How Racism Shapes Undergraduate Medical Education: The Ethical Case for Structural Change

March 25, 2021

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March 24, 2021

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00:00Good evening friends.
00:01My name is Mark Mercurio.
00:03I'm the director of the Program for
00:05Biomedical Ethics at Yale School of Medicine.
00:08On behalf of Jack Hughes and Serra Hall,
00:11our associate Directors,
00:12and Karen Kolb, our program manager.
00:14I welcome you tonight to the
00:16evening Ethics seminar series.
00:18We have a terrific program
00:20scheduled for tonight.
00:21One of our soon to graduate medical
00:23students Max Jordano many Tiako is going
00:25to be speaking tonight on how racism
00:28shapes undergraduate medical education,
00:30the ethical case for structural change,
00:32and I've known Max for a few
00:34years now already and he's he's
00:37getting ready to leave us.
00:39To head up to the Brigham to study medicine,
00:42do his residency in medicine and primary
00:44care where he will no doubt flourish.
00:46Max has a bachelors degree in civil
00:49and environmental engineering from
00:50Howard University Masters degree in
00:52Bio Engineering from Georgia Tech.
00:53He has an interest in improving the
00:55quality of care for people from
00:57marginalized and stigmatized groups.
00:59He hosts a podcast called Flip The
01:01Script which is focused on health care,
01:04inequities.
01:04He writes about racism in
01:06medical education and this year.
01:07In fact, he was named by Forbes Magazine.
01:10Forbes magazine as one of 30 under
01:1230 in health care for his worse
01:14for his work on health care and
01:16HealthEquity Mac is or certainly
01:18Max is certainly a rising star and
01:20he will be missed here at Yale.
01:23But I'm delighted that in his closing
01:25months at Yale School of Medicine,
01:27we get a chance to have him present
01:29to our program the way this will
01:32work to let you folks know is that.
01:35The speaker will speak for about 45 minutes,
01:38plus or minus a little bit,
01:39and when that's done will have Q&A.
01:41I encourage you all to submit your questions,
01:43please by the Q&A portion of the zoom.
01:46I'll then read your questions to
01:47Max during the second part of the
01:49program will have plenty of time
01:51for discussion and Q&A,
01:52and then we will stop at 6:30 promptly,
01:54so there will be a hard stop then an
01:56up till then I'm looking forward to it.
01:59Terrific talking a great discussion.
02:00So with that Max Jordan,
02:02I turn it over to you.
02:03Welcome and thank you for tonight.
02:07Thanks Doctor Mercurio for having me and
02:10thanks for the program for bioethics.
02:12I am thrilled to join you all at it has
02:16been a great almost five years here.
02:19I'm without further ado.
02:20I'm going to start sharing my slides.
02:23Let's see, can everyone see we can?
02:26OK, awesome. So, it's Doctor Mccurry said,
02:30I'm going to talk about racism,
02:32how racism shapes on the
02:34graduate medical education,
02:35Ann Ann, and discuss, you know,
02:37some sources of structural change.
02:39I'm going to be using the sociological
02:42theory of racialized organization.
02:43This is a new theory that was
02:46published about in 2019.
02:48But before I go there,
02:50I want to share a personal story that
02:52sort of launched me on this journey
02:55of sort of exploring organized.
02:57How organizations function and especially
03:00in the context of medical education.
03:03So as a third year Med student
03:05for the first time,
03:06I think this was about 6-7
03:08months into my career.
03:10I had a black male resident for the
03:12first sign I was on psychiatry an.
03:15There's also weekly clinic so you
03:17know I didn't get to see this resident
03:20as often as I typically would
03:22with most residents at work with,
03:24but I felt like we had a great
03:26working relationship and ultimately
03:28he gave me one of the most thoughtful
03:30evaluations gotten before,
03:32and I thought,
03:33man,
03:33this guy's really invested in my learning.
03:36In ways that I you know didn't always
03:38feel was the case when I interacted
03:40with other residents or even faculty,
03:43sometimes not to say,
03:44of course,
03:45that I've done that like I haven't
03:47had great interactions with
03:49with residents weren't black,
03:50but this was in this case I felt
03:53like Lambert was super invested
03:55in my learning an you know,
03:57his evaluation was super
03:58thoughtfully included,
03:59things that you if you were
04:01either faculty or clutch director,
04:03whoever you might want to see
04:05if any violation.
04:06For a medical student,
04:07but interesting Lee that ending
04:09on this rotation had absolutely
04:10nothing to say about my performance.
04:13At least nothing to say that would
04:15be relevant for my transcript,
04:17so that you know the portion of
04:19your of the msde that is supposed,
04:22or the portion of the evaluation that
04:24supposed to go into the MSP he left blank.
