5/3 YES: Be an Upstander

May 03, 2024

ID11628

To CiteDCA Citation Guide

00:00And I think we're going to be recorded, yes.
00:03So good afternoon, everyone.
00:05I'm Andreas Martin.
00:07I'm a professor of child psychiatry
00:10at the Child Study Center.
00:12And I'm here with my hat as a
00:16proud member of the newly remained
00:19Center for Medical Education,
00:21which is thriving and growing.
00:23And it's an exciting set of ventures
00:25and one of the ventures that we started
00:27a year ago is this series called,
00:30yes, the Yale Medical Educator Series.
00:34My colleague,
00:35my partner in crime in this has been
00:37Dana Dunn from Internal Medicine.
00:39I'm sure many of you know and what you
00:42may not know is that today is actually
00:46our very last yes presentation from the year.
00:50And I think it's been incredibly rich,
00:54very helpful practical year.
00:56We've strived to be very practical in what
01:01tools we give all of you learner educators,
01:04clinical educators.
01:05So thank you for being here and it's a
01:10wonderful place to finish the series with
01:14this dynamic duo we have here today.
01:17The first of the duo is someone who
01:19I've known for a couple of years
01:21and I have tremendous respect for.
01:23And that's Shaili Gupta from
01:26Internal Medicine.
01:27She is mostly at the VA and she is the
01:33vice chair and director of Diversity,
01:36Equity and Inclusion at the VA
01:38and she has the many roles within
01:41the Department of Medicine.
01:43But she really has a passion
01:45and an interest in equity,
01:47equitable care in dealing with many of
01:50the issues we're going to be seeing today.
01:52So.
01:53So that's shyly.
01:54And her senior partner in crime
01:56is someone who have just had the
01:59pleasure of meeting very recently.
02:01But I already like him a lot,
02:03and I've already even learned how to
02:05properly pronounce his last name.
02:06So he said me right.
02:08So Doctor Ben Mbah is relatively new to Yale.
02:15He's a professor of medicine.
02:17He's the vice chair for DEI in
02:21internal medicine and in the grad
02:24graduate medical education, the GMBC.
02:28So
02:31Doctor Mbach came to us from Chicago
02:35and he was a a great steal as I'm
02:38looking at his CV because he was
02:41incredibly involved in a range of things.
02:44But those that caught my eye from his
02:47very long CV involve clinical teaching,
02:50which is a passion that again Chile and Ben
02:55share in community participation and action.
02:58And the last thing that
03:00I'll mention about his CV,
03:01something that really caught my
03:03eye is that now there is back
03:05in Rush in Chicago a prize,
03:08a coveted award for clinical teaching
03:12called the Ben Amba Teaching Award.
03:15So just to give you a sense of the
03:17likes of folks we are here with.
03:19So I'm going to pass the baton on to them and
03:26take it away, teach us how to upstand
03:29and be upstanders. Shaylee, Ben.
03:32Thank you, Andres.
03:33All right, so let's begin.
03:36This is the the CME code to text
03:41and it's also in the chat if you
03:42wanted to text it for attendance.
03:44So the objectives of the talk
03:47are 4 objectives here that we
03:49are going to try and accomplish.
03:51One is to recognize the prevalence
03:53of identity based offences that
03:56our faculty and trainees face.
03:58Next we will identify the
04:00barriers to response by faculty.
04:02Recognize your role and find
04:05your professional voice.
04:06And then I'll also review some
04:09reporting pathways and resources that
04:11can be used to continue helping all
04:13of us in being better up standards.
04:15And why is this important?
04:17It's because it does matter a
04:20lot to the learning climate,
04:22no matter what the quality of
04:23education we provide and the
04:25kind of research opportunities
04:26we provide to our trainees.
04:28If we cannot provide them a good
04:30healthy work environment and learning
04:32climate and upstand for them,
04:34treat them respectfully but also
04:36make sure that they are treated
04:38respectfully by others too.
04:39It it those parts are essential in
04:41order to create that kind of climate.
04:44The agenda is going to again cover
04:47all those four objectives with the
04:49status to review the identity based defenses,
04:52go over barriers,
04:54strategies and then some practice
04:57scenarios and I'm going to hopefully
05:00have voluntary participants in
05:02the practice scenarios so you
05:04can use your professional voice
05:06right away in addressing some of
05:07the offences that will play out.
05:11So I'll quickly go over the status first.
05:14I initially designed the
05:16diverse survey back in 2020.
05:19It was a funny time to have designed that.
05:22Right around the time is when
05:23we got hit by COVID then it.
05:26It was a survey that was initially
05:29designed to create as a pilot tool
05:31and I introduced that at one single
05:35site at Yale to measure the extent and
05:38areas of identity based offences and it
05:41provided a whole bunch of very rich data.
05:43We were then able to tweak the
05:45survey better and then redistributed
05:47the more solidified survey in 2022
05:50to all different sites which was
05:52distributed to all departments,
05:54all subsections,
05:57all the trainees and faculty.
05:59It had a lot of open and closed
06:01ended questions and we collected
06:03quantitative and qualitative
06:05data which is extremely rich.
06:08So I'm going to share just a few small
06:11highlights because these are helpful
06:13in order to inform our next few slides.
06:17These are just three or four
06:18graphs that I'll share with you.
06:20So who sustained most of the
06:22damage and most of the offences?
06:24You can see that the green bars
06:26represent non white identifying
06:28women and the light green bars here
06:32represent white identifying women.
06:35And you can see that women took the
06:38majority when it came to who was being
06:40subjected to these kind of insults.
06:42And you can see the number of
06:44insults are quite different variety
06:46of them from hurtful and offensive
06:48language to loss of opportunity,
06:50unwelcome physical contact even the.
06:54The next thing to make sure that we
06:57understand is who is the main category
06:59of people who are subjecting and this
07:02this actually came as a surprise to me.
07:05In general,
07:06when you talk about these with
07:08an anyone else,
07:09people usually believe that it is
07:11the patients and patient families
07:12who are the biggest offenders.
07:14But the data spoke otherwise.
07:16The yellow bars,
07:18these giant bars are the total
07:20offences committed towards faculty.
07:22So this is the data from faculty alone.
07:25304 faculty participated in this and
07:29the grey bar represents the offender
07:31which turns out to be faculty offender.
07:33So most of the faculty reported being
07:36subjected to these offences by another
07:39faculty member and the P values were
07:42quite significant across the board
07:44for all different kinds of offences.
07:47If you look at the training data,
07:49this is when trainees reported it,
07:51322 trainees who reported offences
07:54occurring towards them and we
07:56looked at who the offender was.
