Ghosts in the Chart

Transcript

• 00:02So good afternoon, everyone, and
• 00:04welcome to Grand Rounds.
• 00:06In the spirit of the
• 00:08theme of this week,
• 00:09this holiday, I'm grateful for
• 00:11your participation, everyone online and
• 00:13everyone here in person. And
• 00:14I'm particularly grateful and thankful
• 00:16for, our Grand Rounds Committee.
• 00:18Some of our members are
• 00:19with us here today, for
• 00:21making this series what it
• 00:22is. This is another
• 00:24call to action for anyone
• 00:25that would like to suggest
• 00:26speakers for our upcoming series.
• 00:28We're currently booking speakers into
• 00:30September of twenty twenty five.
• 00:32If you have, speaker suggestions,
• 00:34please do send them our
• 00:36way. In terms of upcoming
• 00:37speakers, I'd like to remind
• 00:39you that next week, we're
• 00:40going to hear from doctor
• 00:41John Pichankis.
• 00:43Some of you will yes.
• 00:45For essentially a redo,
• 00:47you may remember a somewhat
• 00:49traumatic day back in June
• 00:50where, there was a school
• 00:52wide outage of, Internet outage,
• 00:54and that meant we had
• 00:55to, unfortunately,
• 00:56abandon John's presentation. So he
• 00:59very generously agreed to come
• 01:01back next week for the
• 01:02Viola Barnard lecture on LGBTQ
• 01:05affirming
• 01:06health care.
• 01:07Following that, we'll have a
• 01:09leadership series presentation from Eric
• 01:11Clemens, who's the CEO of
• 01:13Concorp.
• 01:14So please do join us
• 01:15for that. And then rounding
• 01:16out our Grand Rounds series
• 01:18for this year will be
• 01:19our very own Kasia Havarska
• 01:21on December seventeenth,
• 01:23which is also, I believe,
• 01:24the day that we will
• 01:25have our, center party. So
• 01:27please do join us, for
• 01:29that grand rounds,
• 01:31to round out, twenty twenty
• 01:33four. And to our speaker
• 01:35today, it is my distinct
• 01:36pleasure and privilege to introduce
• 01:38our very own
• 01:39Tara Sanabria Davila,
• 01:41who is a Puerto Rican
• 01:43bilingual,
• 01:44multiracial
• 01:45clinical social worker with over
• 01:47twenty years
• 01:48of experience working,
• 01:50with underserved
• 01:51youth and families, providing identity
• 01:54tailored care.
• 01:56Tara, as anyone who has
• 01:57worked with her will know
• 01:58that she is skilled in
• 02:00delivering and also providing training
• 02:02in identity adapted evidence based
• 02:06interventions.
• 02:07And now
• 02:08you can read Tara's fairly
• 02:09extensive bio online to hear
• 02:12about her fantastic and fabulous
• 02:13educational background. But what Tara
• 02:15really I think anyone that
• 02:16works with Tara, what you'll
• 02:18already know, what Tara really
• 02:19wants you to know is
• 02:20that she centers,
• 02:21human dignity in all that
• 02:23she does as vice chair
• 02:25for DEI here in the
• 02:26center, as a clinician, as
• 02:28a supervisor,
• 02:29and in her personal life
• 02:30as a wife, a mother,
• 02:32friend.
• 02:33Now Tara derives great joy.
• 02:35She's an avid reader,
• 02:36enjoys cooking, cultural dishes, baking,
• 02:39spending time with her husband,
• 02:40children, and dog. But what
• 02:43some of you may or
• 02:44may not know is that
• 02:45she also drives great joy
• 02:46for her philanthropic
• 02:47work. And so Tara,
• 02:50is a cochair of the
• 02:51Progreso Latino Fund and a
• 02:53founding funder of the Vineyard
• 02:55Project for Black Futures
• 02:56and establishing the Siampre Palante
• 02:59Fund,
• 03:00which supports organizations
• 03:01in New Haven
• 03:02dedicated to racial equity and
• 03:04social justice.
• 03:06And this is also an
• 03:07invitation.
• 03:08Tara very much enjoys
• 03:10working with both aspiring
• 03:12and established
• 03:14cos conspirators to create a
• 03:16more just
• 03:17community and society. So please
• 03:19do reach out and join
• 03:21Tara in that mission. Thank
• 03:22you so much for doing
• 03:23this, Tara.
• 03:29Alright. It was lovely to
• 03:31see you here. Thank you
• 03:32for for being here. I
• 03:33know it's a a short
• 03:34week,
• 03:36but I am excited
• 03:37to bring and to introduce
• 03:39this health equity rounds format,
• 03:42to you.
• 03:43And so I see some
• 03:45of the fellows in the
• 03:46room. We've been using this
• 03:47format in the Tuesday didactic.
• 03:49So I'm gonna I'm gonna
• 03:50hope and lean on your
• 03:51participation
• 03:52for some of this.
• 03:54But this is gonna focus
• 03:56on,
• 03:57ghosts in the chart. So
• 03:58the idea that there are
• 03:59these artifacts that linger in
• 04:01the charts that might have
• 04:02influence and impact that we
• 04:04don't necessarily
• 04:06pay attention to.
• 04:09So
• 04:10this is also available. You
• 04:12can get your continuing
• 04:14education credits both from the
• 04:15CMEs. You can,
• 04:18text in. The code is
• 04:19on the screen. You can
• 04:20also scan this. And if
• 04:22you're in the room and
• 04:22you wanna scan in the
• 04:23back, you can scan in
• 04:24for the continuing education credits
• 04:27from the National Association of
• 04:28Social Workers. We will ask
• 04:30you if you are looking
• 04:31for continuing education credits from
• 04:34NASW to also sign out
• 04:35at the end, and we'll
• 04:36have the QR code there.
• 04:38And we ask anybody and
• 04:39everybody to please, complete an
• 04:41evaluation
• 04:42just so
• 04:43we can stay on top
• 04:44of the kinds of things
• 04:45that we're offering. It offers
• 04:46you not only,
• 04:48the opportunity to give us
• 04:49feedback on the presentation today,
• 04:50which we share with all
• 04:51of the speakers,
• 04:53but you but also gives
• 04:54you an opportunity
• 04:56to give some thoughts and
• 04:57ideas about the kinds of
• 04:58programs you'd like to see.
• 05:03So I'd also like us
• 05:04to hold a moment of
• 05:05silence and recognition
• 05:07for the indigenous people of
• 05:08New Haven and across the
• 05:09United States of America,
• 05:11for whom this week is
• 05:12a reminder and marker of
• 05:13great pain and suffering. And
• 05:15so I encourage you
• 05:17to reflect on that and
• 05:18also to join in the
• 05:20perspectives for inclusion series on
• 05:22December eleventh
• 05:23when Ned Blackhawk will discuss
• 05:25his fourth book and winner
• 05:26of the twenty twenty three
• 05:28national book award, the rediscovery
• 05:30of America, native peoples, and
• 05:31the unmaking
• 05:32of US history.
• 05:34And so in that, it's
• 05:35a basically a transformative narrative
• 05:37of five centuries of US
• 05:38history with indigenous people at
• 05:40its center. So that's gonna
• 05:41be in the Cohen from
• 05:42twelve to one. It is
• 05:43part of
• 05:45the,
• 05:47perspectives for inclusion series, and
• 05:49this is actually one of
• 05:50the talks that the child
• 05:51study center is also, also,
• 05:55sponsoring.
• 05:56So a little bit about
• 05:57this format.
• 05:58So
• 06:00last year, we had the
• 06:01inaugural viola, Viola Bernard social
• 06:04justice and health equity
• 06:06fellows.
• 06:07And so with that, there
• 06:08was also a space that
• 06:09was dedicated on Tuesdays. And
• 06:11so once the month we
• 06:12started having these conversations,
• 06:14focused on health equity.
• 06:16And
• 06:17to do that, we wanted
• 06:18to have a structured format,
• 06:19so we kinda dug through
• 06:21and saw what was already
• 06:22out there
• 06:23and adapted a model from
• 06:24the Department of Pediatrics at
• 06:26Boston Medical Center for us
• 06:28to use. And we piloted
• 06:29it with the fellows last
• 06:30year. So that was Amanda
• 06:31Calhoun, Saja Al Musawi, and
• 06:33Christian Edwards
• 06:34who helped do that, and
• 06:35they helped,
• 06:36do a number of presentations.
• 06:38And then this year, we've
• 06:39got Laura Gallardo, Christina Washington,
• 06:41and Isaac Johnson who are
• 06:43this year's fellows, and they
• 06:44are also using this format
• 06:46as well. And so we
• 06:48piloted this within
• 06:50this fellows only space.
• 06:52And this year, we would
• 06:54like to introduce it to
• 06:55the rest of the community.
• 06:56And so
• 06:57that is why I'm here
• 06:58today with this. And also
• 07:00in
• 07:01January, the Viola Bernard Fellows
• 07:02will present one for grand
• 07:04rounds as well.
