and other things.
59:01I mean I would echo sort of this notion of.
59:05The same structures that are put in
59:09place often as outwardly facing evidence of.
59:14Of progress, right,
59:15such as mechanisms to report discrimination.
59:17Mechanisms to report harassment.
59:19You know, I would say that we we see
59:22that same phenomena in medical education,
59:25right as you describe it in the
59:28military and elsewhere, where people,
59:30the people most vulnerable
59:32inherently in this system, right?
59:34So this is back to the support and empower
59:37the people most vulnerable in this system.
59:40Recognize that as trap right
59:42recognize those that mechanism.
59:44As something that will cause further
59:46harm and so we see, you know,
59:48this avoidance of that right?
59:50And they're not using it for that and
59:53then to the extent that it's used at all,
59:56potentially used by those who ironically
59:58are already higher in the power structure.
01:00:01An already inherently more protected in
01:00:03the system before entering into that,
01:00:04so I think it is this.
01:00:06It is a similar phenomena that we
01:00:08see in in medicine, not just mad,
01:00:11but really just. Healthcare systems etc.
01:00:13Kind of across the field.
01:00:16Thank you and there's a related question
01:00:18that maybe we can just tag onto this one,
01:00:21which is how do we differentiate
01:00:23between actions that give lip
01:00:25service to diversity? Anti racism,
01:00:26but are just for PR versus actions
01:00:28that actually reverse power relations.
01:00:30How do you kind of assess
01:00:32those out from the inside?
01:00:37And that's why I
01:00:38love anybody I know now. Anybody
01:00:40who's making a face should answer that.
01:00:44Go ahead, Victor. I think you
01:00:46got someone say yeah. I mean,
01:00:48I'm happy to talk about this, right?
01:00:50So one of the key things in my
01:00:52theory is resource distribution,
01:00:54right? And so I am.
01:00:56So I had this experience at a
01:00:58University I was at in which this
01:01:00this might tell me if this sounds
01:01:02familiar as I started the story,
01:01:04there was a racist incident.
01:01:06Students of color started organizing
01:01:08many of those students came to me and
01:01:10said we're putting on a conversation.
01:01:12I was like, OK, great.
01:01:14But like I'm not going to do a conversation,
01:01:17I'm like ask at because I've had like sorry
01:01:20I've had conversations for like 15 years.
01:01:23I've been part of the pie red, so I I'm
01:01:26not going to do another conversation.
01:01:28We know what the problems are.
01:01:30We know what the solutions are.
01:01:33Tell them you want.
01:01:34You want to guarantee of 100 more
01:01:36black students admitted to the
01:01:38freshman class and that would alter
01:01:40the power relations at the University.
01:01:42And it would put some resources behind.
01:01:45And I knew that the University is
01:01:47unlikely to do that for a whole
01:01:50host of reasons,
01:01:51but it was a way of framing the
01:01:53question in which like to me,
01:01:55this is not just a problem of as you
01:01:58talked about the Flexner report,
01:02:00it's not a problem of him being a bad person.
01:02:03It's him being a bad person with access
01:02:06to organizational resources that can
01:02:08affect people's lives for generations.
01:02:09And so I want to think about ways
01:02:12that we can leverage those resources.
01:02:15In good ways,
01:02:16right?
01:02:16So I think schools that are looking at
01:02:19certain kinds of reparation policies
01:02:21for slavery or the theft of native land.
01:02:24Or is it kind of?
01:02:26Like positive intervention that goes
01:02:29well beyond the diversity statement or
01:02:32a discussion of a negative incident,
01:02:34right?
01:02:37Yeah.
01:02:40This is part of the part of what
01:02:42sort of frustrates me with the
01:02:44conversation around the renaming of
01:02:46Flex and of course I get straight,
01:02:48but but even in the renaming of
01:02:51the of the award, for instance,
01:02:53there was little acknowledgement
01:02:54of the fact that first of all,
01:02:56the Flexner report was just written right?
01:02:58Like the report didn't get
01:03:00up and close schools right?
01:03:01The the the AMA and the Carnegie
01:03:03Foundation like first the Carnegie
01:03:05Foundation funded the like putting
01:03:07together the report and then the AMA,
01:03:09which at the time did not.
01:03:11Except black physician within
01:03:12its ranks right?
01:03:13the AMA implemented the recommendations of
01:03:15the Flexner Report and so now the double AMC,
01:03:18which is like you know,
01:03:20the sort of the sister organization
01:03:22of the AMA family use that term.