07:57Here.
07:57I thought this time it would be patients.
08:00The yellow bar again is the total offences,
08:02but again faculty took the
08:04lead in most of the offences.
08:07Hurtful language and verbal
08:09threat was more made by patients,
08:12but hurtful language faculty was
08:14competing pretty well in that too.
08:18This is really,
08:19really important data to to start
08:22addressing because it's so important.
08:24It's low,
08:25low hanging fruit.
08:26These are our faculty members.
08:27We should be able to do a better job in
08:30informing them better,
08:31training them better and making sure
08:33that they understand how they are,
08:36how they're being perceived or how
08:39they are causing hurt and insult.
08:42We also looked at how the experienced
08:46offences compared with the witness
08:48offences and one thing that came out
08:50was that it kind of validated the
08:52people who were reporting experiences
08:54because similar percentages were
08:56being reported as witnessed.
08:58So this is not just some something
09:01people are just reporting and
09:02nothing is actually happening there.
09:04There were similar reports
09:05of it being witnessed.
09:07It is important for two things here to
09:09be paid attention to the two areas where
09:13the witnessing response or witnessing
09:15reports was lower in percentage
09:17compared to what was experienced.
09:19Are this the Gray area?
09:22Sorry, I have gone to the next one.
09:27Do I go to the previous slide?
09:31Sorry,
09:36oh gosh, I'll just keep going.
09:38But I wanted to show you the data
09:41showing how the witness offences
09:43were less in the area of suggestions
09:46not heard because and that suggested
09:49that suggestions are not being heard
09:51by the person who who is offending
09:54but at the same time also others who
09:56are unable to hear the suggestions.
09:58So it creates this opportunity for us
10:00to realize how we should be listening
10:03more that information and that data,
10:05that survey data led me to create the
10:09the diverse trainings that I was able
10:13to create the diverse trainings that
10:16raises up standards and trains you
10:18how to become better up standards.
10:21Part of that is this module that
10:23we're going through now,
10:24but it also includes reenactment
10:27scenarios where we invite faculty
10:29to to play a role in simulated
10:32participants enacting out the data
10:34that we can collected from the survey.
10:37There were scripts written for that and
10:39the SP plays out the part and you are
10:42expected to speak up in that moment.
10:44What we realised from that data was
10:47that people felt that they were able
10:50to actually gain a voice when they
10:52were expected to speak in the moment.
10:55Using your voice makes it more comfortable
10:57for you to reuse your voice in the future,
11:00and that's why it's important to
11:02hopefully keep those trainings running.
11:04So I'll pause here and ask if people
11:07want to share some of their experiences,
11:11things that you have seen,
11:13things that you find bothersome or skills
11:16that you would like to learn most,
11:18or your barriers why you are unable to
11:21respond in in the moment when things occur.
11:24Would anyone like to share?
11:28You could share in the chat as well
11:30if you if that's easier for you.
11:42Perhaps we can narrow down to what
11:44would barriers, What do people perceive
11:46as barriers to being upstanders?
11:57I think people are still digging into lunch.
12:01That's OK. So we can actually discuss
12:03the barriers and hopefully people will
12:05be able to relate to some of those.
12:07Ben, do you want to take over this one?
12:09Yes, if you could just so thank
12:12you everyone, for attending this.
12:14So I'm just going to talk
12:16briefly about the themes,
12:18the the barriers that we we all encounter
12:21that stop us from being upstanders,
12:24that stop us from moving from
12:27being bystanders to upstanders.
12:29So I would consider an upstander to be
12:33a bystander who decides to intervene
12:37in a Safeway when they witness an
12:41insult or an offence or an assault.
12:45So again, an upstander is a bystander who
12:48decides to transform from a bystander
12:51to an upstander by intervening safely.
12:54Now what are possible barriers?
12:55So next, next please.
12:58Shari.
12:59So using the acronym QUAD,
13:02one of the first barriers is,
13:04is just basically questioning the
13:07need to respond and if you next click
13:11please and this is one of the issues
13:14here is perhaps not noticing the offence now.
13:17Egregious offences, be them racial,
13:20be them domestic violence,
13:23be them sexual assault.
13:25They are clearly identifiable
13:27and very easy to see.
13:29But but unfortunately,
13:30egregious offences are just
13:32the tip of the iceberg.
13:35Below the water level,
13:36the bulk of the iceberg is understanding
13:39the whole continuum or the whole
13:42spectrum of possible offences.
13:44So on one end is sexual assault.
13:46But it goes, there's also,
13:48there's sexism, there's microaggressions,
13:50there's stalking, there's cyber harassment,
13:54there's verbal harassment,
13:56there's there's extreme,
13:57there's racial violence at one extreme.
13:59That's the tip of the iceberg.
14:01But then there's the racial comments,
14:03microaggressions, denying opportunities.
14:05So all of those that that's
14:07the whole spectrum.
14:09And So what I would encourage all
14:12of us to do is that if we decide
14:15that we we have our personal value
14:18is to work in an environment that
14:20is safe and inclusive for all.
14:23Then it I think it's in to some
14:25extent incumbent on all of us to
14:28try to understand at least to get
14:30to know what the whole continuum
14:31or spectrum of offences could be
14:33in terms of be I be there racial,
14:35gender sexual orientation ageism.
14:37And just to understand that so that
14:39we are on the lookout and then we are
14:42active participants in ensuring we
14:44have an inclusive culture another barrier.
14:46Next click please Charlie.
14:48Oh oh an example of this So this is
14:50where one may ask what does why does
14:52this need intervention But when you
14:54understand the whole spectrum then
14:56you can see that every little cut
15:00to the offended it's almost like
15:02death by 1000 cuts And I don't think
15:05we should it should not be left up
15:07to the offended to respond which
15:09it's all of us should be able to
15:12respond and support the offended.
15:14Next click, please, Charlie.
15:18So unrelatability, and this has to we all
15:22as individuals have our own worldview,
15:26and that is our own bias.
15:29As we look at things through our bias lenses,
15:31through our lived experience or lack
15:34thereof of lived experience through and
15:36our cultures and sometimes our religion,
15:39our our social environments,
15:41all of those contribute to
15:44what our worldview is.
15:45And so an an example would be for instance,
15:48if I if I grew up in so I grew up
15:53in Nigeria and if I grew up in.
15:55If you're if you're in an environment where
15:57you think and I'm not saying that Nigeria,
15:59this is rampant in Nigeria.
