Yale Psychiatry Grand Rounds: September 15, 2023

September 15, 2023

Information

"Pursuing Fundamental Fairness; APA's Response to Structural Bias in Psychiatry"

Speaker: Cheryl Wills, MD, Associate Professor of Psychiatry, Case Western Reserve University

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00:00DK for a lovely introduction,
00:03I'm going to see if I can share
00:06my screen here and get started.
00:11Okay,
00:16okay, good morning.
00:17It's a privilege to be here.
00:20It's been an interesting time in history
00:25of the United States and elsewhere,
00:28especially with the
00:29pandemic and civil unrest.
00:31And one of the things that I've
00:35noticed is that people have responded
00:38differently to stressors than they
00:40would have in other situations,
00:42but with good reason.
00:43Each stressor we've had to deal with has
00:45affected each of us in a different way.
00:48So one of the things that's
00:49important to me is to understand,
00:50try to understand where everyone's
00:51coming from and try to reach a
00:53consensus that moves us ahead.
00:55And the goal is to do that as efficiently
00:56as possible because we know that
00:58there are going to be hiccups along
00:59the way and we have to reconfigure
01:01things and be strategic about it.
01:03And I guess this is what we're
01:05trying to do in forensic psychiatry.
01:07We're trying to look at all the data,
01:10marshal the evidence,
01:12render an opinion,
01:14and then advocate for that opinion
01:18while being cognizant that there are
01:20times that we may have overlooked
01:22something and we'll have to concede
01:24and and and step back and regroup.
01:26So my talk is pursuing fundamental fairness,
01:28APA's response to structural races
01:31of structural bias in psychiatry.
01:33And let me see if I can move these
01:36photos okay now I can see better okay.
01:38The objectives are to explain the
01:40relationship between structural bias,
01:42health disparities, medical morbidity,
01:44and mortality.
01:45To explain examine how organized medicine
01:47is addressing racial bias in healthcare
01:49and to describe the process challenges,
01:51accomplishments,
01:52implementation,
01:52and lessons learned by the Structural
01:55Racism Task Force and present.
01:57The status of the A present status
01:59of the APA's anti bias agenda and
02:02the gap is suggesting the gap and
02:04knowledge of how intrinsic and extrinsic
02:06biases in medicine affect health
02:09disparities and workforce burn down.
02:11I have no disclosures and I would
02:14like to open my talks with a quote
02:17and here's one of my favorite ones.
02:19Great minds discuss ideas,
02:23and we're going to discuss some ideas today.
02:25Average minds discuss events,
02:27and of course we'll be discussing
02:29some events,
02:29but to a lesser degree than the ideas
02:32and small minds discuss people.
02:33We're going to try to avoid that one today,
02:36so let's just look at some basic definitions.
02:39Race is a social construct or
02:41interpretation based on physical
02:42characteristics.
02:43Racism is a system that assigns
02:45value to that.
02:47Prejudice is a belief that is rooted,
02:48and often rooted in unfair assumptions.
02:51Discrimination is an action that is
02:53informed or motivated by prejudice,
02:56whether or not it's deliberate.
02:59And excuse me,
03:02HealthEquity is really what
03:05we're talking about here.
03:08Despite immutable traits, each person,
03:11regardless of station in life,
03:13can achieve the same level of
03:16health by accessing individualized
03:18quality care without bias.
03:20So it's a matter of accessing care
03:22based on what your needs are and not
03:25how much you have in your wallet or
03:28whether which insurance plan you have.
03:31OK, we're going to talk a little
03:32bit about microaggressions.
03:33I'm sure you're familiar with this term,
03:35which was actually coined in the late
03:371960s by a PA member, Chester Pierce,
03:40who just had a an endowed lectureship
03:45funded in his name. And Ezra,
03:47your own Irish Griffith was
03:49one of the people behind that.
03:51But he coined this term in the late 1960s,
03:53described how whites reacted to blacks after
04:01became illegal in the country.
04:02And it was a it was a brief,
04:04commonplace verbal, behavioral,
04:06or environmental indignity,
04:08regardless of intent,
04:09that communicated hostile,
04:10derogatory or negative prejudicial
04:11slides and insults towards a group,
04:13particularly culturally marginalized groups.
04:15Now in the late 1960s,
04:18Doctor Pierce used that to describe the
04:22relationship between whites and blacks.
04:24Black whites towards blacks,
04:25particularly in the South but
04:27also elsewhere and over time.
04:29People like Darryl Wingsu and others
04:32began to study this and realize
04:34that this is not specific to blacks.
04:37The relationships or or a microaggressions
04:39don't focus just on black people.
04:43So they decided it on many levels.
04:46It affects college students,
04:48It affects people and everyday life.
04:51There are studies that show
04:53that it is related to suicide.
04:56It's mediated by depression,
04:57but increased drinking,
04:58increased anxiety are some of
05:00the things that studies have
05:01shown that are related to this.
05:03So we have to be mindful of this because
05:05it may seem like a small incident,
05:08but when it's compiled and
05:10you compound other factors,
05:11this can have horrible outcomes
05:14for a subgroup of people.
05:16Micro inequities is something that
05:18our patients often talk about,
05:20but also our colleagues.
05:21The experience of being undervalued,
05:24marginalized, overlooked,
05:25and devalued because of someone's
05:27status as a minority.
05:29And one of the reasons micro
05:31inequities is important in
05:33Healthcare is because of how,
05:35because how people are perceived or how
05:38they feel during a healthcare encounter
05:41informs how they approach Wellness,
05:44whether or not they return,
05:45whether or not they comply etcetera.