01:03:25He there's no sort of a kind of like
01:03:29organizational accountability when when,
01:03:31when some of these gestures are taken,
01:03:34and that's to me as a sign,
01:03:37that gesture is for show and not necessarily.
01:03:42You know it doesn't have any teeth.
01:03:47Yeah, I mean so I I think
01:03:49that's so really excellent
01:03:51points made both. I mean one.
01:03:53Of course, yes it was written
01:03:54and then there was an entire.
01:03:56The report was written and then there
01:03:58was an entire system anxious to take
01:04:00and implement in that way, right?
01:04:02And we are still, I mean, the you know.
01:04:05I mean, we're only talking about integration
01:04:07of our professional medical societies.
01:04:09You know, like in the 60s, right?
01:04:11I mean so you know,
01:04:12this is all very recent history right?
01:04:15Anime had to be born out of the fact.
01:04:18Air may exclusion that then sort of
01:04:20tide access to privileges to being a
01:04:22member in the local state AMA chapters,
01:04:24so all of that history is really important
01:04:26in probably beyond our scope for tonight.
01:04:28But really glad that you're raising
01:04:30for context and then you know
01:04:32to this point about resources.
01:04:33And I think, yeah, I mean,
01:04:35I think that is the that that's right,
01:04:37that's the mic drop.
01:04:38I think Max was sort of signaling,
01:04:41which is.
01:04:41That is how you have to move that right?
01:04:44Beyond the sort of discussion
01:04:46and the discourse to sort of.
01:04:48It's a follow the money always
01:04:50in these organizations.
01:04:57Um so.
01:05:00I'm going to pose this question
01:05:04another question about.
01:05:06A topic that was discussed a little
01:05:08bit before about kind of the weed
01:05:10out class classes in Med schools,
01:05:12so the rhetoric of rigor and weed
01:05:15out classes in Med school and
01:05:17especially the questioner asks in the
01:05:19pre Med curriculum as a racialized
01:05:22component of medical schools.
01:05:23Slash Graduate School.
01:05:24Then you know
01:05:25anything else.
01:05:26This is I just had this very,
01:05:28very heated conversation about this
01:05:30on Twitter. Not super long ago.
01:05:32You know, I think the classes
01:05:33themselves are not the problem, right?
01:05:35So Full disclosure,
01:05:36I was never premed.
01:05:37I took premed classes because they
01:05:39were required in my major and then
01:05:41eventually fulfill additional
01:05:42premium classes so I never took
01:05:44those classes with the expectation
01:05:46that I have to get an A because if I
01:05:49don't get an error then I won't get
01:05:51a letter from the premed Committee.
01:05:54And then I'll never get into
01:05:55medical school right there.
01:05:56There are all these sort of like.
01:05:58Structures around what pre Med
01:06:00life is like that.
01:06:01I personally escaped and so
01:06:03I think we should not.
01:06:05I mean the courses matter right?
01:06:07Like you have to understand organic
01:06:09chemistry and people argue that
01:06:11you don't but when you do become
01:06:14an anesthesiologist you need to
01:06:16know you know you need to know
01:06:18like there is racemic version
01:06:20of EPI or whatever right?
01:06:21Like those courses are are
01:06:23required for a reason and I think
01:06:26what what really is the issue.
01:06:28An in the requirements of like
01:06:30getting to medical school,
01:06:31is how they operationalized.
01:06:33Like I think it should totally be
01:06:36OK that you get an AB and or go
01:06:38or even a see if you pass or go.
01:06:40You have a decent understanding of
01:06:42the matter and you probably going to
01:06:44do OK at the beginning of biochemistry.
01:06:46Now a lot of undergraduate schools
01:06:48right have the sort of gatekeepers
01:06:50and marcella and I talked about
01:06:52this before and again I went to
01:06:55Howard so again I will say from
01:06:56a lot of the things that.
01:06:59People face in that premed journey but
01:07:01like premed offices are gatekeepers,
01:07:03sometimes like they themselves have.
01:07:05As like you know they have
01:07:08decided right that OK.
01:07:09This is our standard for sending people
01:07:12to medical school or for writing.
01:07:14People like you know committee letters
01:07:17from medical school and part of
01:07:20that is because it makes once like
01:07:22biology program looks good or bad.
01:07:24Depends you know depending on what
01:07:27their admissions rates are, so I.