16:01But if you grew up in an environment
16:03where you think and perceive that
16:05sexual harassment, for an example,
16:07is only from a man to a woman,
16:09you may not actually perceive
16:12same gender sexual harassment,
16:14same sex gender harassment.
16:16You may not perceive that as a
16:18problem because you're looking
16:19at it through your own lens.
16:21So again,
16:22incumbent of all of us to to try to be
16:24this should lead to self-awareness of
16:26what our own lens is and so that we can
16:29in effect take double takes and decide,
16:31oh, looking at this,
16:32I'm looking at this through my own lens,
16:34but is this?
16:35Should I take a second look here?
16:37Should I consider intervening?
16:39So next click.
16:40This is the question of if we don't
16:43expand our scope in that way,
16:44then we may be feeling that,
16:45oh,
16:45this is not hurtful because we're
16:47looking at it through our own lens.
16:49Next click please.
16:52Then this is the avoidance.
16:53This is basically a
16:55combination of the hassle bias.
16:57I don't want to get in trouble.
16:58I don't want to see anything because
17:01there may be some hierarchical dynamics.
17:03I'm I'm uncertain who I should talk to.
17:07I just don't want to get involved.
17:08I just want to do my own thing and move on.
17:10And this is next click.
17:12This is the issue of you know,
17:14why is it my job to address this?
17:16Why? Why isn't yield?
17:17Why shouldn't be some office at Yale?
17:19Why me? And then the last theme for
17:22barriers would be next Click, please.
17:25Divided loyalties.
17:26Many times as bystanders,
17:28not as bystanders, we are caught
17:31between the offender and the offended.
17:34Literally.
17:34Sometimes we're friends with both,
17:35sometimes we are answered
17:38to one or the other.
17:39And so this is the problem of
17:41trying to please both parties.
17:43But when it comes to microaggressions
17:45and repeated assaults,
17:48really there's only one victim
17:52in the sense that the offended is
17:54the person that is the priority,
17:56him or her the priority when it
17:58comes to being an upstander.
17:59Now we we we could re educate the offended,
18:03hopefully. And that's the case.
18:04And then eventually everyone,
18:06eventually everything is not
18:08intentional and therefore we can try
18:10to have a more inclusive environment.
18:12Yeah. So. So that's pretty much it.
18:14Just a brief 1 slide on the barriers.
18:17And then next Shirley will take us on
18:19to strategies to use in real time.
18:22Back to you.
18:23Thank
18:24you, Ben. So now that we've
18:26reviewed the barriers, let's start
18:29looking at how do we strategize
18:31to use our professional voice and
18:33actually break our own barriers.
18:38Why is professional voice
18:39important in these situations?
18:40Because it can be used to call out hurtful
18:43and insulting behaviour and language.
18:45At the same time,
18:46you also use that same voice
18:48to support the offended Often,
18:50as you'll see in the strategies,
18:52if you use it well,
18:53you will be able to do both the things
18:56together in the same moment at the same time.
18:59It's important to know
19:00your reporting pathways,
19:03so the strategies of using
19:05your professional voice.
19:07I've split them into four different
19:09categories, direct intervention,
19:10which is usually done in the moment
19:13or it can be done after there
19:16is defending and supporting the
19:18person who's feeling offended.
19:20There are times when you may not
19:23have a direct system or a direct
19:25approach to how to address it.
19:28Those are the times when you can
19:30use delegation and reporting
19:31either to the leadership or to
19:33the DEI leaders and we'll review
19:36some of the reporting pathways.
19:38And the last one is distracting
19:40and de escalating.
19:41This is one that I would hope that
19:44we don't need to use it very often,
19:47but there are times when this is
19:49the only strategy that you can use.
19:50One good example of that is a
19:53patient who does not have a mental
19:55status that would retain anything
19:57that you're trying to coach them.
19:59And in those moments at least,
20:01the least we can do is to de escalate
20:03and to stop the offense from occurring.
20:06So that is the time when we can
20:08use distraction as as a strategy.
20:10The idea is if you see something,
20:14please say or do something.
20:16So let's review some of the strategies.
20:19Direct intervention is by far the
20:22most effective tool among all the
20:25strategies to stop the behaviour
20:27in the moment.
20:28It is the best used one that can stop it,
20:31prevent it and correct the
20:33behaviour for future two.
20:34And you can use several different
20:37ways of direct intervention,
20:40the the least and the smallest.
20:41And the easiest way to do this is just to
20:44have a quick check on the comment or gesture,
20:47or to clarify.
20:48It can be something we used
20:51to teach about saying Ouch.
20:53I feel that Ouch is too light a word,
20:57so sometimes it's good to use the word.
21:00I'm sorry, what did you just say?
21:02It's as simple as that,
21:03and people would usually not even repeat it.
21:07Setting expectations is another
21:09direct intervention tool and
21:11it is done pretty effectively.
21:13You'll see some of these examples.
21:15So let's read a couple of the
21:17the examples of clarifying and
21:19checking the comment or gesture.
21:21One is as simple as what was that.
21:25Another one, if if a patient is referring
21:28to your trainee as sweetie honey,
21:31it can be an immediate correction
21:33in the moment, done gently,
21:35very professionally and then moving on
21:37to the history and physical anyway.
21:40But it makes sure that that patient does
21:43not step any further down in that direction.
21:47So a person,
21:48a patient who's calling your
21:49trainee sweetie or honey,
21:50you could easily say we don't refer to our
21:52physicians or patients in those terms here.
21:54This is Doctor Stein and I am Doctor Singh.
21:58Let's hear one of my other colleagues.
22:00This kind of language is not
22:02acceptable in our healthcare system.
22:03We are here to provide care for
22:05you and this must be done in
22:06a mutually respectful setting.
22:10That setting, tone and setting of the
22:13expectations is one of the words that
22:15these sentences and these statements
22:17about this kind of language is not
22:19acceptable in our healthcare system.
22:21I want all of you to be able to say
22:23that even if you say it in the privacy
22:25of your car, if you say it once,
22:27you'll be able to say it in the real moment.
22:29It is important to say it once verbally.
22:34The 3rd way of direct intervention is
22:37naming the offence, and usually all
22:38three of these are done at the same time.
22:41But naming the offence is important,
22:43especially for situations, for example,
22:46when people are not even aware,
22:48or at least not that you can see that
22:51they're aware of what they say is offensive.
22:53And when you call out the offense,
22:55many people would immediately realize
22:57that what they said was perceived
22:59this way and would check it.
23:01Let's hear someone else say this.