• 07:05And then there will also
• 07:07be
• 07:08for the, space that is
• 07:10curated for fellows. Their supervisors
• 07:12will be invited for,
• 07:14a health equity rounds there
• 07:15as well. So you should
• 07:16be getting an invitation for
• 07:17that soon.
• 07:20So the purpose and the
• 07:22objectives of this is to
• 07:23analyze how racism and other
• 07:24forms of oppression have impacted
• 07:26the care of children and
• 07:27families.
• 07:29We know
• 07:30that I mean, Kieran and
• 07:31I were just talking before
• 07:32this. Right? Like, we live
• 07:33in
• 07:35very,
• 07:36racist, biased
• 07:38society.
• 07:39It is impossible
• 07:40to not be permeated by
• 07:42the messages that are being
• 07:43sort of thrown at us
• 07:44at all times.
• 07:46That's why it's important for
• 07:47us to actually continuously work
• 07:48against that. And so the
• 07:50hope behind this is to
• 07:51offer as well an additional
• 07:53opportunity
• 07:54to continue to scrutinize how
• 07:55this bias sort of creeps
• 07:57into our everyday thinking and
• 07:58work, and more importantly, how
• 08:00to mitigate the the impact
• 08:02and work against it. It
• 08:03also takes some time to
• 08:05examine the historical and current
• 08:07underpinnings of racism and oppression
• 08:08in the medical system and
• 08:09in the work that we
• 08:10do,
• 08:11and also explores some evidence
• 08:14based tools to recognize and
• 08:15eliminate,
• 08:16racist and other oppressive ideas
• 08:18and actions,
• 08:19which also offers some strategies
• 08:21that can be used,
• 08:22in
• 08:23practice.
• 08:26The overall framework, and this
• 08:27is directly from,
• 08:29Boston Medical Center,
• 08:32is, in front of you.
• 08:33So right. So so we've
• 08:34got the motivation.
• 08:35That is that real life
• 08:37cases
• 08:38give us a number of
• 08:39examples for us to be
• 08:41able to use this format
• 08:42and highlight the way bias
• 08:43has been present in the
• 08:44work that we do. The
• 08:45case that we're gonna talk
• 08:46about today is actually a
• 08:47case of mine from years
• 08:49ago as part of this
• 08:50practice.
• 08:52It also examines the impact
• 08:53of racism, discrimination,
• 08:55oppressive practices, and that those
• 08:56have lasting impact on groups
• 08:58that have been historically marginalized.
• 09:00It offers the space for
• 09:01reflection.
• 09:02In almost every model that
• 09:05talks about being anti racist
• 09:06or anti bias, there is
• 09:08the constant
• 09:09of ongoing critical self reflection.
• 09:12And so this also builds
• 09:13that in as an opportunity
• 09:15and as a way to
• 09:16employ those best practices.
• 09:19We also wanna increase knowledge
• 09:20of origins and the perpetuation
• 09:22of structural racism and other
• 09:23structural barriers,
• 09:25and then learn new skills
• 09:26that might help you work
• 09:27against these structures.
• 09:31We also enter with some
• 09:32agreements.
• 09:33So the agreements in the
• 09:34fellow space have been co
• 09:36constructed by the fellows. Today,
• 09:38I'm offering you some borrowed
• 09:40from there and others that
• 09:41seem more appropriate for this
• 09:43space.
• 09:44And so we ask people
• 09:45to participate freely and that
• 09:47when you do that, you
• 09:48center language and ideas that
• 09:49don't perpetuate oppression.
• 09:51We assume that the providers
• 09:53acted in the best interest
• 09:54of the child
• 09:56and that those actions were
• 09:57likely informed by implicit bias
• 09:59that have explicit impact.
• 10:02Some details of the case
• 10:04have been changed to protect
• 10:05confidentiality.
• 10:07When you are participating and
• 10:08speaking, please be conscious of
• 10:09positionality and power dynamics in
• 10:11the room. Make some space
• 10:12for others if you notice
• 10:14that they'd like to speak
• 10:15and be aware of not
• 10:16dominating the space.
• 10:19Please enter with the desire
• 10:21to listen to understand, not
• 10:22necessarily
• 10:23just to respond.
• 10:25Sit with it.
• 10:27Spend some time, form your
• 10:28thoughts, and join us in
• 10:30the conversation.
• 10:31And know that being uncomfortable
• 10:33may happen.
• 10:36I like to think of
• 10:37that as,
• 10:38like an oyster and sand.
• 10:40Right? Your little piece of
• 10:41sand gets inside the oyster
• 10:42shell, and the oysters are
• 10:44terribly uncomfortable in trying to
• 10:45move it out. It's uncomfortable,
• 10:47but what it ends up
• 10:48with is a beautiful pearl.
• 10:49And so if we can
• 10:50sit with that discomfort,
• 10:52work with that discomfort, perhaps
• 10:53we also can produce something
• 10:54beautiful.
• 10:58So
• 10:59we are gonna spend some
• 11:00time thinking about some of
• 11:01these definitions,
• 11:02some things that will appear
• 11:04in this presentation.
• 11:06So for those of you
• 11:07who don't do clinical work
• 11:08or work directly with children,
• 11:10a one thirty six. A
• 11:11one thirty six is the
• 11:12report to the Department of
• 11:13Children and Families for suspected
• 11:15abuse and neglect. It's what
• 11:16it's called in the state
• 11:17of Connecticut.
• 11:19Enhanced care clinic,
• 11:21that was a designation or
• 11:22is a designation determined by
• 11:24the state for clinics that
• 11:25agree to meet certain access
• 11:26guidelines.
• 11:28Our outpatient clinical services are
• 11:31an enhanced care clinic.
• 11:33White normativity,
• 11:34This naturalizes power asymmetries between
• 11:37white and nonwhite people as
• 11:38primarily,
• 11:40merit meritocratic. Excuse me. I
• 11:42couldn't get that word out.
• 11:43And it rests on the
• 11:44idea that white dominant culture
• 11:46is the norm, and people
• 11:48of color are judged as
• 11:50a deviation from that norm.
• 11:52And then, of course, systems
• 11:53of oppression, which calls attention
• 11:55to the historical and organized
• 11:56patterns of mistreatment in the
• 11:57US.
• 11:59We also wanna
• 12:01call attention to intersectionality
• 12:04and the complex cumulative way
• 12:06for which the effects of
• 12:07multiple forms of discrimination combine,
• 12:09overlap, and intersect, especially in
• 12:11the experience of marginalized individuals.
• 12:13So it's layer upon layer
• 12:15upon layer.
• 12:17And then a term introduced
• 12:19by Dorothy Roberts,
• 12:21who's a legal scholar who
• 12:23proposes that perhaps the a
• 12:25different name for the child
• 12:26welfare system might be the
• 12:27family regulation system.
• 12:30Going back into the history
• 12:32of it and how it
• 12:34has,
• 12:35really been designed and used
• 12:38to regulate and punish black
• 12:39and other marginalized folks and
• 12:41parents whose parenting skills and
• 12:43approaches may not align
• 12:45with some of those defined
• 12:46through white normativity.
• 12:49So
• 12:50now imagine
• 12:53you are a seasoned clinician,
• 12:55and you're part of an
• 12:56intake team.
• 12:57You receive a referral for
• 12:59a seven year old bilingual
• 13:01male from South America with
• 13:02presenting
• 13:03problems that's being described as
• 13:05doesn't like to be far
• 13:06from their mom, occasionally has
• 13:08trouble falling asleep alone, and
• 13:10is easily aroused in new
• 13:11situations.
• 13:14Sounds routine?
• 13:16You schedule a routine intake
• 13:18to occur within two weeks
• 13:19of the referral within the
• 13:20guidelines of the enhanced care
• 13:23clinic.
• 13:24So
• 13:26let's continue to imagine
• 13:28that you get several urgent
• 13:31emails, epic in basket messages,
• 13:33and voice mails from the
• 13:34pediatric practice asking to speak
• 13:36with you about this referral.
• 13:43What starts to come up
• 13:44for you?
• 13:46You think it's routine.
• 13:48You schedule two weeks, and
• 13:50you get all of these
• 13:50messages.
• 13:52What might arise?
• 13:55Darren?
• 13:59Mhmm. Have a page that
• 14:01or they have a consent
• 14:02to
• 14:03that the fact that someone's
• 14:05calling
• 14:06you about the case. It
• 14:07may not be
• 14:09totally appropriate because there haven't
• 14:11been releases such. I don't
• 14:13know them. What do you
• 14:14what do you want? Like,
• 14:16I haven't met this family
• 14:17yet. I don't know if
• 14:18I can even speak with
• 14:19you yet. Sure.
• 14:20Jose?
• 14:23It sounds like somebody is
• 14:24trying to
• 14:28manage your perception of the
• 14:30case before you even see
• 14:31the case.