01:07:29Really think it's rather the
01:07:31structure around.
01:07:32Like OK,
01:07:33do we like how much do we care about GPS?
01:07:37How much do premed committees
01:07:39you know emphasize?
01:07:41Being competitive, like amongst your peers,
01:07:44like those structures I feel
01:07:46are the racialized one.
01:07:48It's not physics.
01:07:49Physics is fine,
01:07:51it's not by biology,
01:07:52right?
01:07:53But it's the way in which we
01:07:55we then like design how those
01:07:58requirements like Influence
01:08:00Medical school admission.
01:08:04Marcela, I know you have
01:08:06something about this.
01:08:08Yeah, so I mean I I I agree so I mean,
01:08:12I've I've never been one who said,
01:08:14you know, I'm not of the I, don't I?
01:08:16I don't know too many voices in the camp,
01:08:19but I'm certainly not in
01:08:21the camp that says you know,
01:08:23these classes are not relevant,
01:08:24right to Max's point,
01:08:25but I think what we failed to do is
01:08:28have conversations about the factors
01:08:29that influence one's performance
01:08:31in those very set classes, right?
01:08:33And we go back to all these very first
01:08:35principles about our segregation redlining,
01:08:37and what kind of educational
01:08:39opportunities you have access to.
01:08:40So when you're showing up
01:08:42at that or go class right?
01:08:44People are coming not with the same,
01:08:47the same set of preparedness,
01:08:49which has been systematic and structural and
01:08:51deliberate and intergenerational, right?
01:08:53And so it is not 'cause I do
01:08:56not wanna in anyway.
01:08:58Sort of conflate race and class.
01:09:00And although we know right,
01:09:02we know that sort of access to
01:09:04opportunity and more importantly,
01:09:06denial of opportunity is very linked
01:09:08to race in our country, period.
01:09:10And so when we kind of hold up on these
01:09:14pedestals, these things like science,
01:09:16GPA or whatever M CAT score
01:09:18and don't do a deep.
01:09:20What is my most frustrating conversations
01:09:22have been comparing sort of students.
01:09:24Applicants you know,
01:09:25one of whom comes from deep,
01:09:27deep privilege, right,
01:09:29and every opportunity and every
01:09:31tutor and has like a so so GPA or so.
01:09:34So score and one of these standardized tests.
01:09:37And to me,
01:09:38that is the flag that nobody ever calls,
01:09:41right?
01:09:41This is back to the sort
01:09:43of light as credential,
01:09:45because nobody calls that flag.
01:09:46This person I said,
01:09:48every possible support right.
01:09:49Access to everything.
01:09:50And so why do we see a C in Oregon,
01:09:54right like?
01:09:55Like like that begs a question for me,
01:09:57like will this person be able to
01:09:59get through really the rigor?
01:10:01Of the program,
01:10:01but that flag doesn't get called,
01:10:03but the flag gets called for the
01:10:05student who was like working 5
01:10:07jobs and you know has a C and or
01:10:09go right and like the flag gets
01:10:11called and so or whatever.
01:10:13I should never say these things.
01:10:14I don't know anything about sports
01:10:16but like this I think is part of
01:10:18the challenge that we see when we
01:10:20talk about these grades, right?
01:10:22So it's nothing inherent?
01:10:23Yeah we need to know or go.
01:10:25Yeah absolutely,
01:10:25but we don't have a conversation at
01:10:27all about and literally we can have
01:10:29these equivalent grades and one.
01:10:31Is is framed as like we should
01:10:33be so careful I don't know and
01:10:34this other one isn't to me again,
01:10:36different perspective.
01:10:37I'm sort of like if you have everything
01:10:40in the world and you can only sort
01:10:42of get a C then that's going to be
01:10:44a problem for us academically, right?
01:10:45But it's never called that way.
01:10:50I'd like to just shift,
01:10:51we just have 15 minutes left
01:10:54to a question that's focused
01:10:56more on the clinical years.
01:10:59And the concept of professionalism and
01:11:02the questioner asks, can you comment?
01:11:04I know you love this one Max.
01:11:07Can you comment on the racialization
01:11:10of professionalism in medicine which
01:11:12plays a role in clinical rotation
01:11:14evaluations and evaluations throughout
01:11:16graduate graduate medical education?
01:11:19So the Victor you and I'm going to
01:11:20just be quiet and listen to Max, OK.