05:48So we have an important role to play
05:50in in addressing micro inequities,
05:53being responsive in to it in our patients,
05:55but also being aware of it around us.
06:01Intersectionality, the complex cumulative
06:03way in which the effects of multiple
06:06forms of discrimination such as racism,
06:08sexism, ableism, and classism combine,
06:11overlap or intersect, especially
06:13in the experiences of marginalized
06:16individualized individuals or groups.
06:18For example, right before the
06:20Structural Racism Task Force,
06:22I had broken my ankles.
06:23So what was my intersectionality?
06:26African American, female,
06:28overweight and on crutches.
06:31And I can tell you, based on one
06:33experience when I had to travel by air,
06:36the treatment was horrendous.
06:38I was stuck on a plane for almost an hour
06:42because no one would help me get off.
06:44And that was before I was on
06:46crutches and I needed a knee scooter.
06:49I also was placed on the plane last
06:51and stepped up first because there
06:53wasn't enough staff and mind you
06:56this was pre pandemic not during
06:58the pandemic so they they should
06:59have had sufficient staff.
07:03Also it made me think about how difficult
07:07it is for people who are differently abled.
07:11Do you driving to the store and not
07:14being able to get a handicap parking
07:17spot because someone that fell the need
07:19to run into it to a store, etcetera.
07:21So these things while the everyday
07:24person may consider not too important,
07:26those cumulative perceived slides can
07:28have an impact on one sense of wellbeing.
07:33Okay, structural or systemic racism,
07:36also known as institutional racism
07:38is a combination of public policies,
07:41institutional practices,
07:44social forces and processes that generate
07:49and perpetuate inequities about races.
07:52And the key to racism is that is that
07:54it evolves, it's dynamic, it's adaptive.
07:57We can look at the the caste system,
08:00we can look at housing discrimination.
08:03Often times it's legislative, but look,
08:04historically we see how after slavery
08:08was adopt abolished, the policies
08:11and the laws morphed to Jim Crow.
08:14And then we thought that the Civil
08:17Rights Act of 1964 actually outlawed
08:21discrimination against minorities.
08:23But we see what's going on,
08:25what will happen in 2020 during COVID in
08:28the health inequities and other inequities,
08:30police brutality,
08:32housing discrimination, etcetera.
08:34And then we still see some
08:38in a different form in 2023.
08:40And as someone who has been
08:43subjected to housing discrimination,
08:44I I I think this is extremely concerning
08:47because when I tell people my experiences,
08:50I say, you know,
08:51I've had housing discrimination
08:53experiences ever since medical
08:55school and I overpaid for my house.
08:58Why?
08:58Because I didn't want to be bothered
09:00with the process.
09:01I just wanted somewhere to to become
09:04that I was comfortable with.
09:05But they say,
09:06well you know why it's experienced
09:08this also I said I get it and I
09:10believe it and I've seen it happen,
09:12but do they have it occur as often as
09:15it has happened to someone like me?
09:18Even when I paid,
09:20when I finished my fellowship,
09:22I went and I paid 2 months,
09:26two months of deposit and the first
09:29month's rent came back and Phil Resnick,
09:31secretary, called me and said
09:33you have to go back to Buffalo.
09:35Your apartment fell through,
09:36I said, But the money's in the bank.
09:38So over time, if that's impacting me
09:40or someone like me or one of your
09:42colleagues or one of your patients,
09:44you can see where how that
09:46can impact their attitudes.
09:47The presentation at work,
09:49the the perceived stressors at
09:51work because they have more to
09:54deal with that most people don't.
09:57And classification of of racist
10:02racism is based on intent.
10:04Now let's not forget that for 85% of
10:08the time that blacks have been in this
10:11country since sixteen 1985% they've
10:14lived under legalized discrimination,
10:16so up until 1964.
10:18So when you look at that,
10:20you see how harsh this is
10:23and how it can happen,
10:25impact on our perceptions of others.
10:29And it's not a matter of you didn't cause it,
10:31this person didn't cause it,
10:32that person didn't cause it.
10:34It's a matter of these
10:36things occurring over time.
10:37So classification can be direct or indirect.
10:41So direct racism is deliberate.
10:43It's often legislated.
10:43It's that policy.
10:44We don't allow these types
10:46of people in our system.
10:47And I I'm working with on the I MG's and
10:49working with residency training directors.
10:52One of the things that I MG's submitted
10:54a report to the Board of Trustees,
10:57GA Board of Trustees.
10:58One of the things they requested is
11:00that the APA take a position on using
11:03some type of filter to filter out
11:06international medical graduates when
11:07one is selecting residency programs.
11:10And I heard many people say we don't do that.
11:13But then I had two training directors
11:16from two different programs in two
11:17different parts of the United States,
11:19and both of them said their
11:22chairs had asked them to filter
11:24out I M g's on the first round.
11:26So that would be deliberate.
11:28Indirect is when you know it's
11:31wrong and you still do it,
11:35you still perpetuate that.
11:37And in post those cases,
11:39those training directors said that
11:40they told their chairman Okay,
11:41they do it,
11:42but then they didn't because they
11:44knew it was the wrong thing to do.
11:45Okay. Now let's talk about privilege.
11:48This is a very polarizing turn these days,
11:53But I'm going to talk with you about
11:55privilege from the perspective
11:57of Peggy Mackintosh,
11:58who was a professor of women's studies
12:01at Wellesley, and she wrote a paper,
12:05a seminal paper titled White Privilege,
12:11Unpacking the Invisible Knapsack.