23:03Hey Morgan, those comments on accent
23:05and country of origin that you made
23:07to Tianmin made me feel uncomfortable
23:09and likely made him feel unwelcome.
23:11I'm sure you did not mean to offend him,
23:13but it may be a good idea to reach
23:16out to him and clarify.
23:17Notice that you can do this in that
23:20moment where you can immediately
23:22correct when the behaviour is occurring,
23:24or you can do it after.
23:25That's also a direct intervention.
23:27You're just talking to your colleague
23:29in privacy so that they don't feel
23:31too too disrespected because you
23:33checked them right away.
23:34If you feel more comfortable
23:36checking them later,
23:37or at least sharing that what they said
23:39was something that came across that way,
23:41it can be easily done and then it's up
23:44to them to go ahead and correct it.
23:47The second D is defendant support.
23:50Defending and supporting is something
23:52that's best used for when you're noticing
23:55someone else's suggestions not being heard,
23:58someone else not being included in a
24:01conversation or in an opportunity,
24:03a position or a role not being
24:06offered to someone.
24:07A patient questioning A
24:09trainee's credentials,
24:11a nurse double checking a
24:13trainees instructions.
24:14All these are some specific situations where
24:19you can use the defendant support strategy.
24:22So let's use some of these.
24:25The idea is to highlight the
24:27contributions of someone, for example.
24:29Oh,
24:29I'm glad you're bringing up the same
24:31suggestion that Liz did a few minutes ago.
24:34I love this idea too.
24:36Liz,
24:36can you share a bit more about how
24:38this could be implemented?
24:40Notice that this person uses this
24:44strategy so beautifully without
24:46challenging or offending the offender.
24:48So let's say you're in a section meeting.
24:50A section chief is hearing everyone and
24:53Liz goes ahead and suggests something.
24:56That was a brilliant new idea.
24:583 minutes later,
24:59the section chief is presenting
25:01that as their own idea.
25:02You don't want to call, call it out perhaps,
25:05but you can easily say, oh,
25:06I'm glad you said that I was going
25:08to say the same thing.
25:09I love Liz's idea.
25:11And then invite Liz into the conversation.
25:14The other thing that defending and
25:17supporting does is actually helps
25:19you recognize the value of someone
25:21and highlighted to the others too.
25:23Susie has been one of our most
25:25productive colleagues.
25:26I'm so impressed by her thoughtful
25:29ideas or I'm so curious to hear
25:32Jamal's thoughts on this.
25:33Jamal, how should we approach this?
25:36These are both ways to incorporate
25:39and invite people.
25:40Draw them back into a conversation
25:42that they have been marginalized from,
25:44people whose ideas are not being heard,
25:46or they just don't feel comfortable
25:47enough to speak anymore because
25:49they have been sidelined so often.
25:51This is one way of you inviting
25:52them back into the conversation.
25:57The main idea for all these strategies
25:59for defendant support is to defend,
26:02lift and support all three at the same time.
26:06We can do that in in another situation
26:10where the slide just keeps jumping.
26:12But let's say a nurse is not
26:16listening to a training suggestions.
26:18You can use your voice and say
26:22this physician is one of the most
26:24excellent ones that we've had.
26:25She's acting in phenomenal caregiver
26:27and I learn from her every day.
26:30Is there something specific that
26:32wasn't clear in her instructions?
26:34It's something that helps you
26:35highlight the point that that that
26:38person has the right credentials
26:39that you respect them and you expect
26:42the nurse to to respect them.
26:43So we'll go the over the third D this is
26:46the delegation on reporting pathways.
26:48It has taken a massive amount of work
26:50in the last three years to create and
26:53consolidate these reporting pathways.
26:54There were some structures already
26:57in place about five years ago,
27:00but very few,
27:01even those were great to have
27:04consolidated and really clarified so
27:05that the pathways are clear to everyone.
27:08If you're in doubt and you don't
27:10know when you see an offence about
27:12who the reporting person would be,
27:14who should you reach out to?
27:15You can always seek direction
27:17from your leadership or from the
27:20Dai leader of that section.
27:21And there's a variety of these structures
27:23that deal with different things and
27:25we'll go over the reporting pathways,
27:27but they include from everyone
27:29from department section,
27:30leadership all the way to
27:32Title 9 office or OAPD.
27:38So let's review some of the reporting
27:39back base and there will be a
27:42handout that will contain all these.
27:43So you don't have to
27:45memorize these right now.
27:46I've put them in the handout.
27:48Linda, if you would be able to put the
27:50handout in the chat that would be great.
27:52So in cases of abusive behaviour or language,
27:54if you have noticed someone use
27:57abusive behaviour and language
27:59who is a faculty member,
28:01you may have decided to check
28:02them or talk to them in private.
28:04But if you want to then seek further
28:07advice and you want to perhaps pick it up,
28:09the best way to do it is to take
28:13it to the department leadership.
28:14If it is a patient who's using
28:16abusive behaviour and language,
28:17it should be reported to the Workplace
28:20Violence Committee which is called
28:21the Disruptive Behaviour Committee,
28:22DBC at the VA and work with
28:26Violence Committee at York St.
28:28Harassment Prevention Committee is
28:30another committee that gets involved.
28:32SAFER is the new Rs Solutions and
28:36it's beautifully designed now.
28:37If you ever use that you'll see
28:39it has very great,
28:40very good structure where it self
28:42guides you as you use it so that
28:45you can report all different kinds
28:47of offences that are listed here.
28:49JPSR is the VA form format of
28:52the safer and then of course
28:55your department leadership.
28:57In cases of unprofessional conduct
28:59or workplace bullying by a faculty,
29:01it's best to talk to your leadership
29:03first the section chief to start
29:05with or ADEI leader and then they
29:08can then decide if that needs to be
29:11upgraded and taken up to the OAPD
29:14or to HR if there is verbal threat
29:17or violence or assault occurring.
29:19The best of course this you know
29:21already would be hospital security
29:22and police to be called.
29:24Workplace violence.
29:25Committee actively gets involved
29:27in these things and same does the
29:30Disruptive Behaviour Committee.
29:32I want to make sure to highlight the
29:34reporting pathways for sexual harassment,
29:36which are slightly different when
29:38the harasser is patient versus when
29:41it's an employee or a faculty member.
29:43When the sexual harasser is a patient,
29:46it goes it's best to report it in
29:49immediately through SAFER because
29:50it actually documents it.
29:52That part is more critical than
29:55I can say it is.
29:57It.
29:58It's so important to document it right away,
30:01and also because it creates that report
30:04in the freshest way where memories
30:06are fresh and you can put it in there.