• 14:32Possibly.
• 14:35In addition thank you for
• 14:36that. In addition, you also
• 14:38receive calls. So I also
• 14:39got calls from the mom.
• 14:40So a lot of phone
• 14:41calls, a lot of in
• 14:42basket messages, emails, it felt
• 14:44like rapid fire.
• 14:45And then
• 14:47I also get calls from
• 14:48mom asking about the intake,
• 14:50saying that the pediatricians have
• 14:51told her to please call.
• 14:53Again, now think with all
• 14:55these pieces put together, what's
• 14:56coming up for you as
• 14:57a provider? So, yes, Jose,
• 14:59I agree with right. I
• 15:00hear what you're saying on
• 15:01that, Cara.
• 15:02This is gonna be a
• 15:03more intense case than I
• 15:04thought. Clearly, there's some crisis
• 15:06happening that I'm not aware
• 15:07of.
• 15:08Yeah. Like, if you're getting
• 15:10all these messages and all
• 15:11of these things and there's
• 15:12such urgency behind it, we
• 15:14do begin to think there's
• 15:15gotta be something else going
• 15:16on. Like, what what am
• 15:17I missing?
• 15:19So I return the call.
• 15:22Had a conversation with this
• 15:23social worker who's embedded in
• 15:24that pediatric practice
• 15:26who conveyed the very same
• 15:27reasons for the for the
• 15:29referrals. So nothing has changed.
• 15:31Trouble sleeping, doesn't like to
• 15:32be far from mom, etcetera.
• 15:34But also says this,
• 15:37mom is not a reliable
• 15:38reporter.
• 15:39We suspect something else is
• 15:41going on.
• 15:45Oh,
• 15:46And then
• 15:48oh, actually, let me see.
• 15:49Didn't show up, but here
• 15:50it is. And when asked
• 15:52about the information that they
• 15:53have that has elevated the
• 15:55current worry
• 15:56because remind they they've repeated
• 15:58the same referral,
• 16:00same issues that I took
• 16:01down that I thought was
• 16:02routine.
• 16:04They refer to this artifact
• 16:06in the chart,
• 16:08a one thirty six that
• 16:09was filed by the hospital
• 16:11four years ago and language
• 16:13that suggests that mom was
• 16:14lying.
• 16:20There is nothing related to
• 16:22the current presenting problem
• 16:24that is,
• 16:26cited as urgent.
• 16:28It goes back to this
• 16:29idea.
• 16:32I'll tell you about the
• 16:32one thirty six in a
• 16:33minute, but what's coming up
• 16:34for you now?
• 16:36What are some thoughts you
• 16:37have? So they're they're telling
• 16:38you same thing.
• 16:40Accept that
• 16:42something happened four years ago.
• 16:47Are you worried? Want you
• 16:48to be an investigator.
• 16:49They might want me to
• 16:50be an investigator. For sure.
• 16:53Yes. Was there anything related
• 16:55to the current concern or
• 16:57recent history that makes this
• 16:59valid or relevant? It's a
• 17:01great question. So the one
• 17:03thirty six that was filed
• 17:05was,
• 17:06mom brought the two little
• 17:08children at the time. So
• 17:09it's four years ago, so
• 17:10he was three years old,
• 17:11and his little brother was
• 17:12a toddler.
• 17:14A younger toddler, brought them
• 17:15in because the, this child
• 17:18had a burn on his
• 17:19back,
• 17:20a hot water scalding burn.
• 17:23And so mom brought him
• 17:25in to treat that burn.
• 17:27And mom's story about that
• 17:28burn is that she had
• 17:30turned the spigot of the
• 17:31water, ran the tub, put
• 17:33both of the kids in
• 17:34there, turned off the water.
• 17:35She turned her back for
• 17:36a minute, and he turned
• 17:38the spigot. The water hit
• 17:39his back, and that's where
• 17:40the burn came from.
• 17:42They decided that that burn
• 17:45that that's a lie, that
• 17:46that couldn't possibly be the
• 17:48truth.
• 17:49And this is where this
• 17:50whole thing started going. But
• 17:52as they're supposed to, right,
• 17:54there's this thing. You don't
• 17:55need to have
• 17:56proof you are not the
• 17:58investigator as Carla was pointing
• 17:59out. Right? You just have
• 18:00to report suspicions of abuse
• 18:02or neglect.
• 18:03That's what they did.
• 18:05So
• 18:06the reason why the pediatrician
• 18:08saw the kid was
• 18:09during the regular checkup,
• 18:11The mom mentioned that they
• 18:12were having some of these
• 18:13anxiety symptoms.
• 18:15That's it.
• 18:18Any other things come up
• 18:19for you as you think
• 18:20about this?
• 18:22I've been just wondering since
• 18:23you've put it up, just
• 18:23like the the language piece.
• 18:24Like, I wonder about, what
• 18:25what services was she offered
• 18:26when she tried to share
• 18:26what happened. I know you
• 18:27spoke about them being the
• 18:29youth being from Latin America.
• 18:31And so,
• 18:36like, wondering about
• 18:38language services potentially that were
• 18:40needed and maybe not,
• 18:41sometimes the most helpful at
• 18:43times. And so I wondered,
• 18:44like, how the message may
• 18:46have gotten lost in translation
• 18:47or affect,
• 18:49lost in translation.
• 18:51Those are some things that
• 18:51I'm wondering about. Absolutely. We
• 18:53know that there's not always
• 18:54translation services used or available.
• 18:57So was that a factor?
• 19:00My initial question would be,
• 19:01what was the outcome?
• 19:03What was the outcome? Great
• 19:05question.
• 19:05So within
• 19:07so, Carla, to your point,
• 19:09they made me investigate, but
• 19:10they didn't make me investigate
• 19:11mom.
• 19:12I went on a deep
• 19:13dive into the chart because
• 19:15I wanted to know what
• 19:16else was there.
• 19:17And so you can find
• 19:19the one thirty six very
• 19:20easily.
• 19:21But I went to look
• 19:22through social works notes to
• 19:24see if there was anything
• 19:25else. And that report,
• 19:26there's a a single sentence
• 19:28in the chart
• 19:30later on, maybe, like,
• 19:32maybe four or five days
• 19:33later that said, report was
• 19:35unsubstantiated.
• 19:38Right? So that means, of
• 19:39course, that this was not
• 19:40found to be the case.
• 19:41They did not think abuse
• 19:42or neglect occurred.
• 19:44But
• 19:48this crew, like, this group
• 19:49of people were really concerned.
• 19:51These two there were two
• 19:52people. It was the pediatrician
• 19:53and the social worker embedded
• 19:54in the pediatric practice.
• 19:56So
• 19:57let's take a minute and
• 19:58let's reflect. Right? What think
• 20:01about yourself as a provider.
• 20:03What are the implicit and
• 20:04the explicit messages you've received
• 20:06through your life about
• 20:09lies, truth, and trust.
• 20:11Who gets believed?
• 20:15Who doesn't? In my family,
• 20:17my brother and sister did
• 20:18not get believed a lot
• 20:19because they did a lot
• 20:20of hijinks.
• 20:22So even when they were
• 20:23telling the truth,
• 20:24they were not believed immediately
• 20:26because of this this this
• 20:27history of hijinks.
• 20:29Right? But who gets believed?
• 20:32Who gets questioned?
• 20:36Think about the kids you
• 20:37see.
• 20:39Think about the schools. I
• 20:40think about I there was
• 20:41these kids that I once
• 20:42worked with there as a
• 20:43brother two brothers, an older
• 20:44and a younger brother in
• 20:45the same school.
• 20:47One was adorably endearing
• 20:50and had this way of
• 20:51just pulling everybody to his
• 20:53way.
• 20:54The other one was honestly
• 20:55rather annoying and not as
• 20:56cute as his little brother.
• 20:59The annoying child
• 21:01got cited for everything
• 21:03that he did wrong,
• 21:05where his brother,
• 21:07who raised hell
• 21:09all the time,
• 21:10did things that were really
• 21:12mean and really should have
• 21:13had some correction,
• 21:16splashed his cute little blue
• 21:17eyes at them and gave
• 21:18them a smile with was
• 21:19missing some teeth.
• 21:21And they and was, like,
• 21:23forgiven.
• 21:24Right? So there's bias in
• 21:25that school system about sort
• 21:27of, like, who's trustworthy, who's
• 21:28not.
• 21:31What have you learned in
• 21:32your life about measures of
• 21:33right and wrong?
• 21:38There's a lot
• 21:39Go ahead. There's a lot
• 21:40of gray area. There's a
• 21:41lot. There's absolutely. Right? And
• 21:43what you might have learned
• 21:44in your household about what's
• 21:46right and wrong and what
• 21:46I might have learned in
• 21:47my household about what's right
• 21:48and wrong might be
• 21:49different. We might have some
• 21:51general things that are sort
• 21:52of, consistent themes, but based
• 21:55on nuance and different things,
• 21:56there might have been, difference
• 21:58in that. Right?