04:27He did have feedback for me
04:29in the formative section,
04:31which included whatever deficiencies
04:32I had as a medical student,
04:34which who's perfect, right?
04:35Who hasn't had any lapses?
04:37On rotation, but I was really,
04:39really shocked to see that there
04:41was like nothing to be sad about.
04:44I don't know even the final
04:46presentation I gave that was like
04:48relevant to the patients that we saw
04:50over the course of these six weeks.
04:52So because of this I emailed my class
04:55ship director and rightfully she said,
04:57you know,
04:57we only solicit evaluations from
04:59attendings and so because of
05:01school policy and your residence
05:02evolution coming in late we we can't
05:05include your residence evaluation.
05:06But either way, it's fine.
05:08You did super well on psychiatry.
05:10And we're really impressed.
05:11So it wasn't a big deal and I didn't
05:14want to make a big deal out of it
05:16because like the collection director
05:18say I I did find it will not have
05:20changed my grade, but I thought.
05:22Well, what if I was a borderline
05:24student during this rotation and
05:26needed my residency violation to push
05:28me from say hi pasta honors, right?
05:30Then I would have been in a
05:32little bit of a bind,
05:33especially if I was someone that
05:35was applying into psychiatry at
05:37the time an that left me thinking
05:39about different ways in which.
05:40Otherwise, or seemingly neutral rules
05:42in the backdrop of some what you know,
05:46a racially unequal system end up,
05:49sort of disadvantaging individuals
05:51along racial lines, right?
05:53So the faculty here I think something
05:56like 3% of the faculty's black
05:59or even less so 6% of residents.
06:04Yeah,
06:04I think 6% of residents are black
06:06and the medical student body
06:08is even more diverse.
06:10But what that means is one we are
06:12far more likely to interact with
06:14with a diverse group of residents
06:16and we are faculty and instances
06:19like this ultimately puts people
06:21like me added disadvantage, right?
06:22I actually never had a black attending
06:25to like write me an evaluation like
06:28throughout clerkship year so that is
06:30what got me started on this subject.
06:33So quickly in terms of learning objectives.
06:35So I want everyone in the audience,
06:38if possible,
06:39to sort of become acquainted with this
06:41theory of racialized organizations and
06:43to apply it to an end to the to your
06:47respective analysis of medical education.
06:50To understand the implication of the
06:52racialization of medical education
06:53for workforce diversity efforts
06:55and racial health disparities,
06:57I am going to discuss a little
06:59bit of historical context here.
07:01Sort of share why I think this
07:04matters on some key definitions,
07:06and then we'll review the evidence
07:08that supports these mechanisms that
07:10I'm Speaking of across the span of
07:13undergraduate medical education.
07:14An some implications for you
07:16in terms of you know,
07:18career, you know.
07:20Residency faculty level,
07:21some health implications,
07:23and some potential sources for change.
07:26So let's go in history first.
07:28So who's medical schools ideas, right?
07:30So this is a slide from John Warner.
07:32Doctor Warner was my professor.
07:34One of our professors here
07:35for history still is on this.
07:37I I borrowed this from when
07:39I was a second year,
07:41so there was a time where people like me.
07:44You know,
07:45our job in medical school was to be the
07:47handler of bodies from which white male or,
07:50well,
07:50you know,
07:51because medical schools were also
07:53gender segregated white male medical
07:54students gleaned knowledge from right,
07:56like Med schools.
07:57For the most part were not designed
08:00or created for me to attend.
08:02You know,
08:03in the.
08:04Late 1800s early 1910s there where
08:06at least the HBCU medical schools.
08:09I went to an agency for underground
08:12Howard University,
08:12but eventually the majority of
08:14those issues were closed after
08:16the release of the Flexner Report,
08:19which was, you know, supported by
08:21the Carnegie Foundation and America,
08:23the American Medical Association.
08:24And I'm going to read an excerpt
08:27from the Flexner report,
08:29which, by the way right,
08:30has been exalted as one of the very major
08:34advances in medical education, although.
08:36Obviously has had a tremendous impact on,
08:39you know, the racial representation
08:41an in medical school.
08:42So this is a you know,
08:44clip, like sort of clip.
08:46Different sentences from the report to make
08:49this coherent instead of reading 2 pages,
08:51here we go.
08:52The physical well being of the is
08:55not only a moment to the himself.
08:5810 million of them live in close
09:01contact with sixty million whites.
09:03Not only does an equal and solve
09:05suffer from hookworm and tuberculosis,
09:07he communicates them to his white neighbors.
09:10He has his rights and value as an individual,
09:13but he has,
09:14besides the tremendous importance
09:16that belongs to a potential source
09:18of infection and contagion,
09:20the needs good rather than many schools.
09:22Schools to which.
09:23The more promising of the race can
09:25be sent to receive a substantial
09:28education in which hygiene rather
09:29than surgery is strongly accentuate
09:31it an the hygiene rather than surgery
09:34thing like has struck me so much every time.