30:09DBC and HPC are the same body
30:11with the same kind of system,
30:13reporting pathways that are
30:14created at the VA.
30:16You can easily use them from the website
30:20for a patient who is sexual harasser.
30:23Nurse leadership always considers it
30:25important for them to be informed
30:28and understand why this is important.
30:31Most of the caregiving for any
30:34hospitalized patient is actually
30:35provided by nurses.
30:36Out of the 24 hours,
30:37I think physicians are providing
30:39that care at most for
30:40an hour. The rest of the 23 hours,
30:42it's nurses.
30:43So if there is a sexual harassment
30:45that's occurring from a patient,
30:47it is very important for nurses to
30:49know so that they can then create flags,
30:52make their own nurses aware and
30:55train train better while they're also
30:58addressing talking to the patient
31:00and getting the workplace violence
31:02committee to address the patient.
31:04Program and form leadership are often
31:06good to inform for trainees who are
31:09being sexually harassed by patients.
31:11And then SHARE and CT Alliance.
31:13I want to make sure that you
31:15understand what those are.
31:16These are the supporting structures.
31:19They're not the report report bodies,
31:21they are support structures.
31:23SHARE is the University,
31:25Yale affiliated through the Title 9 office.
31:30It actually provides more support
31:32to students because they are
31:35their primary responsibility,
31:36but they are happy to hear and
31:38provide support to residents
31:40and fellows if we call them.
31:42CT Alliance is a non profit organization
31:45that is active in Connecticut
31:47and we were able to establish a
31:50relationship with them two years
31:52ago because SHARE was overburdened
31:54with cases that they were having
31:56to hear about from all over the the
31:59York Street site and other sites.
32:02When their immediate responsibility
32:04for staff based on staffing
32:06was only towards students.
32:07The CT Alliance is actually one of the
32:10most beautiful resources that I've had
32:12and if you ever need information on them,
32:14you can reach out to me.
32:17Sexual harassment by employee.
32:19It could be a non physician employee
32:22or it could be a physician employee.
32:24The pathway is to you can pursue
32:28safer or first seek counsel from OAPD.
32:31How to report further or what?
32:33If you want to create and use
32:36the online reporting system,
32:38it's available right on the OAPD website.
32:42HR usually gets in involved
32:43and so does the Equal Employee
32:45Opportunity Office at the VA.
32:47They would get involved.
32:49If it is specially if it's a non
32:51physician staff who is doing that,
32:53they would get involved.
32:55And most of this is done
32:57as an investigation first.
32:59It's not just if someone said it,
33:01this is you know a fireable offence.
33:04It is done in a very cognizant from
33:07and formed way where both the offended
33:09and the offender are equally supported
33:12and an investigation is completed.
33:15The support pathway for this is
33:17again share and CT alliance,
33:19lots of opportunity.
33:19I hope that we will all be able to
33:22invite people into discussions ourselves.
33:24But again department, section,
33:26leadership are great resources.
33:30So word about sexual harassment before we
33:33move on to the 4th T Yale faculty and VA
33:36employees are expected to report sexual
33:39harassment when they're aware of it.
33:42So if a Co worker or a trainee
33:44report sexual harassment to you,
33:46in addition to thinking about
33:48using the reporting pathways,
33:50the first important thing is to listen
33:53and hopefully not ask too many questions.
33:56This is important because sexual
34:00harassment related experiences
34:03are best repeated at most ones.
34:06So if that person is going to have to
34:09report it to an HR investigator or a
34:12police investigator or OAPD or whoever
34:14else is going to actually hear it.
34:17Unless we really need to know
34:20some of the details in order to
34:22decide where this finally goes,
34:24it is not necessary for us to
34:26really hear all the details.
34:27It should be best heard by people who can
34:30decide how to proceed to the next step.
34:33ADEI leader in your section a program
34:36leadership person who is DEI expert
34:38in this or sexual harassment case
34:41expert would be better to to be
34:43that person and give them autonomy.
34:46Many trainees who have sustained
34:48this kind of harassment don't want
34:51to report it themselves, but many do.
34:53It would be important to know do they
34:55want to be the people reporting it and
34:56you can share the reporting structure
34:58with them and they can then report it.
35:01Or do they want it to be reported
35:04anonymously by you where you would have
35:06to do that without using their name
35:10it. It's also important at the same
35:11time to check in and make sure that
35:13their Wellness is taken care of,
35:15that they have someone providing Wellness
35:17support and to give them the contact
35:20information for share or for CT Alliance.
35:22It's one of the most egregious and the
35:26most sustaining offence because most
35:29people who sustain it would revisit it
35:32and get triggered and re traumatized
35:35several times two years after that.
35:39The 4th D is distract and disrupt
35:42and this is, like I said,
35:43it's used for patients who
35:45have cognitive deficits,
35:46behavioral challenges.
35:48It's just a small strategy to
35:49at least stop the thing that's
35:51occurring in that moment so that
35:53the person who's getting offended
35:54does not sustain even more hurt.
35:58So it's disrupting the stream
36:00and changing the direction.
36:01We're not here to talk about that.
36:03Let's talk about
36:04your chest pain.
36:08What about the new figures
36:09from the data set? Why
36:11don't we look at those?
36:13So this the second one,
36:14what about the new figures from
36:16the data set is not something
36:18that you're saying to a patient,
36:19but sometimes when you're in a in
36:22a situation where the hierarchy
36:23and the power dynamic is such that
36:26it's hard to intervene directly,
36:28sometimes destruction itself would
36:30at least stop it and take the
36:32conversation in a different direction.
36:36Racism and sexism are not psychiatric
36:39disorders even for patients
36:41who have cognitive deficits.
36:43The what we have seen and this is proven
36:48when we had several such insults occurring
36:51in the Vaer where in the psych ER.
36:54So the psych ER we're seeing a
36:56lot of these insults where the
36:58N word was used against nurses.
37:00A lot of different insults were thrown on
37:02a very routine fashion by by patients.
37:05Once we implemented these four DS,
37:08including the distract and disrupt,
37:11these diminished significantly to
37:1320% because even when the patient
37:16is not with it intoxicated or having
37:19a cognitive deficit event,
37:21they are still able to retain
37:23what you're telling them.
37:23This is not accepted here by which is
37:27direct intervention or when you disrupt it.
37:30It is important that we do that
37:32at least to stop the damage,
37:35so we'll try and do some practice
37:37scenarios now.
37:40The idea is for me to see if someone would
37:46perhaps volunteer.