01:11:23Everything, yeah, I've been on
01:11:25war with with how we talk about
01:11:28professionalism in Mexico and Marcella
01:11:29knows I have walked into her office upset
01:11:32because of things that were literally
01:11:34written in my evaluations, right?
01:11:36So you know, if I want to think
01:11:38about professionals and let's
01:11:40look back at history first, right?
01:11:42The way we think about
01:11:44professionalism in medical,
01:11:45medical school today.
01:11:48Has many roots, one of which in this,
01:11:51succeeds when medical students were
01:11:53protesting against the AMA for many things,
01:11:56including their exclusion of black
01:11:59physicians from their ranks and their lack
01:12:02of support for Medicare and Medicaid, right?
01:12:05Like the medic at the AMA,
01:12:07was like the enemy for these activities.
01:12:10Medical students an you know
01:12:13it's funny here in New Haven,
01:12:15there's sort of a similar version
01:12:18of this where.
01:12:19Yale medical students like protests that
01:12:22with the Black Panthers right during Mayday,
01:12:24one of my friends Antar Antar Anderson's
01:12:27Med school thesis was about Yale medical
01:12:30students involvement with the with the.
01:12:32With Mayday in you Haven.
01:12:34So at the time then, in order to punish
01:12:38these rebellious medical students,
01:12:39medical school started sort of,
01:12:41you know, enforcing certain dress codes,
01:12:44certain rules about facial
01:12:45hair because you know,
01:12:47it's not atypical that students who are.
01:12:50Rebellious,
01:12:50like down for the cause and the
01:12:53protest movement like they grow their
01:12:55hair you know they dress different
01:12:57differently as also a form of protest.
01:12:59Sanso Med School started enforcing
01:13:01certain dress codes in the 60s that
01:13:04where very sort of like you know,
01:13:06centered around like what is
01:13:09the standard Eurocentric.
01:13:10And especially like you know,
01:13:12white male,
01:13:13sort of like a standard of like
01:13:15how you're supposed to dress right?
01:13:17But then there is also,
01:13:19you know,
01:13:19besides the you know the codes
01:13:21are on like how you're supposed
01:13:24to dress at work and what not.
01:13:26There's an element of just behavior
01:13:28or or like how we how some people's
01:13:31behaviors are perceived differently.
01:13:32If someone you know you might perceive
01:13:35me to be louder than I actually am
01:13:38because of just the psychology of of like.
01:13:40People are afraid of black people, right?
01:13:43All of these things shape peoples like
01:13:46understanding of our respective actions,
01:13:48an altogether end up.
01:13:50Yes,
01:13:50absolutely.
01:13:51Being weaponized against
01:13:52either students of color.
01:13:54Students were sort of like not not
01:13:58conforming with respect to the malt.
01:14:01You know a good example for me is like in
01:14:03the operating room having been told OK,
01:14:06today we're gonna do this case.
01:14:07We're going to try to be a little
01:14:10more quiet and and I like don't
01:14:12speak for the case and then I get
01:14:14an eval later that says I don't have
01:14:16an inside voice in our right like.
01:14:20Ann,
01:14:20it's just sometimes it's like fascinating,
01:14:22right?
01:14:23Like the psychology of the of the
01:14:25human being, and how people perceive you,
01:14:28Anne Anne, then act.
01:14:31Or sort of like weaponized what they?
01:14:33What they believe their rules are an.
01:14:36Unfortunately the professionalism
01:14:37is like a huge deal in Med
01:14:40school like you will get thrown
01:14:42out of medical school for lack of
01:14:45professionalism before poor grades.
01:14:46As far as I understand and feel free
01:14:49to chime in but so when you combine
01:14:52how we use professionalism in medical
01:14:55education to sort of decide who is fit
01:14:58for practicing medicine, who who is fit.
01:15:01To continue throughout training and how
01:15:05how we you know how it's racialized.
01:15:10It has true consequences for you
01:15:12know who gets dinged over and over
01:15:15an an ultimately who might be thrown
01:15:17out or suspended or whatever.
01:15:19And that's not to say that some of us,
01:15:22you know, sometimes like,
01:15:23have lapses in professionalism.
01:15:24I will be the first to say I have a huge,
01:15:28you know, sometimes I'm not on
01:15:30time like it happens, right?
01:15:31Like?
01:15:32And it is considered to be a lapse of
01:15:34professionalism when you're not on time.