• 22:01These are all the things
• 22:02that influence our ideas
• 22:04and our biases.
• 22:06And this is another one.
• 22:07Have you ever been judged
• 22:09for something in your past
• 22:11that you kinda can't get
• 22:12away with, like that one
• 22:13mistake you made?
• 22:15And, like, you learn from
• 22:16that mistake, but you kept
• 22:17going. And now, like, you
• 22:18no longer commit that thing,
• 22:20but everybody loves maybe around
• 22:22Thanksgiving
• 22:23to tell the story of
• 22:25the time you did that.
• 22:26And they think it's hilarious
• 22:27and endearing, and you are
• 22:28dying of humiliation.
• 22:31There's nobs.
• 22:33So people know that story.
• 22:34Right? That's a thing.
• 22:36Were there any of the
• 22:37reflections that anybody wanted to
• 22:38share? And, also, if you're
• 22:39online, please feel free to
• 22:40jump out and on as
• 22:42well.
• 22:44Yeah. I'm just thinking about,
• 22:46like, early in my training,
• 22:47like, making a mistake and,
• 22:48like, documentation and having that
• 22:49supervisor, like, think I'm going
• 22:51to make that mistake, like,
• 22:52every single time. Forever. Yeah.
• 22:55It's like Yeah. That was
• 22:56learning experience. And Well, and
• 22:57how did that make you
• 22:58feel?
• 22:59Like, I was incompetent and,
• 23:00like, was never gonna actually,
• 23:02like, get better at that
• 23:03mistake, but, of course better.
• 23:04So
• 23:05Yeah. Thank you. Thank you
• 23:06for sharing that. Any other
• 23:07reflections that folks wanna share?
• 23:10Thanks. Thank you, Janice.
• 23:14Hospital and medical appointments,
• 23:17schools, the parents who kind
• 23:18of look well put together
• 23:20and, you know, talk articulately
• 23:22to the staff. You know,
• 23:23they can they'll be believed
• 23:24about pretty much anything. But
• 23:26if someone comes in and
• 23:27they're sort of disheveled and
• 23:28they have flat affect or
• 23:30they don't seem particularly
• 23:31concerned
• 23:32or overly concerned if something
• 23:34happens to their child, they
• 23:35get judged for that and
• 23:36there's an assumption that they
• 23:37don't care, that they must
• 23:39be abusing their children, whatever
• 23:40it may be.
• 23:42Thank you for for elevating
• 23:43that. And there's actually a
• 23:45piece of that that,
• 23:47comes up a little later
• 23:48in this story. So
• 23:50Amy Myers Yes. Says that
• 23:52ride the stars and values
• 23:53that are often culturally defined.
• 23:55Yeah. Exactly.
• 23:56That there's a cultural aspect
• 23:58to the definition of these
• 23:59things.
• 24:00Think thinking
• 24:01about the work that we
• 24:02do with wonderful Mary Ginsales
• 24:03with the schools. Sometimes we
• 24:04get a kid on the
• 24:05unit
• 24:06who has a history or
• 24:07has a past
• 24:09that is troublesome or has
• 24:10had a lot of interaction
• 24:11with school
• 24:12leadership.
• 24:13Mhmm.
• 24:14But even in our conversations,
• 24:15we kinda get the idea
• 24:16that they're not gonna get
• 24:17a fair shake Right. At
• 24:19that school. And so sometimes
• 24:20we would even recommend it
• 24:21to the parents
• 24:23to switch schools because they
• 24:24will continue to get in
• 24:25trouble because
• 24:26of that. Bias runs deep.
• 24:28Right?
• 24:29Absolutely. I saw another hand
• 24:30over here. Oh, that's okay.
• 24:32Maybe it's kind of like
• 24:33a minor example, but I
• 24:35think it's definitely impacted my
• 24:37colleagues and mine's perception at
• 24:39least during residency.
• 24:41If there were patients and
• 24:43families
• 24:44who were inconsistent
• 24:46with their appointments or were
• 24:47late, that sort of thing,
• 24:49it created this negative perception
• 24:51of they're not serious about
• 24:52their treatment.
• 24:54Can we really trust their
• 24:55judgment? It it really placed
• 24:57a lot of concern about
• 24:58their
• 24:59motivation.
• 25:00Yes. So, yeah, that was
• 25:02something I saw as a
• 25:03consistent theme
• 25:04back in that clinic.
• 25:06Yes. Thank you. Thank you
• 25:07for for raising that. And
• 25:09there's another slide that we're
• 25:11think about and wonder where
• 25:12some of these biases come
• 25:13from. And I'm gonna dig
• 25:15in a little bit to
• 25:15that one you just lifted.
• 25:18So
• 25:19so alright.
• 25:21You you you have the
• 25:22facts so far. Right? You
• 25:24know what's going on.
• 25:26Put yourself in mom's shoes.
• 25:29She went to the doctor,
• 25:30the pediatrician for a regular
• 25:31checkup. Her normal, like, once
• 25:33a year checkup for her
• 25:34kid mentioned that her kid
• 25:36is feeling anxious.
• 25:38They make a referral, and
• 25:39then
• 25:40everything blows up, and they
• 25:41keep have you called? Have
• 25:43you gone? Have you gone?
• 25:44Have you made that appointment
• 25:45yet? Have they called you?
• 25:46Have they called you for
• 25:46the appointment yet?
• 25:48What do you think might
• 25:49be going on for mom?
• 25:53I think mom might be,
• 25:55guarded initially,
• 25:58due to the feeling of
• 25:59being, like, under a magnifying
• 26:00glass or a microscope based
• 26:01upon pre
• 26:02interactions
• 26:03and,
• 26:04history. I think absolutely.
• 26:06Yes. I also think that
• 26:08the pediatrician is kind of
• 26:10conveying this message that there's
• 26:11such a high level of
• 26:12acuity, and mom could likely
• 26:14be very, very anxious and
• 26:15nervous about her child's health
• 26:17herself.
• 26:18Whereas you think this is
• 26:19just a normal case, and
• 26:22the pediatrician likely does too.
• 26:24It's just they're adding all
• 26:25the extra stress that mom
• 26:26doesn't need.
• 26:27Absolutely. Thank you. Any other
• 26:29thoughts?
• 26:34So here are some of
• 26:35the things that mom thought.
• 26:37I don't know why they're
• 26:37pushing so hard to get
• 26:38this appointment.
• 26:39Is there something really wrong
• 26:41with my child? So really
• 26:42wondering, like, is there more
• 26:43going on and they're not
• 26:44telling me? Is my kid
• 26:46really ill and nobody wants
• 26:47to let me know?
• 26:51They're so worried, and they're
• 26:52keep they keep asking me.
• 26:54And why are they worried
• 26:55about DCF? So I think
• 26:56at some point, they mentioned
• 26:57DCF to mom.
• 26:59Did I do something wrong?
• 27:01And then she reflects on
• 27:03when the hospital was called
• 27:04when the DCF was called
• 27:05by the hospital last time,
• 27:07and they closed the case
• 27:08and the wonder and the
• 27:09worry if they're gonna call
• 27:11again.
• 27:12And although she didn't explicitly
• 27:14state this, I always wondered
• 27:15if she thought we were
• 27:16unresponsive
• 27:17because the other group was
• 27:18like, you have to get
• 27:19this this appointment. You have
• 27:20to get this appointment.
• 27:21And we were not seeing
• 27:23I was not seeing based
• 27:24on what they saw and
• 27:25what they were saying anything
• 27:27that conveyed urgency and didn't
• 27:28want to join in
• 27:30with making an urgent situation
• 27:31out of a current
• 27:33kind of routine situation.
• 27:35But I did always have
• 27:36that wonder in my head
• 27:37as if if for a
• 27:37while she wondered if we
• 27:39were somehow ignoring,
• 27:41her needs or her kids'
• 27:42needs.
• 27:45So we can think about
• 27:47possible
• 27:48biases and where they might
• 27:49come from. So I actually
• 27:50wanna go to the one
• 27:51that you mentioned, which was
• 27:52when families don't come and
• 27:54this idea that they're noncompliant
• 27:55and whatever. But
• 27:58how many of you here
• 27:59have taken the bus in
• 28:00New Haven?
• 28:01Nope. Mhmm. What do you
• 28:03think about the bus system?
• 28:06Very annoying and unreliable.
• 28:08It is very annoying and
• 28:09unreliable.
• 28:10Is it effective and efficient?
• 28:13It's cheaper. It's cheaper for
• 28:14sure.
• 28:16But is does it get
• 28:17you
• 28:18places effective efficiently, I better
• 28:20better said. No. No. It
• 28:22takes a very long time
• 28:23to get there. Thank you,
• 28:25doctor Emmons. Absolutely. And it
• 28:27runs on a hub system.