12:13And what Doctor McIntosh did was in
12:16the late 1960s, she wrote a seminal
12:19paper about male privilege, and again,
12:21as a professor of women's studies,
12:24this was at Proco. But over time,
12:26she realized that relative to her
12:28black colleagues in the department,
12:30she had access to resources that they didn't.
12:33She knew people, the networks,
12:35the opportunities,
12:35and they didn't have those opportunities.
12:38So even if they were equally qualified,
12:40their careers would not advance as
12:42fast because they didn't have access.
12:44So she uses metaphor white
12:46privileges like an invisible,
12:48weightless knapsack of special provisions,
12:51assembly, excuse me, Provisions, maps,
12:53passports, code, books, visas, clothes,
12:57tools and other blank checks, etcetera.
12:59And the key to this invisible
13:02knapsack is that you're born with it
13:04and contains these unearned apps,
13:07assets that you count on cashing
13:10in on every day.
13:12Now your condition to be
13:16oblivious to cashing in on that.
13:19And that is key.
13:20We each have different types of backpacks,
13:23and the backpack and our knapsack
13:25would vary depending on where you are.
13:28For example,
13:28if you're Jewish in New York,
13:30you may have a burlap knapsack
13:32with a lot of provisions in it.
13:35If you move to South Dakota that
13:36the fabric on that knapsack may thin
13:38out and the resources may thin out,
13:41but you're walking into a situation
13:43where you have a advantage and a level of
13:47resources that other people may not have.
13:50I have privilege.
13:51I sit on the board of trustees of the APA.
13:54Is that not privilege?
13:55That's something that most people don't have.
13:57So I have access to knowledge,
13:58resources, people,
13:59etcetera, by virtue of that.
14:02So in that situation, I have privilege.
14:04But when I went to pick up some artwork
14:07from a museum that I had purchased,
14:10I was accompanied by two friends
14:11and they asked me.
14:13It was a Saturday morning and they asked me,
14:15why are you dressed for work?
14:17I said because I'm going to get my artwork.
14:20They had on jeans and ski jackets,
14:22but why do you need to dress that
14:25way when you're picking up artwork?
14:27It's the weekend,
14:28I said,
14:29because I'm going to pick up my artwork.
14:31So we walked into the museum and
14:33this was the at the end of an art
14:35show and the three of us walked in.
14:37They're older white women and they
14:41walked right through. I got stopped.
14:44I was asked, may I help you?
14:45I said I'm here to pick up my artwork.
14:48Oh, are you working for one of the artists?
14:52No,
14:52I'm here to pick up artwork that I purchased.
14:57Well how do you think you get artwork?
15:01I purchased my artwork.
15:04So I said, here's my ID,
15:06which they told me to bring,
15:08and the woman looked at my ID
15:11as if she was perplexed.
15:13So I said, well,
15:14I have my passport and my
15:16medical license here too,
15:18if you'd like to see them.
15:20And then things changed.
15:22I was able to pick up my artwork.
15:25I was happy. We walked out of the
15:28museum and my friend asked me,
15:30how could you be so calm?
15:32I said I'm happy.
15:33Why are you happy after you
15:35were treated like that?
15:36Because I got my artwork,
15:38I came here to get my artwork,
15:39I got my artwork and I'm going,
15:41I'm, I'm going home.
15:44So they couldn't understand that.
15:46Why can't you be mad?
15:47And I explained to them,
15:48if I allow that to ruin my day,
15:51I would have more ruined
15:53days than you can imagine.
15:55So I dressed a certain way and I prepare.
16:00I had more ID than I needed,
16:03just in case,
16:03and it worked for me.
16:05I'm not going to give her and her
16:08ignorance the opportunity of the
16:09privilege of controlling my mood and my day.
16:13I'm happy, mission accomplished.
16:14And they were miserable for
16:15the rest of the day.
16:16And we still talk about that because
16:19they didn't realize what it was
16:22like until they saw it first hand.
16:25So let's talk about another aspect of
16:30discrimination, systemic discrimination.
16:31This is a wonderful study by Calco,
16:34Calfeld and Hancock.
16:35And what they did was they went
16:38to the Philadelphia court system,
16:40and they're linguists.
16:41They went to the Philadelphia
16:43court court system and they asked
16:46transcriptionists to participate in a study.
16:49In 27 agreed.
16:50And what they did was they recorded
16:538 native speakers of African
16:55American English and asked the the
16:58transcription is to to transcribe it.
17:02Those transcriptionists got 59.5%
17:06accuracy in terms of sentences.
17:09Words were transcribed 82.9%
17:13of the time correctly.
17:1582.9% of the time.
17:17Who, what,
17:18where and when were often
17:20transcribed incorrectly.
17:21Sentences were correctly
17:22paraphrased 1/3 of the time,
17:25but that was not systematically
17:27related to accuracy.
17:28So you can see where when some
17:31if you were in a situation and
17:33you were in court and someone in
17:36contract directly transcribed
17:37what you were saying and that goes
17:39up to that case goes to appeal,
17:41that can have a bad outcome.
17:44And I'll note that in order to
17:46be certified as a court reporter,
17:4995% accuracy is required.
17:50But the problem with this is
17:52that the transcription is said
17:55they want more training,
17:56they want more help when they are trained.
17:59They are trained on the
18:01voices of news reporters,
18:02judges and attorneys.
18:04They don't reflect the
18:06people that are in court,
18:08the general population that
18:10appears in the courtroom.
18:11So they get tested on one thing
18:15and then they are in another
18:17situation and it's hard to
18:22be inaccurate. But they also say that
18:26they were trained to tell people when
18:29I asked people for clarification when
18:31they didn't understand what was said.