37:47I'm going to play out some scenarios
37:50and Ben and I will take the lead
37:52in prompting you to see if you
37:55can use your professional voice.
37:56So I'll introduce the first scenario.
37:59When we go into this,
38:01the main strategy is just to review again.
38:04For direct intervention you would use
38:06clarifying or checking the comment
38:08or gesture, setting expectations,
38:10naming the offence For defending
38:13and supporting.
38:14Highlight contributions,
38:15recognize value, basically your defend,
38:18lift support and you can use any of
38:21these in any of these scenarios.
38:23Delegation and report.
38:24Tell us a little bit if you are
38:26thinking of perhaps this is something
38:29that would go to that reporting
38:31pathway and then distracting and
38:33de escalating so we can start.
38:35Is there a volunteer for the first scenario?
38:38Before I play it?
38:47I volunteer his tribute.
38:49Awesome. Thank you so much.
38:51This is wonderful.
38:52So you are in the room.
38:54You are this physician
38:55who's standing right here,
38:57and you're in with a patient who is
39:00a major endowment donor to Yale who
39:03unfortunately had to come to the
39:05resident clinic today because of an
39:06emergent visit that they had to make.
39:08Usually they end up just seeing you alone.
39:11She's here and you have a trainee
39:14who's standing right here.
39:15You'll see her as I play the scenario.
39:17The trainee's name is Doctor White
39:20and the patient has already said some
39:23things to kind of challenge the name of
39:27challenging the name of that trainee,
39:29making fun.
39:30And you have hopefully checked that.
39:32But now we are at the point where the
39:36trainee is going to examine the patient.
39:39And let's see if you can you
39:42tell me how you would address it.
39:44So let's play it.
39:50Go ahead, Doctor
39:53White, can you volume up? Yeah.
39:55I don't know what happened to the volume.
40:00OK, back off, back off. You know,
40:04I'm not your kind that you can
40:06treat me so roughly. I
40:08mean, where did where
40:10did you even go to school?
40:11I couldn't have been
40:12here. So this was odd because it was
40:15playing beautifully for the video
40:16and the audio part before, right.
40:19You want to just maybe stop it
40:22and restart it then. I mean,
40:24go out of screen share and try again.
40:26I don't. Hopefully. Yeah,
40:29yeah. Or maybe even try without the
40:32optimizing the sound. You think undress.
40:36Yeah, that's what I'm thinking. Because maybe
40:37because we played last time. Yeah,
40:39yeah, Maybe that's the problem.
40:42Let me do that without optimizing it.
40:50OK. You can see the screen, right? Yes,
40:59No, no. And the and the video is choppy.
41:02I'll be the patient. So the patient,
41:06the Doctor White is leaning towards the
41:09patient now ready to examine the knee
41:11which is the reason for this visit.
41:13And the patient basically says go
41:15ahead Doctor White first making fun
41:18of the patient of the trainee's name
41:20because she has already made fun
41:22of that before, and then says OK,
41:23you can go ahead and examine me.
41:25Doctor White then examines the knee and
41:28has barely touched it and is trying
41:30to manipulate it just a little bit.
41:31When the patient feels the pain and
41:34screams out at the trainee saying
41:38I'm not your kind,
41:39that you can touch me this way,
41:42you have to be gentle with me.
41:44Where do you even go to school?
41:46Certainly not here.
41:48And she's looking at you,
41:50trying to make you an ally because she
41:52thinks that you can relate to her.
41:54You went to school here,
41:55you she can identify with and she says
41:58she clearly didn't go to school here,
42:00did she? And then ends up saying,
42:04go back to your school,
42:06go back to your country, Get out of here.
42:09What would you say or do?
42:14OK, so sorry. Who was the volunteer?
42:18I was the volunteer.
42:20OK Phillip, Is I I see your name?
42:22Phillip, Is that correct?
42:23Yeah, That's great. OK.
42:25So Phillip, if I can just ask,
42:27do you, do you see any offense
42:29committed in this scenario,
42:34sort of multiple offenses using
42:36that the using the patient,
42:39the patient's race as a as
42:42a doorway to offend and also
42:47apparently her apparent age and
42:50then also her position.
42:52So I think those three things
42:55are being used
42:57are are being offended. Absolutely.
42:59So placing yourself in the in the
43:02duct on the white coat
43:04in the real in real time.
43:06What strategies do you think you
43:08would what voice would you be able to
43:10use or do you think you would use.
43:13I would say something along the
43:16lines of whatever the patient's name is.
43:19You know, ma'am, I can tell that you're
43:20in a lot of pain right now, but that's
43:22no excuse for
43:23you to speak to this physician this way.
43:26She's simply trying to help you.
43:29And I would sort of kind of go right there.
43:33So you kind of start things.
43:35How does that sound? Yeah.
43:38So that's basically you're going
43:40straight at it directly, I mean,
43:42politely but directly intervening and
43:44saying that this is not acceptable in our,
43:46in our health system.
43:48And I like that you're starting
43:50with acknowledging the pain,
43:53so, so I think that's excellent.
43:54There's also room to to,
43:57I would say there's room to to defend
43:59and support but I I do agree that after
44:01the direct intervention hopefully
44:02that will nip it in the in the board.
44:08Some things I would say as an as a
44:11upstander just some general things.
44:13When you notice an offence,
44:16it's best to speak for yourself.
44:21In other words to say,
44:23I know you're in a lot of pain,
44:25man, I do not think you.
44:27I I don't think,
44:28I mean this one is different.
44:29You can say there's no need to
44:31talk to the trainee like that.
44:33Doctor White is,
44:34is simply here to help you, etcetera.
44:36But depending on the scenario,
44:37sometimes because for instance,
44:38if it was something that you, you know,
44:41let's say it was another kind of
44:43racial scenario where you said,
44:44oh, I don't think,
44:47I don't think
44:50Mr. John being a black man
44:52like what you said. Right.
44:54So rather than that, it would be like,
44:56I don't think what you said is acceptable.
44:58I don't think what you said,
44:59I think what you said is, is,
45:03is it's is there a racial microaggression,
45:08something like that.
45:09But but yeah, So directly intervene.
45:11Does anybody else,
45:13thank you very much,
45:13Philip, directly intervene?
45:14Does anybody else want to share
45:16what they would say before
45:18we move on to another case?
45:20Yeah, this is Fred Chrome.
45:24I have a little problem with this
45:27case and it's an ethical problem
45:29that as offensive as the patient is,
45:33as out of line as she is, she's expect.
45:38She's expressed a preference, hasn't she?
45:41Even though she's done it in a rather
45:43foul way, she says I do not want you
45:46to touch me if this is her knee.