• 28:29Right? So you you might
• 28:30see where you need to
• 28:31get to, but you've gotta
• 28:32come to the middle and
• 28:33then you go out in
• 28:34another direction, and it takes
• 28:35forever.
• 28:36So this is another thing
• 28:38that if you don't know
• 28:39that and you don't know
• 28:41that it, isn't the best
• 28:43system,
• 28:43then you're thinking the parent
• 28:45is late all the time
• 28:46because they don't care.
• 28:48Has nothing to do with
• 28:49this bus system. Has nothing
• 28:50to do with the fact
• 28:51that there are other systemic
• 28:53issues that are getting in
• 28:54the way. So thank you
• 28:55for that. Also had to
• 28:57be mindful in New York
• 28:58because MTA is not the
• 29:00most reliable transit system either
• 29:01even though it's like a
• 29:03glorified symbol for America. And
• 29:05so there was always something
• 29:06breaking down. True. But I
• 29:08have to say as a
• 29:09as a as a New
• 29:11Yorker, I still think it's
• 29:12way better than New Haven.
• 29:14So
• 29:15Yeah. That is true. So
• 29:17then one of the things
• 29:18too is to think about
• 29:18privilege.
• 29:19Right?
• 29:20Have any has anyone here?
• 29:24So, like, I I'm thinking
• 29:25about the water situation and
• 29:27the description of mom's water.
• 29:30Have who in here has
• 29:31ever rented an apartment in
• 29:33their life?
• 29:35Okay.
• 29:36Have
• 29:37you been able to control
• 29:39the water temperature
• 29:42in all the places you
• 29:43rented?
• 29:44Okay. For those on the
• 29:45screen, we got a lot
• 29:46of no's.
• 29:48No.
• 29:49Yeah.
• 29:50Sometimes you can't even control
• 29:51the thermostat. Right? When the
• 29:52heat when the heater and
• 29:53the radiators are on, it's
• 29:54on. Like, my sister always
• 29:55had her window open in
• 29:56the middle of January because
• 29:57it was so hot in
• 29:57her apartment because she had
• 29:58no control over that.
• 30:00So if you
• 30:01have always had the luxury
• 30:03and the privilege
• 30:04of controlling
• 30:05the temperature of your water,
• 30:08you would think she's lying
• 30:11about this water being so
• 30:12hot. And if you've rented
• 30:14an apartment and you know
• 30:15that you have no control
• 30:16over the water temperature,
• 30:18you know that it is
• 30:19very possible
• 30:20that it was scalding hot
• 30:22the moment you turned it
• 30:23on because everybody else in
• 30:25the building has been using
• 30:26it and it's ready to
• 30:27go. So the idea
• 30:29that the child accidentally turned
• 30:31the spigot on and the
• 30:32water was hot enough to
• 30:33burn his back is absolutely
• 30:35possible.
• 30:36But if you've never rented
• 30:38an apartment for or or
• 30:39was a long time ago
• 30:40and you forgotten that, you
• 30:42don't remember that and you
• 30:43might go immediately to that's
• 30:45a lie.
• 30:49Immigrants.
• 30:50Some people have biases
• 30:52based on who they think
• 30:54does and does not belong.
• 30:56Right? This mom was an
• 30:57immigrant.
• 30:58It's possible that the person
• 30:59who was treating her had
• 31:00some thoughts and feelings about
• 31:01that.
• 31:03In I was born and
• 31:04raised
• 31:06in
• 31:07here in New York City
• 31:08and then came to move
• 31:09here. And then in twenty
• 31:10seventeen,
• 31:12I was on the telephone
• 31:13in East Rock, and someone
• 31:15rode their bicycle by me
• 31:17and screamed in my face
• 31:19that I should get out
• 31:20of this country and go
• 31:21back to my country
• 31:23just because how I looked.
• 31:25No other reason.
• 31:27So there are people, right,
• 31:29who have these thoughts and
• 31:30ideas. So it is possible
• 31:32that whomever was treating mom
• 31:33in the hospital, this was
• 31:34something that was on their
• 31:35mind.
• 31:36Darker skin.
• 31:39Possible they were operating with
• 31:41racist beliefs and actions that
• 31:43did we know and we'll
• 31:44see later on that DCF,
• 31:46especially in the state of
• 31:47Connecticut, has not only, but
• 31:49at least in Connecticut, they've
• 31:51acknowledged
• 31:51that there's disproportionate representation
• 31:54of calls and actions taken
• 31:56against calls made for black
• 31:57and brown families.
• 32:01Could be a bias against
• 32:02the fact that she spoke
• 32:03another language and that she
• 32:04was Spanish speaking. There's language
• 32:06discrimination
• 32:07all around us.
• 32:12This was also a single
• 32:13parent household.
• 32:15That is yet another,
• 32:17demographic that is disproportionately reported
• 32:19to DCF.
• 32:23Maybe it was mom's socioeconomic
• 32:24status,
• 32:26which is often conflated with
• 32:28being good or bad, which
• 32:29somebody also mentioned
• 32:31in here. And the thought
• 32:33of, white normativity,
• 32:35which is judging based on
• 32:36white dominant cultural norms.
• 32:38Right? So
• 32:40maybe
• 32:42the thought is everybody owns
• 32:43their own place.
• 32:45Everybody has control over this.
• 32:47Not always true.
• 32:52So
• 32:54I wanna think a little
• 32:55bit about my own
• 32:56perspective, thoughts, and feelings on
• 32:58this because I I was
• 32:59the person who was working
• 33:00with this family.
• 33:01So
• 33:02the first was kind of
• 33:03just this idea of access.
• 33:05Right? So as as a
• 33:06provider,
• 33:08I had access to the
• 33:09chart.
• 33:10I also had
• 33:14access
• 33:15and later on actually, it's
• 33:17not here. I think I
• 33:18took it off. But I
• 33:18also had some some privilege
• 33:20in decision making because of
• 33:21the position that I held.
• 33:23Okay.
• 33:24I had disbelief.
• 33:26And mostly, it was because
• 33:28the person who was embedded
• 33:29in the pediatric practice who
• 33:31was calling frantically
• 33:33is someone that is a
• 33:34friend of mine.
• 33:37And
• 33:39she was sharing
• 33:40her worry. And I was
• 33:42in such disbelief
• 33:44that she had just, like,
• 33:45bought in
• 33:47to this worry without exploring
• 33:49and examining. She herself also
• 33:51a Spanish speaking individual
• 33:52and an immigrant from another
• 33:54country.
• 33:55So I was just
• 33:57very I was struck by
• 33:58that.
• 33:59Felt some frustration
• 34:00for the amount of calls.
• 34:02It was, it was seriously
• 34:03ridiculous, the amount of contacts
• 34:05that that were were coming
• 34:07at me.
• 34:09In addition,
• 34:11there was anger
• 34:12that this was following mom
• 34:14around.
• 34:15Right? I had dug deep
• 34:16because I had access to
• 34:17the chart and could find
• 34:18that was unsubstantiated.
• 34:20I will admit it was
• 34:22way easier to find that
• 34:23one thirty six.
• 34:24Much easier than it was
• 34:25to find the little note,
• 34:27the one, like, sentence note
• 34:28that said unsubstantiated.
• 34:30Right? But I felt determined
• 34:32because I was I really
• 34:33wanted to understand, like, is
• 34:34there like, should I be
• 34:35more worried about this like
• 34:36the rest of the folks
• 34:38or not?
• 34:40My identity played into it
• 34:42as a brown skinned
• 34:43Latine woman, Spanish speaking.
• 34:45You know, I was born
• 34:46here, and my recent ancestors
• 34:48were born here in Puerto
• 34:50Rico. Right? All citizens
• 34:52because of the Commonwealth status
• 34:54of Puerto Rico. Right? But
• 34:56I shared that experience with
• 34:57you. Right? Being yelled at
• 34:59to to leave the country
• 35:00that I was born in
• 35:01and that I'm a citizen
• 35:02of just based on someone's
• 35:04biases.
• 35:06And so just knowing and
• 35:07acknowledging that mom had some
• 35:08of that herself was just
• 35:09really
• 35:10it it's striking when it
• 35:12when when you share
• 35:14identity with folks for whom
• 35:15that's happening.
• 35:16It gives you pause.
• 35:20I felt empowered to challenge
• 35:21this because I was and
• 35:23am one of the associate
• 35:25directors of the clinic.
• 35:27I also have some
• 35:28credibility with my colleagues
• 35:30so that they trust my
• 35:31judgment.
• 35:32And so I wasn't
• 35:34forced to do something with
• 35:35this case fast sooner and
• 35:37faster to feed into this
• 35:38worry.
• 35:39I did call mom and
• 35:40let her know, like, hey.
• 35:42I know that they're all
• 35:43worried. I'm reading all the
• 35:44things.
• 35:45The reasons why you're coming
• 35:47all make sense. I think
• 35:48I gave her if I'm
• 35:49not mistaken, I gave her
• 35:50the option to come in
• 35:51sooner if she wanted,
• 35:52but she chose to hold
• 35:53the two weeks.