18:34But that was quietly discouraged
18:35in a courtroom and could cost
18:37them their jobs as a subtext.
18:39So again these implications are profound.
18:42I've had it happen with transcriptionist
18:44I found in some and and one case that
18:49Ebonics was included in my transcription,
18:52which is why I read all of them.
18:54It said D&amp;D and she be doing this net
18:58during a forensic deposition that I gave.
19:03So what about medicine?
19:06From Martin Luther King Junior said
19:08in 1966 to a group of reporters,
19:11Of all the forms of
19:12discrimination and inequality,
19:13injustice and Healthcare is the
19:15most shocking and inhuman because
19:17it often results in physical death.
19:21So the AM may begin to look at this during
19:27the beginning of civil unrest about May 2020,
19:32as well as during the pandemic when
19:34all the data was coming out to.
19:36That reinforced the inequities and made
19:38it a reality for some people who fail to
19:41believe racism is a threat to public health.
19:44So they wanted to focus on creating pathways
19:47to truth healing and reconciliation.
19:50They want to advance equity
19:52in medicine and public health.
19:53They said something that they've
19:55known for years or decades.
19:57Race is a social construct which
20:00is different from ethnicity,
20:02genetic ancestry or biology,
20:03and race is not a biological
20:06determinant of health.
20:12The AM A supports ending the practice
20:14of using race as a proxy for biology
20:17or genetics and medical education,
20:19research and clinical practice.
20:20And I often get the question,
20:23well, if you don't use race,
20:24then how do you get this information?
20:27And it's simple.
20:28The AM A recommends that clinicians and
20:30researchers focus on genetics and biology,
20:33the experience of racism and social
20:37determinants of health and not race when
20:41describing risk factors for disease.
20:46So it seems simple,
20:48but to get people to buy
20:50into this will take decades,
20:52especially in research,
20:53because already in research people are
20:56screened out because they are not the
20:59quote UN quote ideal study subject.
21:02So the patients I see,
21:04most of the patients I see do not
21:06qualify for research studies for
21:08a variety of different reasons.
21:10But they they have.
21:11They would never check off all the
21:14boxes for one reason or another.
21:16So let's talk about social
21:19determinants of health.
21:21The county health ranking study
21:22was one of the first studies that
21:25showed that clinical care accounts
21:28for 16% of health outcomes.
21:31Some other studies showed 18 to 20%.
21:35But most of what happens and what most
21:40of what determines those outcomes are
21:42the social determinants of health,
21:44how we live, work, worship,
21:47are educated, our families,
21:49our situations,
21:50etcetera.
21:50So when we look at all of those
21:53lifestyle factors,
21:54we go back to the concern about
21:57the bias in these systems.
22:01So Metzel and Hanson Metzels in Tennessee
22:05and Hanson's at USUCLA came up with concept
22:10called structural competence and they
22:14said that it's the more you understand
22:16about structural bias in the country,
22:19the better the outcomes will be.
22:20And studies have since reinforced that.
22:23So they're part of being structurally
22:26competent is understanding the
22:27downstream effective policies,
22:29biological, economic, cultural, etcetera,
22:32including different forms of class
22:37disenfranchisement and HealthEquity.
22:39Despite immutable traits,
22:41you have access to the potential
22:44that have similar house health
22:46outcomes that can reduce internal
22:48and external bias and stigmatization.
22:51For example, when you come into a hospital,
22:53if you have tattoos of a certain type,
22:57that may explain or that may be
23:02telling in certain situations.
23:04Now these days, so many tattoos occur,
23:07but they still use people have tattoos,
23:10but you still look at these things
23:13and I always ask about study stories
23:14about the tattoos, the histories,
23:16the background, etcetera.
23:18But this is one of the things that
23:20has been associated with gangs
23:22and certain communities etcetera.
23:24So now a number of hospitals are
23:26taking on structural competence
23:28training as part of their orientation.
23:31For example,
23:32at Boston Medical Center with orientation,
23:36no healthcare professional can go and
23:39touch a patient in that hospital until
23:42they learn about structural bias and
23:45the things that they're going to see
23:48based on the community that they they serve.
23:52That can support culturally competent care,
23:55but it also promotes evidence based care.
23:57Because once you understand these
23:58things and can filter those out,
24:00you can look at the medicine
24:02and the physical,
24:02the the physical health and mental health
24:05concerns because without that bias.
24:07And that's going to be extremely
24:09important in how we proceed.
24:10And I'll show you a study in a few
24:12minutes that will reinforce that,
24:14but it also can reduce professional burnout.
24:16I had a colleague who once said I see my
24:21worst patients more often than others,
24:24and someone asked why those are the ones
24:27you probably don't want to see and he said,
24:29well, I think of it this way.
24:31The more I see them,
24:32the better chance I have of getting
24:34them well and not seeing them as often.
24:37And once they're well,
24:39I feel very effective and I'm
24:42less likely to burn out.
24:44So when you understand and can
24:47filter out the structural biases,
24:49the racism, and other forms of bias,
24:52you can look at that person.
24:54It improves health outcomes,
24:55it supports culturally competent care
24:57and promotes evidencebased care.
24:59So you do feel more confident and
25:01you're less likely to burn out because
25:03your practice seems less overwhelming.
25:05So here's an example in Madison that is
25:09interesting for a number of reasons.
25:10As you see, there are four, three men there.
25:15We have the Chala from Chadwick
25:18Boseman from who starred in the
25:20first Black Panther
25:24movie as well as in a number of other
25:28movies and was one of our bright stars,
25:30who died of cancer in his early 40s.
25:33Colon cancer, even.