09:37I think about it.
09:38An especially Fast forward to today,
09:40where you know when the middle
09:42of this pandemic,
09:43which is caused by communicable
09:45communicable virus an like today's
09:48version of like 19 tents like
09:50hygienist or sanitary and as as
09:52they used to be called is who.
09:54It is basically right.
09:55Primary care of frontline providers
09:56whose job is to prevent or contribute
09:58to preventing you know spread of.
10:00Infection.
10:01So just remind I just want everyone
10:04to hold on to this quote 'cause
10:06I'll come back to this later.
10:09So why does this matter?
10:10And I you know,
10:11one of the things is I want
10:13everyone to think,
10:14especially if you involve the medical
10:16education or I'm sorry I'm going to
10:18room where the lights depend on me moving.
10:20Why does what do we owe society
10:24as medical schools right?
10:26And one of those things is that one,
10:29I think of medical school.
10:33An opportunity for upward mobility,
10:35although that's not.
10:36But that is not the first
10:38thing that comes to mind,
10:40but as I've navigated the hospital
10:41these last like 4 1/2 years,
10:43the majority of black people that
10:45I've met are janitors or cashier's.
10:47They're, you know,
10:48fixing our place in the cafeteria.
10:51Not the attendings right?
10:52And so I think one one thing that
10:55does not get discussed nearly as
10:57often is that an opportunity to attend
11:00medical school is a way out of poverty out,
11:03you know,
11:04out of suffering,
11:05especially in this society an and
11:08that is in itself.
11:09You know it's a strong argument for
11:11for diversifying medical schools.
11:13The other argument that
11:15gets made very often is that
11:17you know, like workforce diversity is key to
11:20addressing health care disparities, because.
11:22You know, black patients are more
11:24likely to like, I don't know.
11:25Follow advice when they have a
11:27black doctor and that like you know,
11:30more diverse teams are more creative.
11:32There are more innovative in terms of
11:34scientific inquiry and it's true not
11:36just teams but also individuals, right?
11:38So there's good evidence that individuals who
11:40are minorities in their given field of study,
11:43regardless of the type of memory
11:44that we're referring to, right?
11:46So like genders and ****** and gender,
11:48minority, racial, ethnic, racial,
11:50and ethnic minority and whatnot are more.
11:52So this is a study that looked
11:54at PhD dissertations, right?
11:56They found that.
11:58Those individuals who are more
12:00minoritized in in their respective
12:02fields had dissertations that were
12:04deemed to be more innovative.
12:05An and and like tackling more novel or,
12:08you know, coming up with more
12:11novel solutions to problems. Uhm?
12:15And so why else does I think this matters?
12:19Is there's to me,
12:20there's just so much inertia in academia,
12:23right? So?
12:24And by the way,
12:25I'm going to often like use black
12:28people as an example,
12:30and in part because I'm black,
12:32but but this applies to many groups,
12:35especially those who are under
12:37represented in medicine.
12:38So black people are 13% of the US population,
12:415% of physicians,
12:42but only 3.6% of academic physicians.
12:46And in fact,
12:47between 1990 and 2016,
12:49there's actually been a decrease in
12:51the representation in most clinical
12:53in the representation of actually
12:55all racial ethnic minorities in most
12:57clinical specialties except black women.
12:59And over again, right?
13:01That like,
13:02that's like the one specialty
13:04that has seen an increase in
13:07representation in academia.
13:09Of all specialties and for all racial groups.
13:12And if, when you look at 1996 to 2020,
13:16there's Vince,
13:16or almost a very clear stagnation
13:19in the number of black medical
13:21students who who who get accepted.
13:24So between 1996 and I think, 2015.
13:28I as I look at it right,
13:30it's the number is like stayed around 1200.
13:33No matter how many applied
13:34every year it almost.
13:35I mean this is very controversial to say,
13:38but it almost feels like there is
13:40like an invisible hand that's like
13:41keepingacaptive.org dot kept account
13:43there for the longest right somewhere
13:45around or hovering around 1200.
13:46Maybe the cap got lifted in 2016 and like
13:49there's a slight like uptick in the 1400s.
13:52But it's pretty clear that there's
13:54been very little movement in terms of,
13:56like, you know,
13:57increasing the number of.
13:58Black medical students who get
13:59to be black students who get to
14:01be accepted into medical school.
14:03And by the way like this doesn't account
14:04for like the expansion of medical schools,
14:07right?
14:07Like there,
14:07there are many medical schools that have
14:09been created between 1996 and today.
14:11And and like this number has remained right.
14:16So now I'm going to talk about
14:19this like framework, right?
14:21The theory or visualize
14:22organization so broadly speaking,
14:24it basically posits that in the way
14:27organisations function through like
14:29rules and individuals who like hold
14:32leadership positions and what not.