• 35:57So
• 35:59there are reasons
• 36:00why these biases exist.
• 36:05So
• 36:06part of this
• 36:08is
• 36:09examining the origins of the
• 36:10child welfare system.
• 36:12Right? So Henry Berg founded
• 36:14the the nation's first child
• 36:16protection society in eighteen seventy
• 36:18four, and it was because
• 36:19police refused to intervene on
• 36:21behalf of a nine year
• 36:22old child who also happened
• 36:23to be white, who had
• 36:25been abused by her parents.
• 36:27Now before this, Berg had
• 36:28also
• 36:30established
• 36:30the American Society for the
• 36:32for the Prevention of Cruelty
• 36:33to Animals.
• 36:35And by nineteen twenty two,
• 36:37three hundred privatized
• 36:39child protection societies existed nationwide.
• 36:42But let's pause for a
• 36:43second
• 36:44because
• 36:45what was happening before eighteen
• 36:47seventy four?
• 36:52Slavery
• 36:56and
• 36:58the eradication of indigenous peoples.
• 37:02Children,
• 37:03black and brown children were
• 37:05being abused
• 37:07and neglected,
• 37:08forcibly removed from their families,
• 37:12but there was not a
• 37:13single child protection
• 37:14effort.
• 37:18Animals
• 37:20got a child got a
• 37:21protective
• 37:22entity in society before
• 37:25black and brown children.
• 37:28And private orphanages did not
• 37:30accept black children equally until
• 37:31the nineteen
• 37:32sixties.
• 37:38That's a long time.
• 37:44Also,
• 37:46in the nineteen hundreds, child
• 37:47guidance clinics were intertwined with
• 37:49the burgeoning juvenile court system.
• 37:51They were targeting poor immigrant
• 37:53families based on racist and
• 37:55classist beliefs.
• 37:57And this white normativity came
• 37:59into play because they were
• 38:00judged as not being able
• 38:01to raise their children correctly
• 38:04by whose norms?
• 38:07By whose rules?
• 38:12And the implications were rather
• 38:14violent.
• 38:16Black youth were coerced into
• 38:17juvenile court caseloads for behaviors
• 38:19that would have been sanctioned
• 38:20if they were white.
• 38:23Right. So there's deep origins
• 38:25here.
• 38:29And the chill the delinquent
• 38:30children were seen as having
• 38:32psychic constitutional
• 38:33deficiencies.
• 38:38And all of these clinics
• 38:39ended up, exalting this sort
• 38:41of white middle class ideal.
• 38:45And a number of different
• 38:46themes emerged during this time,
• 38:47including family separation,
• 38:49punishing and policing,
• 38:52white innocence and BIPOC blame,
• 38:54harm in the name of
• 38:55help.
• 38:58The the white nuclear family
• 39:01middle class nuclear family was
• 39:03what was exalted as the
• 39:04ideal.
• 39:05So any other family that
• 39:07deviated from that measure
• 39:09was judged
• 39:11as needing correction.
• 39:19So,
• 39:20nationally,
• 39:21in twenty sixteen,
• 39:23there was a report
• 39:24from the Federal Children's Bureau
• 39:26that highlighted that children of
• 39:27color entered foster care
• 39:29at disproportionately
• 39:30high rates, that African American
• 39:32children are represented in foster
• 39:34care one point eight times
• 39:35higher than the rate in
• 39:36general population,
• 39:38and that Native American children,
• 39:40their racial disparity index has
• 39:42increased from one point five
• 39:43in, two thousand to two
• 39:45point seven in twenty fourteen.
• 39:49And, locally,
• 39:51Connecticut had seen similar profiles
• 39:54of disproportionality
• 39:55in child welfare and other
• 39:56public systems.
• 39:58And this is this is
• 39:59direct you can find the
• 40:00DCF reports
• 40:02online
• 40:03very easily.
• 40:05This was cited from their
• 40:06report in twenty nineteen.
• 40:12And this is really when
• 40:13they started
• 40:15really putting even more effort
• 40:16into addressing this disproportionality.
• 40:19And so but this was
• 40:21what was in their report.
• 40:24And so it is possible
• 40:25that child welfare professionals or
• 40:27others involved with the case
• 40:28or family may knowingly
• 40:30or unknowingly
• 40:31let personal biases
• 40:33affect their decision making.
• 40:36Race, risk, income, all influence
• 40:38case decision.
• 40:40But even though African American
• 40:41families tended to be assessed
• 40:43with lower risk scores than
• 40:45white families, they were more
• 40:46likely
• 40:47than white families to have
• 40:48substantiated
• 40:49cases,
• 40:51to have their children removed,
• 40:53and be provided family based
• 40:55safety services.
• 40:58It's all in DCF's report.
• 41:00Right? So this is publicly
• 41:02available and out there and
• 41:03being,
• 41:06brought to light.
• 41:08This is from twenty twenty
• 41:09three.
• 41:10So this was the most
• 41:11recent report that they have.
• 41:13So DCF puts out this
• 41:14report every February.
• 41:16So the new one will
• 41:17be out in February, and
• 41:18you'll be able to see
• 41:19new information there. But the
• 41:21figure shows that the percentage
• 41:23of each racial group that
• 41:24comprises the DCF child population
• 41:26at each stage. Right? So
• 41:27it shows that.
• 41:29And it shows the involvement
• 41:30at key decision points in
• 41:32comparison to the general Connecticut
• 41:34child population. Each bar depicts
• 41:36a stage of level of
• 41:37increasingly deeper and deeper child
• 41:38welfare agency involvement,
• 41:42read from left to right.
• 41:45Each segment represents the total
• 41:46unique population of each race
• 41:48and ethnicity observed for that
• 41:50stage.
• 41:52And disproportionality
• 41:53occurs when racial or ethnic
• 41:55groups in the child welfare,
• 41:56agency child population are under
• 41:58or overrepresented
• 42:00when compared to the general
• 42:01child population.
• 42:04And so this continues to
• 42:05reveal, though, that there is
• 42:07considerable overrepresentation
• 42:09of black, African American, and
• 42:11Hispanic Latino children
• 42:12along the way.
• 42:16So they've made efforts.
• 42:18It's made some changes,
• 42:20but it still occurs.
• 42:24And so all of that
• 42:25makes it important for us
• 42:27to pause and stop for
• 42:28a second. And, Carla, I
• 42:29wanna go back to that
• 42:30point that you had made
• 42:31before, which is, like, sometimes
• 42:33they don't report either when
• 42:34they should because, oh, it's
• 42:36such a nice family, or
• 42:36I've known them for so
• 42:37long.
• 42:39What was also going on
• 42:40for me personally in that
• 42:42case is we had just
• 42:43had another case,
• 42:46for a middle class,
• 42:48white family
• 42:49that had been seen in
• 42:51the in the ED,
• 42:53and were sent to us.
• 42:54And during our intake, we
• 42:55filed a one thirty six
• 42:57for reports of,
• 42:59neglect and abuse.
• 43:02That same information was known
• 43:04by the people who referred
• 43:05her to us,
• 43:07but they just didn't fit
• 43:08the description for them, and
• 43:10they did not make the
• 43:11report. And so I'm holding
• 43:14that this family
• 43:15with similar kinds of
• 43:17things came through without a
• 43:19single report, and then this
• 43:20other family
• 43:22is being held hostage, if
• 43:24you will, by something that
• 43:25happened four years ago.
• 43:30And so these implicit biases
• 43:32have very explicit
• 43:33outcomes and impact.
• 43:36So,
• 43:38also,
• 43:39the electronic health records part
• 43:40of this now. Right? And
• 43:41so there was a study
• 43:43done in a hospital in
• 43:44Chicago, and the the findings
• 43:45were raising concern about racial
• 43:47bias and possible transmission of
• 43:48stigma in the electronic health
• 43:50record.
• 43:51And so black patients had
• 43:53two point five four times
• 43:54the odds of being described
• 43:55with more mega negative descriptors,
• 43:57noncompliant,
• 43:59not interested,
• 44:02resistant.
• 44:03All those kinds of words
• 44:04were found much more often.
• 44:08So then what do we
• 44:09do about it?
• 44:14So some recommendations that came
• 44:16up.
• 44:18So from this particular article,
• 44:19race of bias in child
• 44:21maltreatment diagnosis and reporting.
• 44:23So they this was actually
• 44:24these
• 44:25recommendations made for pediatrics,
• 44:28practice, but I think that
• 44:29they're they are applicable to
• 44:31anyone who works with children.
• 44:33So and one of the
• 44:34first recommendations,
• 44:35again, going back to that
• 44:36that, like, gold star of
• 44:38ongoing critical
• 44:40self reflection.
• 44:42Providers need ongoing education with
• 44:44comprehensive information about definitions,
• 44:46examples, and indicators of the
• 44:48major types of childhood maltreatment,
• 44:50racial disproportionality,
• 44:52systemic and implicit bias.