25:34Kennedy was diagnosed with stage
25:374 colon cancer at age 4039.
25:39And Darryl Strawberry,
25:41who won World Series rings in New
25:46York's for the Yankees and Mets.
25:48He was diagnosed with colon
25:51cancer at age 36. So you have
25:57all that diagnosed with
25:59colon cancer before age 40.
26:01Now we also know that the steepest
26:03increase in colon cancer is in
26:05people ages 20 to 39 years of age.
26:07And also there is increased
26:09incident in women.
26:10Blacks are 20% more likely than whites
26:12to be diagnosed with colon cancer,
26:15and they're 40 to 50.
26:16Blacks are 40 to 50% more likely to die.
26:18So this seems to be a real concern,
26:21especially since it's
26:22being diagnosed earlier.
26:24But the requirements that I think
26:26they came out in 2020 or thereabouts
26:30recommend colonoscopies start at age 45.
26:35So you're overlooking a population
26:37of people systematically who have a
26:40worse prognosis and are more likely
26:42to die and to have the disease.
26:45So this is another example
26:48of systemic or implicit bias.
26:50Now let's look at some other examples.
26:54In 2018,
26:54I opened a newspaper and saw that
26:57a hospital emergency department
26:58found that there was a flaw in their
27:02algorithm for contestive heart failure.
27:04All things being equal with
27:06the severity of symptoms.
27:07If you were white,
27:09the algorithm told you told the
27:12doctors to hospitalize the patient,
27:14and if that patient was black,
27:18the hospital was called,
27:19the instruction was to send the person home.
27:22So somebody put program that in
27:25the algorithm. The question is why?
27:27And how was it somebody who did it By
27:29an error, the wasn't tested properly,
27:32etcetera.
27:32So when you're looking at computers and such,
27:34again,
27:34it depends on what we put in it and
27:36not everything we put in it is equitable.
27:38So we have to look at the data
27:40and do test runs before we use
27:42this to make life the data,
27:44the programs to make life or death decisions.
27:47And we also look at cystic fibrosis.
27:50Blacks are diagnosed an average of four
27:53years later with cystic fibrosis than whites.
27:56Why?
27:56Because in medical schools often people
27:58are taught that it's a white disease,
28:00so people don't look for for it.
28:03And I've had four patients,
28:04black patients with cystic fibrosis and
28:07it was consistent in all the cases.
28:09It was four years,
28:10regardless of age,
28:11from from teens to early 40s.
28:16The perception of pain has been
28:18shown by the national study from
28:21the National Academy of Sciences.
28:23They surveyed medical students,
28:25and they found that they,
28:28like their counterparts in society,
28:31not nonmedical professionals,
28:32believe that blacks have a
28:35higher pain tolerance.
28:36There's also some studies that suggest
28:39that pain perception is disregarded or
28:41outcomes are worse if the person is less.
28:44Lacks English.
28:45The parent lacks English proficiency,
28:47and there's one study looking
28:49at appendectomies.
28:50Now,
28:50a couple of other studies have
28:51come out and they have found
28:53it a little bit different,
28:55but the studies were not duplicated,
28:57so we'll have to wait to see
28:59what happens with that.
29:00But we do know they were less
29:02likely to get imaging studies,
29:04and they went to the the operating room
29:10for an appendectomy at a later stage
29:13of severity. And then we know
29:15about schizophrenia which is
29:17disproportionately diagnosed in blacks
29:19relative to whites regardless of age.
29:23And and this is profound,
29:25even when semi semi structured
29:29clinical interview tool was used,
29:33still blacks were diagnosed with
29:37schizophrenia more often than whites.
29:39And that has a lot of implications
29:43about treatment seeking prognosis
29:45and other forms of care and
29:47longterm outcomes and equity.
29:50So let's talk a little about
29:52resident burnout and racism.
29:54And this is an extremely important
29:57study that came out in 2019, Derby,
29:59Heron and Wes and colleagues,
30:02it was a Co-op study and they looked
30:05at over 3000 non black second year
30:07resident physicians and they did gave
30:09them the mass like burnout inventory
30:11which was basically two questions.
30:13And then they did a hard sort for implicit
30:16bias and a feeling scale for explicit bias.
30:18And what they found was secondyear
30:21residents who were stressed out,
30:22more more likely to engage in,
30:26was more likely to be associated
30:29with implicit and explicit
30:31bias against black people.
30:33So when blacks came into the
30:35clinics or the hospitals,
30:37the bias was implicit,
30:40meaning they may not have been aware of it,
30:42or it was unintentional,
30:45perhaps, and explicit meaning
30:47deliberate against black people.
30:49So if you're one of those black
30:51people going to a hospital and
30:53counting one of these residents,
30:54you're not going to have a good experience,
30:56or you're not going to have as
30:58good experience as you should,
31:00all things being equal.
31:01Now the interesting thing is
31:03they found that in 3rd year,
31:04the same residents were less stressed,
31:06and when they were less stressed,
31:08they were less likely to
31:10engage in explicit bias,
31:11intentional bias against blacks.
31:13But the implicit bias persisted.
31:18So what about the experience
31:20of racism and psychiatry?
31:21We talked a little bit about that, but
31:28there are other areas in
31:31which there's discrimination.
31:32And we talked about schizophrenia.
31:35Let's talk about antipsychotic prescriptions.
31:37Blacks are more likely to get
31:39first generation antipsychotics,
31:41then then second and that study was
31:45from 2004 and it's been repeated
31:47now we see all the metabolic
31:49concerns that are related to
31:552nd generation antipsychotics.