45:48If this is an intimate exam,
45:51you then have to stop and say
45:55should I withdraw.
45:56The patient has told me she does
45:59not want me examining her ethically.
46:01If I am patient centered,
46:04regardless of what I think about the patient,
46:07I have to take that into account.
46:09And I have been in,
46:11I remember years ago as a trainee starting,
46:16you know, into a routine pelvic
46:20for a patient to do screening and
46:23she looked very uncomfortable and
46:25I said is there anything wrong?
46:28She said, I'm really not happy
46:30with a man doing this exam.
46:32I want a woman.
46:34Now.
46:34I went back and I told my staff and she
46:37said that's the most absurd thing I heard.
46:39You tell her that you're a trainee
46:41and you're here to get experience
46:44and her preference doesn't count.
46:46I said I'm sorry, I can't do that.
46:50I see a little of the same happening here.
46:53And I wonder how an ethicist
46:54would respond to it.
46:57Very good point there, Frederick.
46:59Thank you. I, I, I would say
47:01you, you you need a contrarian
47:03in every group, right? Yes,
47:04Yes, yes. No, no, no.
47:06Thank you for bringing that up.
47:07I would say there are two things.
47:08So patience, yes,
47:10patience can to patience can to some
47:14extent where services are available
47:17and can be accommodated requests
47:20certain care from certain individuals.
47:23But what patients cannot do is be abusive
47:27about it in the way they go about it.
47:29For instance,
47:32ultimately patients can switch physicians.
47:34Patients can say at some point I'd
47:36rather have a woman and then if we have,
47:38if if we have a,
47:39a a female physician that's available
47:41and willing to look after the patient,
47:43then that can occur.
47:44But that we don't always have
47:47those options in real time.
47:49You know,
47:49especially when it comes if you're
47:52a trauma center and level 1 trauma
47:55and at those at that time most
47:57patients are not that choosy at all.
48:00But but I do take your point.
48:02So I I think the patient does have the
48:04right to request a different service.
48:06But even before the trainee had started,
48:08she was already, I think,
48:09being a bit abusive.
48:10Yeah,
48:11I think both things can be true.
48:14Yeah, that and I think,
48:17you know somebody should address in
48:20a polite manner as I think it was
48:24Philip who did you know and had a very,
48:27very excellent response to say,
48:30you know, I'm sorry for your pain but
48:35it's not appropriate to be abusive to
48:38to students or members of the staff.
48:41Now then the other thing kicks in.
48:43So these are not mutually exclusive.
48:46That that's my only thought and
48:49I'll be quiet. Oh no,
48:52thank you. Thanks for your confusion.
48:54Any other comments? Yeah, sure.
48:57Ben, may I speak to just.
48:58Yeah, absolutely, absolutely.
49:00So you bring up a great point.
49:02And I agree with Ben.
49:03What he said.
49:04I think it's just very important
49:05to find out the reason.
49:07So if a patient is asking for a
49:09different provider because they they
49:10have sustained sexual harassment in
49:11the past and now they get triggered
49:14every time a male provider touches
49:15their genitals or breasts and even
49:17if it's a physician doing that,
49:19they get triggered.
49:20That's a completely different
49:22reason compared to someone who is
49:24clearly being racist and is throwing
49:26the the trainee out of the room
49:27saying go back to your own country,
49:30where did you even get educated?
49:32That is blatant racism.
49:33So I think you can definitely put
49:35your foot down there and it it doesn't
49:38have to be that we have to throw
49:40the trainee at them because it is
49:42very possible that that patient may
49:44remain offensive to that trainee.
49:46So by forcing that relationship,
49:48we are forcing the trainee to continue
49:50sustaining that kind of consult.
49:52But you have to check that behavior,
49:54you have to call it out,
49:55you have to name the offense,
49:57tell them this is not the expectation
49:59and then ask the trainee to make
50:01the autonomous decision if they
50:02still want to continue providing
50:04care to that patient.
50:05So
50:05I I I think that's exactly the right thing.
50:10Not, not that you needed me to tell you
50:12that, but as I was listening to you,
50:14I thought that's exactly right.
50:17Yeah. But thank you both of you,
50:20Philip and Fred for for speaking up.
50:22I hope we will have another
50:24volunteer for the next one.
50:26Can I shall I leave your your call,
50:29But I think that in the last
50:31five minutes or 6 minutes,
50:33we should also leave a minute or
50:35two to file to fill the evaluation.
50:38And my suggestion would be not to
50:39leave that to the very last minute,
50:41but maybe do the evaluation now.
50:43And if you know, if everybody does that,
50:45then we can see the the next case or two.
50:48Anyway, just a thought,
50:49yeah, no that's good.
50:50So what I'll do is I'm going to
50:53stop sharing and just talk to people
50:55because it's important for me to like
50:58actually see people when we talk.
50:59And I can give you another scenario,
51:03because the video and audio are not
51:05behaving themselves anyway, so will Ben.
51:07Is it OK if we just do one more and then
51:11we just open up the open up the floor
51:14so the next one, let's say a trainee,
51:17comes to you and report,
51:19starts reporting in successive fashion.
51:22She initially comes to you.
51:24You are their supervisor.
51:26She trusts you.
51:27She's been your mentee for for a
51:29while now and she comes to you.
51:31She tells you that I was examining a
51:34patient today in the on my clinical service.
51:37I was with my attending physician and
51:39as I was telling the patient about
51:41what the next steps are going to be,
51:44the patient winked at me.
51:45My attending saw it but did not say anything.
51:49Would you say anything at this
51:50time if you were the attending,
51:52let's say if you were in the room
51:55with that patient and the trainee,
51:58would you have said anything for a wink?
52:07Does anyone want to volunteer?
52:09Because I'm going to go to the next
52:11step to this, so if someone wants
52:12to volunteer that would be great.
52:17Can you repeat the specific question?
52:19I I heard the case but I
52:20didn't hear the question. So
52:21a trainee is reporting that she
52:23was running on a patient on the
52:25inpatient floor with her attending.
52:27They went into the room,
52:28they were talking to the patient and
52:30the patient winked at the trainee.
52:31It's a female trainee.
52:33She was winked at.
52:34The attending is a male doctor.
52:36He saw it. Let's say you were in
52:40the room with being the attending.
52:42Would you have said anything if the
52:44if a patient winked at your training
52:48and it was a suggestive wink.
52:50It was not a wink. As to Oh yeah,
52:52we'll both we both know that
52:54we eat salt. It's not that.