01:15:36But again,
01:15:37when you think about how rules the
01:15:39decoupling of rules or write hard
01:15:41rules are applied or not applied,
01:15:43who gets punished for not being on
01:15:45time or who's like timeliness or
01:15:47lateness gets excused versus not.
01:15:49That also is is one of the ways we see,
01:15:53you know. Professionalism being weaponized.
01:15:55I only
01:15:56open my mic to say because you know.
01:16:01You know everything like Max.
01:16:03I know you're so thought we've had
01:16:05great conversations about this and
01:16:07you just shared amazing insights.
01:16:08I only open my mic to say the
01:16:11thing that I say all night, right?
01:16:13Which is we have the evidence for this
01:16:16already? Like this database exist?
01:16:17We already. We already know that
01:16:19these evaluations these letters,
01:16:21they are the language that is used,
01:16:23the descriptors that are used highly,
01:16:25highly racialized, highly,
01:16:26highly gendered, right?
01:16:27You could you could almost like predict
01:16:29right by reading the letter, kind of.
01:16:31The The sort of who who they're
01:16:34talking about, how you use words
01:16:36like competent when they show up,
01:16:38how they're nested so.
01:16:39But you know, Max provided us some
01:16:42more extreme consequences, right?
01:16:43You said, hey,
01:16:44you know we can get booted out of school.
01:16:48Which is huge,
01:16:49but I would argue with those more subtle,
01:16:52right that are the long lasting damage,
01:16:55because once again this is about the
01:16:57about access to career progression,
01:16:59right?
01:17:00This is how one's choices
01:17:02get limited for them.
01:17:03How ones aspiration's get hijacked because
01:17:06we again look to these letters as objective,
01:17:09so you know,
01:17:10as we sit in these rooms and say,
01:17:13let's blind these applications,
01:17:14let's only read the letters.
01:17:16Let's only look at the board scores.
01:17:19Let's only wait for the chair of the
01:17:22Department to call me and tell me,
01:17:24you know how wonderful this person is like.
01:17:26Let us use these other pieces of information,
01:17:29right?
01:17:29And we do ourselves into thinking
01:17:31that we're doing something that is
01:17:33leveling the playing field, etc etc.
01:17:35So I think you know it,
01:17:37it has real consequences, really.
01:17:38The point, kind of each of those words,
01:17:41how they're written,
01:17:42often often couched in professionalism.
01:17:43But regardless,
01:17:44I mean these are very consequential
01:17:46in the lives of our students.
01:17:55I'm going to jump to the next question,
01:17:56Victor, unless you have
01:17:58something to add to that.
01:18:00OK, so question came in specifically for you,
01:18:03but open to all at from Rupert Johnson,
01:18:06who apparently is a fellow vastor alone
01:18:08who asks how does the lack of pipeline
01:18:11programs and other points of access for
01:18:14persons of color and healthcare fit within
01:18:17the racialized organization theory?
01:18:18I know this is a conversation on
01:18:21medical schools, but in his profession,
01:18:24speech, language, pathology,
01:18:25the profession is 92% Caucasian
01:18:27which is unacceptable.
01:18:28The imbalance is seen in the
01:18:30student body of many speech,
01:18:32language, pathology degree programs
01:18:33in higher Ed as well.
01:18:37So I don't know about speech
01:18:40language pathology in particular,
01:18:42but I'll try and answer this in general,
01:18:45so one of the things and I think I
01:18:49alluded to this earlier was, you know,
01:18:52we've set up this system where
01:18:54admission into subsequent sort of
01:18:57like degree granting organizations
01:18:59is often premised on organizations
01:19:01you had prior access to right?
01:19:03And so having access to those organizations
01:19:06we know because of housing segregation and.
01:19:10Underfunded schools that, on average,
01:19:12of course, there are exceptions,
01:19:14but on average people of
01:19:17color are disadvantage,
01:19:18and so I think about that sort of
01:19:21compounding over the course of one's
01:19:24participation in organizations, right?
01:19:27So you started it underfunded
01:19:29school that limits your pathways.
01:19:31You might enter relatively.
01:19:33Other underfunded school as you
01:19:35move up and so I think that that's
01:19:38one way and I would say I have a
01:19:41colleague Elizabeth Korver Glenn
01:19:42who studies housing and segregated
01:19:44housing and she talks about this
01:19:46compounding two across different
01:19:47aspects of the process of like
01:19:49looking for and buying a house and
01:19:51so that's one way I'd think about it.