31:56So you've got to look at the balancing act,
31:58but we also look at the opioid crisis
32:00in terms of pain perception. Blacks,
32:02usually you see a condition like this,
32:04it it affects all sorts of people.
32:07But early on in the early 2000s
32:09when we began to see the the
32:11casualties due to the opioid crisis,
32:12they were disproportionately black, white.
32:15Only recently have blacks been catching up.
32:17So while many blacks suffered
32:20unnecessarily with pain back then,
32:22it may have saved a number of lives.
32:24So it's a mixed bag there.
32:26But it shouldn't be occurring.
32:29When substance shoots,
32:30treatment is prescribed.
32:32Blacks are less likely to get substance
32:35use care that is cutting edge or
32:40medication assisted therapies when
32:42they are discharged from hospitals,
32:45and these are individual studies.
32:46I have the references if you'd like.
32:48When they are discharged from hospitals,
32:50they're less likely to be
32:52referred for psychotherapy,
32:53They're more likely to be secluded
32:55or restrained in hospitals and other
32:57settings and they're more likely to
33:01complain about perceiving discrimination
33:04in the hospitals in terms of the
33:07ratings that hospitals feedback
33:09studies that have been occurred.
33:11So there may be a number of reasons
33:14about that when you look at the resident
33:17study that shows that there's some bias
33:19and that's a significant part of it.
33:22Now,
33:22one of the things we do in medicine
33:24and psychiatry is prescribed lithium.
33:27And one of the things we look at is
33:29the glomerular filtration rate and the
33:31estimated glomerular filtration rate change.
33:34How we look at the range for or what
33:38the threshold for kidney disease or
33:41renal failure is in black versus white.
33:43So Dorothy Roberts is a law
33:48professor at Upenn,
33:49and when she was a Robert
33:51Wood Johnson's fellow,
33:52she looked at the history of the
33:55difference in a range for a renal failure,
33:58cut offs in blacks versus whites.
34:01She traced it back to about the 1930s and
34:04discovered that it was a case of IPSI Dixit.
34:07Because I say so,
34:09So for generations,
34:10because some person said so.
34:12We trained psychiatrists and
34:15other physicians,
34:16healthcare professionals,
34:17generations of them to say to
34:20to believe that the glomerular
34:22filtration rate range acceptable
34:24range was different based on race.
34:27That difference is as much as 21%,
34:31which means that blacks were
34:33less likely to be diagnosed at
34:36an early stage of renal failure,
34:38which affected morbidity and mortality.
34:40So it wasn't race that it was said
34:44that blacks have a worse outcome.
34:45It was because of the Gomera
34:48estimated gomerial filtration
34:50rate and not because of race.
34:52So that also meant that blacks
34:54were less likely to be eligible for
34:57placement on the renal transplant list.
35:00And in February 27th,
35:022023,
35:03the US Oregon Procurement and
35:06Transplantation Network made an
35:08effort to make that equitable.
35:10They said that they were going
35:12to look at every black person on
35:15the renal transplant list and see
35:17when they how long they had been,
35:23how long they had been delayed treatment
35:26because of the estimated glomerular
35:28filtration rate because now the systems
35:30are more equitable and you there
35:32are many papers coming out etcetera.
35:34Although three years ago people would
35:36fight tooth and nail against us.
35:38So what they decided was that they
35:40were going to look at how long
35:43the diagnosis of renal failure was
35:46delayed and they would compensate
35:48blacks for at least up to 19 months.
35:52In other words, you go back and if
35:55you were misdiagnosed for two years,
35:57they would move you up 19 months ahead
36:00on the transplant list in an effort to
36:03come create some semblance of equity.
36:06And so the wait listing times had
36:08to be backdated.
36:09And this is to it's intended to repair
36:14damage due to structural racism.
36:17The While it sounds good,
36:21it doesn't happen enough.
36:23This is one of the first efforts
36:25to do some type of correction,
36:30attractive action for medical
36:32bias on this level.
36:34And we also look at ADS.
36:35This is a 1974 ad from the Archives
36:39of General Psychiatry and some
36:42of you may recognize this.
36:45This is an ad that says assaultive
36:47and belligerent cooperations also
36:49often begins with hallow paradol,
36:52a first choice for starting therapy.
36:54And what you see in the picture
36:56is the angry black man.
36:57Now that is one of the things that people
37:02used to justify diagnosing schizophrenia.
37:06Incorrectly,
37:06so of course,
37:07but if it's an angry black person,
37:09an agitated black person,
37:11they're more likely to be diagnosed
37:13with a psychosis spectrum disorder
37:15rather than a mood disorder.
37:18So, and this comes when you're taught this,
37:20you're trained this to think this way.
37:24That passes on to generations too.
37:26And that impacts how we treat African
37:29Americans who come in or psychiatric care.
37:34Now, what can we do to remedy this?
37:37Well,
37:37clinician bias and burnout and
37:40structural bias or discrimination in
37:44healthcare can be diminished by health.
37:49Cultural humility.
37:50Let's start with cultural competence.
37:52Cultural competence means that you
37:53go and you study and you learn more
37:55about different cultures, etcetera.
37:57But it the word competence
37:59suggests that it's finite,
38:01but it also can introduce bias.
38:04I've read about how you people function,
38:06so therefore I know what's best for you.
38:08Or this is how you do things.
38:10Or in your hospital.
38:12This is the culture.
38:14So when you use cultural competence,
38:17there is a sense that you have
38:20gained proficiency and you risk
38:22telling people about who they are
38:24rather than listening to them
38:27and learning about who they are.
38:29But what you can do is use
38:32cultural competence to inform your
38:34approach to cultural humility.