52:56That was gonna be my first question is,
52:59you know, is this. My first instinct
53:01would be to say, I'm Jordan
53:03Zinn, by the way, from the VA,
53:05My first instinct would be to say,
53:07did you just wink? Did you wink?
53:09Like did this just happen?
53:10And then to try and figure out, like,
53:12all right, what kind of a wink was this?
53:14But I've been in this situation
53:17before and I have failed to do it.
53:19I've let it slide and
53:20then regretted it later.
53:22So I would hope that I would say
53:25something like, did you just wink?
53:26Did this happen?
53:27And if they say yeah, I would say
53:29we we can't do that here
53:32tell me why you regretted it later.
53:36Wait what What's that?
53:38Why did you regret it later?
53:40Well I talked with the my student
53:42later and I said I in my in the
53:45case I'm thinking of it was
53:47AI think he said cutie to her
53:49instead of her name. And I
53:52was, I didn't, didn't say anything.
53:54But later I took her aside and
53:56I said that probably didn't feel
53:57very good that he said that.
53:59And she said, no, it did not.
54:01And I think I said,
54:02were you wanting me to maybe
54:04do something about that?
54:05And she said, well, you know, maybe
54:07she didn't want to, to get
54:09me angry as a supervisor.
54:11But I sensed from her that
54:13she wished I had done more.
54:16And then I went home that day thinking,
54:18I gotta, I gotta think about
54:20this a little bit more.
54:21I can't just brush it off, Charlie.
54:23I can just share something.
54:25Just this morning I'm on
54:26service just rounding.
54:27I had a patient who has,
54:30who has dementia as one of many,
54:32many medical problems.
54:33And I was there standing on the right.
54:35The nurse was standing on
54:36the left doing something.
54:37And the patients,
54:37I was talking to him and he says,
54:39Oh, yeah, he's he's OK today as
54:41long as he can get to flirt with
54:43the pretty nurses in quote. Right.
54:45And so even though he has dementia,
54:47I'm just trying to go to your point.
54:48And I said, you know, Mr.
54:50Suso, And so that is not appropriate.
54:53That's not what we're here for.
54:56Everyone's here to help you
54:57and you're here to get help.
54:58And he stopped it, right.
54:59Even though he had his dementia,
55:01he completely stopped it.
55:02And he said even as he was leaving,
55:03he was like, OK,
55:04I know you guys don't appreciate
55:06my funny jokes and I didn't laugh
55:08and and but he was able to stop it
55:10right there despite the fact that
55:11there was some cognitive issues.
55:13So this is important and I'll quickly
55:15finish because we are literally on time,
55:17but it's important because
55:19this actually occurred.
55:20A patient winked the first
55:22day wasn't checked.
55:24The next day when they were
55:25examining the patient,
55:26the patient lifted his shirt all
55:27the way and said, yeah, go ahead and
55:29touch me anywhere wasn't checked.
55:30The attending still did not say anything.
55:33The the trainee went ahead
55:34and examined the patient.
55:36The third day she was pre
55:37dawning at 6:00 in the morning.
55:38There was no one else in the room.
55:40The patient pulled her into the bed,
55:42fondled her.
55:43It was the most traumatic experience.
55:46Could this have been checked if the
55:48the attending had spoken at the wink?
55:49We don't know.
55:51But that is why it's important.
55:53When you notice something
55:55which is even a gesture,
55:57if you call it out and you check,
55:59hopefully we'll be able to prevent
56:01at least some of the escalation,
56:02which then goes forward
56:04because they feel empowered.
56:05They feel like, Yep,
56:06I can keep doing whatever.
56:08Most of the sexual offenders
56:10always start with something small.
56:12No one goes and just takes a resident
56:15and does physical assault on them.
56:18Ellie, I'm. I'm sorry, I want to ask folks,
56:23Linda just circulated in the chat AQR
56:25code or a click thingy to give the
56:29evaluation and I think it's it's really
56:31important for us and and sorry to,
56:32to cut the fund to do this,
56:34but it's important for three reasons.
56:36One is that Shaylee and Ben have
56:40worked really hard at this and
56:42we want them to get feedback.
56:45And two is that we're planning
56:47ahead for the next series.
56:50All right, I'm sorry. OK.
56:52I'm just trying to go to the
56:53slide that you told me to go to.
56:55So. So there is a again,
56:58yeah, there you have and in
57:00the chat you also have the,
57:02the link that you can click on
57:04and if you've been good and
57:09finished your your evaluation,
57:10you get to ask a question.
57:11But if you've been naughty you
57:13don't get to ask a question
57:14until you finish your evaluation.
57:15So we have maybe time for a question,
57:17for a question or two
57:24quick question. I filled,
57:25filled my I I filled out my form.
57:28I'm nice, not naughty.
57:31But it seems like as a general theme
57:33in many of in the cases you presented,
57:36the first step I I mean is certainly,
57:39you know, acknowledge to
57:40yourself that it happened.
57:41Yes, I really did see that.
57:44You know don't try to you know
57:46rationalize it away And then you're
57:49saying inquire with the patient.
57:51Did I see this right.
57:53I mean am I understanding you
57:56correctly to always to to sort
57:58of check back and then you know,
58:01based on the response,
58:02you know,
58:04make your point regarding sexism
58:06isn't OK racial bias isn't OK in a
58:10way that people can understand but
58:13in itself is is tolerant and and
58:18doesn't have any abuse about that.
58:21Do do I understand those as the 123?
58:24Yes, absolutely. We summarize
58:26it pretty well, Ben. OK
58:30yeah, absolutely. Yes.
58:31I I agree with you because you you
58:34start with your own ward view.
58:35What lens am I using? Am I noticing it?
58:38Not trying to block it with my
58:41own ward view and I have to turn
58:43from a bystander to an upstander,
58:45but I have to do it safely.
58:47Yeah. And effectively. Yeah.
58:50That as I I didn't put it in my evaluation,
58:52but I'm thinking that probably was
58:55explicit somewhere in the talk.
58:57Maybe I turned away.
58:58But if it wasn't, you know,
59:00if people can walk away with things like
59:03here's the 123 of being an upstander,
59:06then that that makes it an easy lesson
59:09to transfer into clinical settings.
59:12And thank you so much. Thank you.
59:16OK. Well, thank you, Ben, and thank you,
59:21Dailey for a great session. And we'll
59:24see you all at next series of. Yes,
59:31thank you. Thank you, everyone.
59:32Thanks for your time. Thank
59:33you so much.
59:34Thank you so much. It was very important,
59:39very important. Thank you. Thank
59:43you.