• 44:54And that includes a regular
• 44:55review of the DCF
• 44:57definitions of child abuse and
• 44:59annual one thirty six trainings
• 45:01to stay abreast of changing
• 45:02definitions.
• 45:04So
• 45:05I did the training. I
• 45:06know what it is to
• 45:06be a one to be
• 45:07a mandated reporter.
• 45:09Things change.
• 45:11When I started practice,
• 45:13anytime someone was hit with
• 45:15a belt,
• 45:16we were told to report.
• 45:18That's not the case anymore.
• 45:22Right? So
• 45:23there's a different idea around
• 45:25it because they recognize that
• 45:26there are some cultures that
• 45:28do use physical discipline as
• 45:29a form of discipline.
• 45:31If you were not a
• 45:32person who grew up with
• 45:33physical discipline and you're listening
• 45:35to someone
• 45:36getting disciplined
• 45:37physically,
• 45:39it's not, many people will
• 45:40jump to that's abuse.
• 45:42That's abuse.
• 45:43But it is not abuse
• 45:45necessarily.
• 45:46Right? There are things to
• 45:47look out for that would
• 45:49cross the line into abuse.
• 45:51But this is some of
• 45:52the reasons why we need
• 45:53to continuously
• 45:54examine our own biases and
• 45:56know where they come from.
• 45:58I was spanked as a
• 45:59kid.
• 45:59That was part of how
• 46:00my parents disciplined.
• 46:02In my view, that has
• 46:03never been it was never
• 46:05abusive. It never crossed the
• 46:06line into abuse. Just for
• 46:07those of you who are
• 46:08unsure, what crosses the line
• 46:09into abuse is if you
• 46:10have marks that last and
• 46:11bruises that last.
• 46:13Those were that then that's
• 46:14a good reason to suspect
• 46:16that it could be abusive
• 46:17and to file a one
• 46:18thirty six. But just being
• 46:19spanked is not the thing.
• 46:21But I know because I
• 46:22was spanked and I didn't
• 46:23view it
• 46:24as abusive
• 46:26that I have the tendency
• 46:27of maybe leaning a little
• 46:28too lenient
• 46:29with that.
• 46:30So if somebody tells me
• 46:31that they were spanking their
• 46:32child, I know I have
• 46:33to stop, pause, think.
• 46:36Sometimes invite another thinking partner
• 46:37in with me to make
• 46:38sure that I'm not being
• 46:39overly permissive
• 46:40because of my own personal
• 46:42experience of not viewing that
• 46:44as abusive.
• 46:45Right? So it can go
• 46:46in either direction.
• 46:47But these are important factors
• 46:49and and keeping abreast of
• 46:50what the definitions are important.
• 46:52So the child study center
• 46:53makes sure that we have,
• 46:55the one thirty six training
• 46:56annually. I believe the next
• 46:57one's coming up in February.
• 46:58If you have not been
• 46:59in a while and you
• 47:00are working with children, please
• 47:01go.
• 47:02You'll be surprised that things
• 47:03shift and change.
• 47:06The other thing
• 47:07to also do is you
• 47:08can also just go on
• 47:09to DCF's website and look
• 47:10at what the definitions are.
• 47:11They update those as well.
• 47:13And if you can't make
• 47:14the mandated reporter training that
• 47:15happens at the child study
• 47:17center, there's also one online
• 47:19that you can do.
• 47:22The other thing is
• 47:24that,
• 47:25they encourage the use of
• 47:27standard tools such as screening
• 47:29protocols and clinical guidelines
• 47:31to be helpful
• 47:32in deciding whether or not
• 47:33somebody should have a report
• 47:35made to child protective services.
• 47:37And so the paper that
• 47:38I referenced here, they actually
• 47:40suggest
• 47:41having a system in which,
• 47:44the what is documented in
• 47:46the EHR sort of triggers
• 47:48an outside group from the
• 47:50hospital, like a standing group,
• 47:52to then look at the
• 47:53the the information in the
• 47:55chart and decide whether or
• 47:56not a one thirty six
• 47:57should be filed. So it's
• 47:58not actually dependent on clinician
• 48:00bias.
• 48:01They're looking at the facts
• 48:02and not all of the
• 48:03demographic details and from that
• 48:05making the decision. So it's
• 48:06an interesting thought of a
• 48:08different approach
• 48:09on how to do that.
• 48:13But this is it there
• 48:14is, of course, the warning
• 48:15though that the folks who
• 48:17are part of that need
• 48:18to also be aware that
• 48:20they have biases
• 48:21and consistently work against that.
• 48:23You know, and I know
• 48:24AI is something everybody's really
• 48:25excited about, and people are
• 48:27thinking about the many implications
• 48:28for AI.
• 48:30People who who program AI
• 48:32are also biased
• 48:34because they're human,
• 48:36and so they can't get
• 48:37away from that.
• 48:38Right? And so then it
• 48:39learns your biases too.
• 48:42So we're actually gonna have
• 48:42a grand rounds about that
• 48:43in May, which I encourage
• 48:45you to come to where
• 48:46it talks about some of
• 48:47the bias built in.
• 48:51The other thing is to
• 48:52continuously
• 48:54build
• 48:55diverse multidisciplinary
• 48:56teams with a focus on
• 48:57ensuring diverse cultural and racial
• 48:59perspectives
• 49:01to make sure that they're
• 49:02represented
• 49:03in interprofessional
• 49:04teamwork.
• 49:05Right? That this is a
• 49:06really important thing for us
• 49:07to continue to do is
• 49:08to make sure that we're
• 49:09hiring
• 49:11diverse
• 49:11individuals from discipline
• 49:13to race, to ethnicity, to
• 49:15culture, all of those pieces,
• 49:17language,
• 49:18gender identity, sexuality,
• 49:20all of those pieces. We
• 49:22need
• 49:23the diversity of thought
• 49:25to help us
• 49:26because we we can't all
• 49:27think of every single thing.
• 49:31But these biases do happen.
• 49:32But the more diff the
• 49:34the more that we have
• 49:35diverse perspectives available to us
• 49:36to run things by to
• 49:37discuss, the better.
• 49:40And the other is that
• 49:41ongoing reflection and on personal
• 49:44knowledge and biases across domains
• 49:45of identity.
• 49:46And that includes thinking about
• 49:48parenting practices.
• 49:50Right? If you grew up
• 49:51with a wide variety of
• 49:52food available to you as
• 49:53a kid,
• 49:54and you're treating a family
• 49:56that maybe just has sandwiches
• 49:57available,
• 49:59That's not child abuse or
• 50:01neglect.
• 50:02That's maybe poverty,
• 50:05but it is not equal
• 50:07abuse or neglect. Right? So
• 50:08knowing and and checking where
• 50:10you're coming from and what
• 50:11your privileges might be and
• 50:12not imposing them as the
• 50:13measure on the people in
• 50:15front of you is a
• 50:16really important piece.
• 50:19And, again, if you grew
• 50:20up with a very gentle
• 50:21parenting style,
• 50:23anything that feels harsh, you
• 50:25might code as abusive.
• 50:27And so that's another opportunity
• 50:29to stop and scrutinize.
• 50:31So another thing to do
• 50:32is to create
• 50:34friction.
• 50:35And so one of the
• 50:36things that, doctor Eberhardt talks
• 50:37about in her book about
• 50:39bias,
• 50:40is really just the act
• 50:41of slowing down.
• 50:42And so she used an
• 50:43example in which she talked
• 50:45about this app from it's
• 50:47called Nextdoor. Did anybody ever
• 50:49see that? So it was
• 50:50meant to be like a
• 50:50way to connect with your
• 50:51neighbors and maybe learn about
• 50:53the a good plumber or,
• 50:55hey, I need a tree
• 50:56removed.
• 50:57And it quickly devolved
• 50:59into a community policing platform
• 51:02where people were using their
• 51:03ring cameras to say look
• 51:05out for this person.
• 51:07Hey, this is happening. Porch
• 51:08pirates.
• 51:09All of these things were
• 51:10going on, and it quickly
• 51:11devolved. And this is not
• 51:12what the creators of Next
• 51:13Apple excuse me,
• 51:16Nextdoor wanted, so they invited
• 51:18doctor Eberhardt in. And
• 51:20all she did was introduce
• 51:22some friction.
• 51:23And what she did is
• 51:24what she create before you
• 51:25could put in a report,
• 51:27you had a hard stop
• 51:28with a couple of questions.
• 51:30I think it was two
• 51:30or three questions.
• 51:32And
• 51:33just adding that friction
• 51:36decreased the amount of sort
• 51:37of policing activity
• 51:39on that app by seventy
• 51:40five percent.
• 51:44When we are busy
• 51:46and moving quickly and there's
• 51:48lots of demands on us,
• 51:50we tend to move pretty
• 51:51quickly. We're forced to. And
• 51:52that's where we end up
• 51:54making mistakes and making calls
• 51:56that can have these kinds
• 51:57of repercussions.