38:36For example,
38:37I once worked on A at the Navajo Nation,
38:41the hospital there for it
38:43defines an Indian hospital.
38:44So what I did was I read a lot
38:48about native culture and then
38:51I asked questions about it.
38:54Can you help me understand this?
38:56Is this a customary or how
38:58should I think about
39:00this? And they really enjoyed
39:02the have having discussions.
39:04They sent me to a sweat lodge and the
39:07next day they had a debriefing and I
39:10learned so much about indigenous culture
39:13that it was a a a profound experience.
39:16But had I gone in and said, you know,
39:18all I I've read in these books and
39:20use that and not ask questions,
39:22not been looking at critical selfreflection,
39:25where am I being biased?
39:26Am I shutting myself to be open
39:28on to this and to learning,
39:30then the outcome would have been different.
39:32So a cultural humility involves
39:35critical selfreflection,
39:36openness, nonjudgment, curiosity.
39:37And it's been shown to have
39:39benefits and treatments such as
39:41strengthening the therapeutic alliance
39:43and improving health outcomes.
39:45So what about a PA?
39:48Well, APA strategic initiative since
39:532015 has been to advanced integration
39:56of psychiatry and healthcare,
39:58supporting research,
39:59supporting and increasing diversity
40:01within the APA and education.
40:04And I put in yellow here and a larger
40:06type support on the supporting
40:09increasing diversity in the APA.
40:11And the rest of it says serving
40:12the needs of evolving, diverse,
40:14underrepresented and underserved
40:15patient populations and working to
40:17end disparities in mental health care.
40:20OK,
40:21so Apa's response to structural
40:24racism was multifactorial.
40:25And I will say that the task force,
40:28I'm going to tell you how that came about.
40:30In March 2020,
40:31we were in the board room debating
40:33whether or not we're going to have the
40:35May meeting because the pandemic was there.
40:38And I brought up a concern that we were
40:41not following the OR fulfilling the
40:43diversity initiative or requirement
40:45or goal of our strategic initiative.
40:47And after bringing it up a couple of times,
40:49President Bruce Schwartz said let's
40:50look at that. And then his term ended.
40:52And then Jeff Geller,
40:54term open began and as president of a
40:58PA and he said we're going to look at this.
41:01And once he looked at it further,
41:05he was planning a a study or
41:09study group on this.
41:10And then after George Floyd's death,
41:13he changed it to a task force and made
41:16it the focus of his presidential year.
41:19Now back to a PA's response
41:22to structural racism.
41:23They did make some announcements about
41:25COVID-19 and health disparities early on.
41:28They denounced racism and police brutality.
41:30And some of this had occurred before 2020.
41:34In July 2020,
41:34the Board had a round table
41:36discussion and everyone participated.
41:38I think it was about two hours long
41:40about each of our views on race.
41:42And they realized that the APA has does
41:45not have definitions for minority and
41:48representative and underrepresented.
41:50And so there was a whole work group on
41:52that and then they did more studies.
41:54And so the findings have been taken,
41:57sent to the minority and underrepresented
42:00groups and they had focus groups
42:02and discussions about that.
42:03So that's still an evolution.
42:05We hired consultants and this
42:07was one of my big
42:11request. I said that we don't
42:14have the expertise to say whether
42:17or not our board is biased or
42:21conforming practices for boards.
42:23We need someone who knows
42:25how boards function etcetera,
42:28look at what we're doing and give
42:30constructive feedback about what
42:32we're doing well and helping us
42:34understand what we need to do to
42:36improve in those other areas.
42:37So there was also a call self and
42:39looking at structural bias in a
42:41PA's or diversity equity inclusion
42:43in a PA's headquarters.
42:44And the board underwent A sixhour
42:47training with the Barkwell
42:49Group adversity training.
42:50And while it seemed to be a
42:53drop of sand in the water,
42:55it actually got us on a common ground
42:58because everybody had a similar baseline
43:01for discussion and the discussions
43:03began to change in a positive way.
43:06The CEO was appointed A diversity
43:08coach and he found that extremely
43:11helpful and I noticed that his
43:14language and his perspective,
43:15how he processed or presented
43:17I should say how he presented.
43:19Things changed and the tensions actually
43:23diminished when with certain groups
43:26that were perceived to be slighted.
43:29The APA's foundation does pipeline
43:32programs and programs about
43:34psychiatry for high school students,
43:37Historically black colleges and universities.
43:39There are many fellowships for
43:41residents and some of you may
43:43be a PA Foundation fellows.
43:44And then there was a Chester
43:46Pierce Human Rights Award,
43:47which I mentioned before beyond
43:49the Structural Racism Task Force.
43:51Also our publications took it upon
43:54themselves to look at the matter
43:58and introduce areas of reform
44:00or areas to expand diversity.
44:02Now President Geller appointed
44:04Structural Racism Task Force
44:07and here are all the members.
44:10There were five
44:13members, experts and then
44:16there was Doctor DK.
44:18And Doctor DK was a special ask on my
44:20part because of his experiences as
44:23an international medical graduate,
44:25his experiences in Forensic Psychiatry,
44:27because I wanted a systematic
44:29and unbiased approach to this,
44:30and because he was chair of the Ethics
44:33Committee and that was very important.
44:35Or or acting cochair, I forget the,
44:38I forget the position and I
44:40apologize for that Charles.
44:42But he joined without hesitation.
44:46So the goals were providing
44:48education and resources on APA,
44:50psychiatric history regarding
44:51structural racism,
44:52explaining the current impact of
44:53structural racism on the mental health
44:55for our patients and colleagues,
44:57developing recommendations for
44:59change and providing reports.