01:19:53And then the other way I think about it.
01:19:56I think we also touched on is steering
01:19:59how people get steered and so.
01:20:01Of teachers expectations of what what
01:20:03people are capable of based on their race,
01:20:06and then once people decide,
01:20:08I always use the example of the
01:20:10autobiography of Malcolm X in his
01:20:12teacher telling Malcolm X like
01:20:14he couldn't be a lawyer.
01:20:16Anne Malcolm talking about how
01:20:18that like crunches,
01:20:19aspiration and so I think about
01:20:21that in terms of like steering or
01:20:23people putting you sort of in the box
01:20:26of where they think you belong or
01:20:29what you are ultimately capable of.
01:20:37And thanks for coming over.
01:20:40OK.
01:20:43This question is for anybody who wants it.
01:20:46So how does reconstituting the mosaic
01:20:48of racial ethnic composition of any
01:20:51given entering medical school or
01:20:53residency or fellowship class relate
01:20:55to the larger truth that entry into
01:20:57medical school is at the outset,
01:21:00in impossibility for essentially
01:21:01all working class individuals,
01:21:03regardless of racial identification?
01:21:10Yeah, actually I have a slide about
01:21:13especially you know how household income
01:21:15and I think there's another question
01:21:17about or it's the same question.
01:21:20Great, OK, so yes, right?
01:21:22I mean there are incredible
01:21:24incredibly high barriers when we
01:21:26think about like how does how.
01:21:28What does it take to get
01:21:30into medical school right?
01:21:32That the cost of the M cat or M Cat
01:21:35preps prep courses and what not?
01:21:38And so you know.
01:21:39The majority of the majority of US
01:21:42medical students come from, you know,
01:21:45wealthier households an that is also
01:21:48something that's racialized right.
01:21:50So I mean, on average, right?
01:21:52Like black people have significantly
01:21:55lower household income compared
01:21:56to their white counterparts,
01:21:58but just even overall,
01:22:00when you look at the household
01:22:02earnings of of medical medical
01:22:05students by families virus right over
01:22:08half of white students come from.
01:22:10I'm households that earn over
01:22:12150 K per year compared to just
01:22:14a quarter of black Med students.
01:22:16And you know this is simplified
01:22:18black V White,
01:22:19but of course just a snippet of data.
01:22:23An the households you don't look
01:22:25at household earning under $50,000.
01:22:27Similarly like Black Native an to an extent,
01:22:31Hispanic students are over
01:22:32represented in those buckets.
01:22:34And if you also look at
01:22:36like pre Med school debt.
01:22:39So any form of that be just
01:22:41like credit card whatever debt.
01:22:44Right now I'm not even not even
01:22:46yet including educational debt.
01:22:48Minorities should again black
01:22:50native and Hispanic students have.
01:22:53The armor represented amongst
01:22:55those who have pre Med school debt,
01:22:57and then if you look at the degree right,
01:23:00like how much pre Med school
01:23:02that people have used you also
01:23:04see an over representation of a
01:23:06black Med students amongst deals
01:23:08with the highest amount of debt.
01:23:11So there absolutely are some you know,
01:23:13incredibly high barriers to
01:23:15accessing medical student.
01:23:16Sorry medical education if you
01:23:17if you are from a low income
01:23:20background and I think one of the
01:23:23things that some some of the data.
01:23:25That you know that we have from the
01:23:27AMC doesn't sort of get doesn't at
01:23:29least show is that you know this
01:23:32isn't taking into consideration
01:23:33social networks and net worth, right?
01:23:35So one student's family,
01:23:37especially if they're black.
01:23:38My income might be 150,
01:23:40but their net worth,
01:23:41you know might be like 10 times lower
01:23:43compared lower than the next white family,
01:23:46who that has the same,
01:23:47you know, yearly income.
01:23:49And then when you think about social
01:23:51networks in terms of family, right?
01:23:53Like who else in the family
01:23:55makes that much money?
01:23:56Who else is?
01:23:57Are the students parents accountable
01:24:00to in terms of like taking care of
01:24:03them or helping pay their bills?
01:24:05Like that's like an incredibly even among.
01:24:08Sort of you know,
01:24:10upper or upper middle class black students.
01:24:13Typically that is something
01:24:14that comes into play.
01:24:16So yes,
01:24:17I agree,
01:24:18we have a huge huge issue in
01:24:20general with with making medical
01:24:23school accessible to people
01:24:25who are from working class.