• 51:59Right? And so finding the
• 52:00ways to be able to
• 52:01introduce some of that friction.
• 52:03And ask yourself, why am
• 52:05I suspecting maltreatment?
• 52:08What is the objective evidence?
• 52:10In this case, they didn't
• 52:11have any objective evidence for
• 52:13this for elevating the concern
• 52:14in that moment.
• 52:16They had an artifact.
• 52:20Ask yourself. Right? How how
• 52:22is the difference between my
• 52:23experience and theirs impacting my
• 52:25thinking right now? So that's,
• 52:26like, my my spanking example.
• 52:28Right? Like, I think, like,
• 52:29I was raised with it.
• 52:30I gotta be careful
• 52:32not to be so permissive
• 52:33about it.
• 52:35And don't just trust your
• 52:37gut without scrutiny.
• 52:39Your gut is telling you
• 52:40something,
• 52:41but you should ask your
• 52:42gut
• 52:43some questions as well. Right?
• 52:45Where is that coming from?
• 52:46Is it telling me to
• 52:47report?
• 52:48Why is it telling to
• 52:49me me to report? What's
• 52:50the evidence? What's the facts?
• 52:52Is it telling me not
• 52:53to report?
• 52:54To your point before, Carla.
• 52:56Right? Why?
• 52:58Oh, they're such a nice
• 52:59family. I've known them forever.
• 53:02Kids so cute.
• 53:03Mom's really smart. You know,
• 53:05they live in my neighborhood.
• 53:08All those things are also
• 53:10biases,
• 53:12And you could actually not
• 53:13be protecting a child that
• 53:15you should be protecting
• 53:16because you're being guided by
• 53:17your biases.
• 53:22So
• 53:22just some questions to ponder.
• 53:27Is the one thirty six
• 53:30part of a medical record,
• 53:31or is it part of
• 53:32the child welfare record?
• 53:36Is documenting that we filed
• 53:39a one thirty six and
• 53:40perhaps adding a v code
• 53:41for child abuse or something
• 53:43else enough?
• 53:46Have you ever found yourself
• 53:48doing a deep dive in
• 53:49a chart for certain clients
• 53:52but not others?
• 53:54In this case, I admit
• 53:55to you that I did,
• 53:56but I needed to find
• 53:57the facts.
• 53:58I was convinced that there
• 54:00was not another reason to
• 54:01be upset about this and
• 54:02that there wasn't. Right? But
• 54:04have you ever dug deep
• 54:05in a chart for your
• 54:06confirmation bias?
• 54:10And maybe that's what I
• 54:11was operating under myself. Right?
• 54:12But I I looked for
• 54:13the facts,
• 54:15and the facts did not
• 54:17confirm that this was an
• 54:18emergency.
• 54:20Do you have a practice
• 54:21of scrutinizing your gut?
• 54:25We are often told, right,
• 54:26to trust our gut.
• 54:29But what is your gut
• 54:30informed by?
• 54:34And think about the words
• 54:35you use in your chart.
• 54:36Is it are is it
• 54:38words like noncompliant
• 54:39and resistant?
• 54:42Are there are you using
• 54:43words I mean, many of
• 54:44us were trained with these
• 54:46kinds of words in mind.
• 54:48Are you using words that
• 54:49are perpetuating
• 54:50bias
• 54:52that could follow the family
• 54:54later on and create this
• 54:56moment? Yes.
• 54:57I was gonna say regarding,
• 54:59just
• 55:00what to ponder. So one
• 55:02of my friends, and he's
• 55:03a psychiatrist, and he has
• 55:04three children. And, the kids
• 55:07go to private school. And
• 55:08so the oldest, he's ten,
• 55:09and he is he's, you
• 55:11know, he want he's a
• 55:12straight a student and wants
• 55:13to be on the teacher's,
• 55:14you know, good list. And
• 55:16so,
• 55:16I guess I'm not sure
• 55:17what the teacher was teaching
• 55:18about,
• 55:20racially and ethnically minoritized populations.
• 55:23And I suppose what she
• 55:24was saying kind of othered
• 55:25him in the classroom,
• 55:27and she asked him to
• 55:28share about his experience. And
• 55:30so trying to align with
• 55:31what she just taught, he
• 55:32said, oh, yeah. Sometimes
• 55:34I don't get fed at
• 55:35home.
• 55:36And so she filed a,
• 55:38I guess, there at CPS
• 55:39or ACS, DCF, what have
• 55:41you, report. And, my friend,
• 55:43he's like, you know, well,
• 55:44first of all, my kid
• 55:45is, like, ninety percent all
• 55:47weight and height. He's not
• 55:48missing a meal.
• 55:50But, you know,
• 55:52just, you know, he he
• 55:52told me about it because
• 55:53the perspective of what it
• 55:55looks like on the other
• 55:56side. Yeah. Right? Because as,
• 55:57you know, providers we call
• 55:58DCF, you know, we do
• 55:59these things. And so they
• 56:00came to his, you know,
• 56:02ginormous house, and they looked
• 56:03around and saw the food
• 56:04and, you know, it was
• 56:05unsub it was not substantiated.
• 56:08And this is in a
• 56:09chart somewhere. This is now
• 56:11part of the file because
• 56:12his son wanted to kind
• 56:14of, you know,
• 56:16live up to what the
• 56:16teacher
• 56:17was teaching Wow. And othered
• 56:19him. And so,
• 56:21this will be in a
• 56:22chart. Yep. Yeah.
• 56:24These are the things. Right?
• 56:25And so are the words
• 56:26that we use that describe
• 56:28them. Right? So are all
• 56:29of these other things. And
• 56:31so it's a really important
• 56:33opportunity for us to stop
• 56:34and think about
• 56:35what we're using and why
• 56:37and also to think about
• 56:38how you yourself how can
• 56:39you prevent the ghosts in
• 56:41your chart? Carla, did you
• 56:42have a question?
• 56:44If you saw
• 56:45that
• 56:47the transition to open notes
• 56:48where clients can view their
• 56:50notes has
• 56:51helped with some of this,
• 56:53and certainly not all of
• 56:54it. But I just I
• 56:56know for me, it's made
• 56:57me much more more mindful
• 56:58about what I'm writing because
• 57:00I know the client's gonna
• 57:01see it.
• 57:03So although sometimes
• 57:05I find the open notes
• 57:06very challenging
• 57:08that,
• 57:09yeah, maybe a positive in
• 57:11terms of how we're writing
• 57:12our notes. We're more thoughtful
• 57:14about those. We shifted a
• 57:15lot of our training around
• 57:17documentation
• 57:18with the idea of open
• 57:19notes, and it really caused
• 57:20a, a good pause point
• 57:22for us. Right? Because we
• 57:25were thinking about being accurate
• 57:26and documenting.
• 57:28But now when with the
• 57:29open notes sort of concept,
• 57:30we're also thinking about perception
• 57:32by others. Right? And so
• 57:34the times that
• 57:36I don't know, dad is
• 57:37coming and saying, oh, mom
• 57:38is terrible and mom and
• 57:39mom and mom and mom
• 57:40and he document, oh, all
• 57:41this stuff dad said about
• 57:42mom. And then mom decides
• 57:44to join treatment someday,
• 57:46and she looks at all
• 57:47these things you wrote.
• 57:50How on earth could she
• 57:51easily engage with you
• 57:53thinking about all these things
• 57:55that you've already heard, learned,
• 57:56and decided by codifying in
• 57:58a chart
• 57:59were true? So I think
• 58:00there has been some shift
• 58:01and change
• 58:03to being more thoughtful and
• 58:04mindful about the potential impact
• 58:06of words in the charts
• 58:08around the open notes. So
• 58:09I think there's still more
• 58:10to do.
• 58:11Right? I think thinking more
• 58:13about themes versus
• 58:15verbatim
• 58:16sort of charting
• 58:18is is helpful. And, of
• 58:20course, documenting in words that
• 58:21make sense to the family,
• 58:23which is the other thing
• 58:23that I think is really
• 58:24important. So I think in
• 58:25in a lot of ways,
• 58:26it's
• 58:27I've mostly and I I
• 58:29think that there's a lot
• 58:30more benefit for the patient
• 58:31and a lot more shift
• 58:32for us in learning how
• 58:34to do it.
• 58:37Any other thoughts, questions, or
• 58:38reflections?
• 58:41And so that if if
• 58:42you wanted CMEs, you also
• 58:44excuse me. CECs.
• 58:46They're confusing. I know.
• 58:48You you must scan out.
• 58:50So please make sure that
• 58:50you sign out. The CMEs,
• 58:52you're good if you just
• 58:52signed in. That's just the
• 58:53way it goes.
• 58:55So but thank you again
• 58:57for
• 59:01for your participation, for being
• 59:03here, and for,
• 59:04making for a lively conversation.