45:02And
45:05and these these programs need
45:07quality insurance because you have
45:09to go back and follow through.
45:10Did we do this right? Did we not?
45:12What can we do to do to what
45:13can we do to get back on track?
45:15Because they often fall off track.
45:17We have so many other competing
45:19interests and I didn't learn until
45:21after the task force meeting that
45:25I mean task force ended that that
45:28each task force is usually given
45:30one staff member to work with.
45:32I was rallying them all and we
45:35had 15 and they were fantastic and
45:37helped us make the work go much more
45:41smoothly and much more efficiently.
45:43They heard about what was going on,
45:44they were interested and they
45:46were fantastic and we couldn't
45:48have done it without them.
45:50So my personal goals were to be
45:53bidirectional and collaborative.
45:54We did surveys and other things
45:55and I read every survey answer
45:57to understand what was going on.
45:59And one of the things,
46:00reasons we went and looked at the APA
46:02was because the survey responses were
46:04don't look at it in the psychiatry,
46:06look at it within the APA.
46:07So just proportionately we got that feedback.
46:09So we did what the members wanted.
46:11We wanted it member driven.
46:12So we did have groups and meet
46:13with groups and talk with groups
46:15and it because it takes a village.
46:16This is it's a member driven organization
46:19and we cannot relook the needs and
46:21concerns of our members and it needed
46:23to be transparent and balanced.
46:25So we had all of these different work
46:28groups as well as I mentioned the
46:30publications looked at things from
46:33their own and DS M5 as you see in
46:37DSM5T R there are that was edited to
46:40reflect on structural bias and racism.
46:43So the text, if you look at it,
46:45it's different in a TR version
46:47than the five outcomes.
46:48We had 19 action items.
46:50I knew one was not going to pass
46:52and justifiably because of what we
46:54learned from our from our consultants.
46:56But we had a historic 18 accepted
46:59by the Board of trustees.
47:01They voted on 18 and accepted them.
47:03Now usually they just accept the
47:05report and it sits on a shelf.
47:07And my research before I got started
47:10with the task force showed me that
47:14we have the consultants we had.
47:17We have now have a section in the
47:19medical director CEO's report that
47:21describes all of the anti racism
47:23and equity and inclusion initiatives
47:27in one section.
47:28Because it turned out we were doing
47:30a lot of things that we weren't
47:32aware that we were doing.
47:33But once you compile them,
47:35you can see that as a body of work,
47:38we reviewed on the strategic
47:40initiative at every board meeting and
47:42everybody has a plaque in front of
47:44them to remind them of what they are.
47:47And one of the survey questions after
47:49board meetings were did I include diversity,
47:52equity,
47:52inclusion in all of the deliberations.
47:55Also did the group and did the
47:57chairman or the president of
47:59the APA who chairs the group.
48:01We had several town halls work
48:04group meetings and we also concern
48:06firm that a PAAPPN is looking at
48:09specific readings and diversity,
48:11equity, inclusion,
48:12structural racism or and made
48:15to include in maintenance
48:18of certification readings.
48:21We removed the
48:25the likeness of Benjamin Rush.
48:26It had already been moved but removed.
48:28But he owned slaves, among other things,
48:31and so now people have an option
48:34to turn in their own old fellows
48:37medals and badges and to get the
48:39new one with the brain on it.
48:41And they were two resident projects and
48:43we are extremely proud of our residents.
48:45Under Doctor DK's leadership,
48:47they developed a model curriculum
48:50for A on structural bias, diversity,
48:52equity, inclusion and a database
48:54for resident concern.
48:56So now when you go to an APA meeting
48:58on there is a way to report when
49:02you experience bias and they're
49:03looking at that and the trends to see
49:05what's going on and if there are any
49:07patterns how they can approach that.
49:09So in terms of ally ship,
49:11this is what I leave you with.
49:13If you see something wrong,
49:14say something,
49:14be accountable to yourself and
49:16look with them.
49:17Don't forget cultural humility
49:19because those concepts are we are
49:22taught in psychotherapy training,
49:24but they also can apply to
49:26other aspects of our lives.
49:27Focus on self-care to reduce
49:30extrinsic bias because we know
49:32that extrinsic bias and influences
49:35how we treat our patients,
49:38especially certain groups of patients
49:40or certain class of patients.
49:42Equity councils can help but don't
49:44overburden your colleagues because they
49:46don't want to be the expert on black people.
49:48There's not one black person,
49:49but they don't want to be the
49:51expert on people who have physical,
49:52who are differently abled or who
49:55speak Spanish or what have you.
49:57And don't forget about the invisible pack.
49:59Pack privileges situation specific
50:01and we must be cognizant of that
50:05and and everything we do.
50:07So basically now where are things we
50:09have the structural racism accountability
50:10committee they're required to report
50:12to the board and every board member.
50:15Looking at those 18 action items,
50:18we've gotten some of them completed and
50:20closed but we're still working on other
50:22ones and that is charge of work committee.
50:27But in 2023,
50:28it was moved to the membership
50:30under the membership committee.
50:32So we look forward to seeing at our next
50:34board meeting in October how far it's
50:36gone and what we need to propel things ahead.
50:39And I'd like to end with this
50:40quote from Barack Obama.
50:42You can be completely right and you
50:43still are going to have to engage
50:45folks who disagree with you.
50:46So don't try to shut folks out.
50:47Don't try to shut them down,
50:48no matter how much you might disagree
50:50with them.
50:51And thank you for your time.
50:52And I was able to add a couple of
50:54slides I had limited because you're so
50:56gracious with your time and I'm going to.