01:24:27And you know that's not necessarily specific
01:24:30to to medical education itself, right?
01:24:33And when you look at disparities
01:24:36and even public education, you see.
01:24:40That, for instance,
01:24:42you know based on housing segregation.
01:24:44Again, you you have like wealthy or like
01:24:47you know upper or upper middle class
01:24:49black families that are raised children
01:24:52that are more prone to downward mobility,
01:24:55that the schools you know,
01:24:57the public schools they have access
01:24:59to tend to have fewer resources,
01:25:02financial resources,
01:25:02even compared to lower or lower
01:25:05middle class white families.
01:25:06So there's this sort of like
01:25:09crazy and intertwining between.
01:25:10Race and class here that you know it makes.
01:25:15It makes things just generally
01:25:17things really hard in terms of
01:25:20wanting to deconstruct these barriers
01:25:22and access to medical education.
01:25:28We're almost out of time,
01:25:30so I just wanted to give Victor Raeann,
01:25:32Marcella Nunez Smith a
01:25:34chance to make a closing.
01:25:36Paragraph, just a statement or
01:25:38you know something you want to
01:25:39leave everybody with based on
01:25:41what you've been so generous with.
01:25:42Teaching us so far.
01:25:45Or I am just going to thank Max
01:25:48and Marcella and you Anna for and
01:25:50caring for helping to arrange this.
01:25:53I really enjoyed getting a chance to meet
01:25:55you and talk about ideas. So thank you.
01:26:01Thank you so much I
01:26:03really. I mean I I go that in just
01:26:05great and to you know things to all the
01:26:08participants for for coming and engaging
01:26:10and contributing to that discussion with
01:26:13those really thought provoking questions.
01:26:16You know, I forced myself these days to lean
01:26:19into hope and light and optimism, right?
01:26:21That's where that's where I think we need.
01:26:24We need to be.
01:26:25I think this conversation is important.
01:26:27These are realities.
01:26:28Are realities today, right?
01:26:31Folks in, but we didn't have this
01:26:33conversation when I was in medical school,
01:26:36right? I mean,
01:26:37this is like that's that's also a truth.
01:26:39Is the same phenomena or at play?
01:26:43And these were not there were
01:26:45there weren't spaces for for this.
01:26:47For this kind of exchange rate and
01:26:49opportunities to to not just raise awareness,
01:26:51right to Victor's point,
01:26:52but to be thinking really about where
01:26:55those policy levers are, and that
01:26:57opportunity for structural transformation.
01:26:58And you know.
01:26:59And so I I do really feel that like and hope.
01:27:03And I do feel that the the
01:27:05sort of 20 years from now,
01:27:07or I've been out of my school longer.
01:27:10But we won't, you know,
01:27:1120 years from now,
01:27:13the group that's having this conversation.
01:27:15Right, it's gonna it's it's
01:27:17it will be different right?
01:27:19Because we will have had by then.
01:27:22Hopefully the multiple decades of
01:27:24some change in in the way that we
01:27:28organize ourselves and not that we.
01:27:30This this will always be our legacy,
01:27:33but it doesn't have to be our future, right?
01:27:35So to leave to with everybody,
01:27:37I hope energized in a way that you
01:27:39exercise your own power to contribute to
01:27:42that structural transformative change.
01:27:43I think it is possible in 2020 and beyond,
01:27:46in a way that perhaps it wasn't,
01:27:48you know,
01:27:49even in the 60s and be our building of you,
01:27:52know, the shoulders of all the Giants.
01:27:54So we have big shoes to fill.
01:27:57And I think I think we can so.
01:28:00Light hope optimism is going to be better.
01:28:05I like that. Thank you very much
01:28:07and Max will give you the the final
01:28:09word and then you can close us out.
01:28:12I just want to say thank you both later.
01:28:15Marcella for joining us tonight.
01:28:16This was a great conversation to.
01:28:18I mean, we've had these
01:28:20conversations and you know,
01:28:21in private many times.
01:28:23And thank you, Anna, thank you, Karen.
01:28:25Thank you Sam for setting up this platform.
01:28:27It you know, it's a delight.
01:28:29Ann, thank you both for your scholarship,
01:28:32which has like tremendous,
01:28:33tremendously inspired me and made me
01:28:35feel like I am not crazy over, you know,
01:28:38these last four and a half years so.
01:28:44Thank you everybody.