14:34For the most part right,
14:36a lot of seemingly against seemingly
14:39neutral rules and processes end up
14:42creating disadvantages along racial
14:44lines an you know what does this mean?
14:47Basically racialized organisations.
14:48Enhance or diminish the agency for
14:51certain racial groups and and you know,
14:53agency sociologists like to think about
14:55agency in terms of time and a good.
14:58I think a good example is.
15:02When you think about like time and
15:04and being able to actualize one's
15:06future is how often times you'll hear,
15:08say, black faculty say, well,
15:10you know I was hired to do an 80% research,
15:1320% clinical,
15:13but then like finding themselves doing,
15:15I don't know.
15:1615% like diversity,
15:17equity and inclusion service.
15:18That's like, not, you know,
15:20that's not compensated an,
15:21which eats away at the time that they
15:24were supposed to be using to do their
15:26research and then ultimately like impacts.
15:28You know,
15:29like the ability to actually say,
15:31do research, get grants.
15:33Publish whatever.
15:35An ultimately like their progression
15:37along the academic ladder,
15:39right?
15:41There is ultimately an unequal
15:43distribution of resources.
15:44I think of the NIH has a great example,
15:47right? Like the amount of money
15:49that is allowed across different
15:50institutes and who gets what grant,
15:52what type of research get funded right?
15:55Also falls along racial lines
15:56both in terms of the populations
15:58that are studied and in terms of
16:01the people who apply for grants,
16:03and this has been studied
16:05at nauseam at this point.
16:07Whiteness as a credential is is one
16:09of the tenets of this theory in
16:12that basically many organisations
16:13actually recognize this right,
16:15like the reason why we embrace
16:17affirmative action is a recognition of
16:19the fact that prior to applying into
16:21or joining one given organization,
16:23being white is like and and all
16:26the things that come with it is
16:28a form of advantage,
16:30all other things being equal,
16:31but then also that once one once
16:33once one joins the organization.
16:36Being white also makes it.
16:37Easier to navigate state organization
16:39again on all other things being equal,
16:41right there are other layers of
16:44identity and privileges that like can
16:46make this a little bit more dynamic
16:48than than than a flat like white is a
16:51credential and then the last tenant
16:52is a decoupling of formal rules
16:54right from organizational practices,
16:56which is often racialized and a coupling
16:58I think is a really interesting concept
17:00in that organisations like in theory,
17:03right like embrace diversity
17:04and equity and what not.
17:06That really good example is.
17:08You know the double AMC like has
17:10this whole framework for like
17:11addressing structural racism in
17:13medicine an but at the same time
17:15like when you look at the how the
17:17double AMC functions and like what
17:19is their source of revenue right?
17:21Like like in many different like
17:22Irras which I just went through is
17:24the hell of applying to residency
17:26erases the number one source of
17:28revenue for the double AMC an and
17:30it almost sort of like profits off
17:32of inequality in different ways.
17:34And I'll talk about some of this.
17:36Well like another good example
17:37is the NFL right?
17:39Like fired Colin Kaepernick.
17:40But has since, like Vince,
17:42wearing that Black Lives Matter
17:44and has yet to like React.
17:46You know,
17:46like help Con Company get another job,
17:48so that's that's what the coupling
17:51means where where basically use you?
17:52You don't walk the talk, that's that.
17:55That would be a simplified version of that.
17:58I want to think about culture, right?
18:01So Clifford Geertz is a cultural
18:03anthropologist and he defines culture
18:06as a system of inherited conceptions,
18:08expressed in symbolic forms by
18:10means of which people communicate,
18:12perpetrate and develop their knowledge
18:14about and attitudes towards life.
18:16In other words, culture isn't.
18:20Culture is random, right?
18:21Like we inherit things like I.
18:23I came here as a first year whitecoats
18:25where the things that we Warren residents,
18:28where the Patagonia and like
18:30and all these things are like.
18:32Subject to change and and and there,
18:34there is no rhythm or rhyme
18:36to culture person right?
18:38So we do not have to follow rules
18:40per say or whatever norms that are
18:42associated with a given culture.
18:44I personally am one that,
18:46like almost always wants to question
18:48rules and that are related to a
18:51given culture and the last thing I'm
18:53going to share before I go into,
18:55you know the progression along
18:57medical school is that race class,
18:59gender, ****** orientations and like
19:01all these many layers of identity.
19:03I sort of the next inextricably linked
19:06there tide to how we present how we perform.
19:09Are you know who we are and
19:12how people perceive us?
19:14They're just like dynamism, you know.
19:18With all of these layers and ultimately.
19:22They they have limitation.
19:23So this is, uh,
19:24I really like this is, you know,
19:26meant to be funny.
19:28I really like the this yearbook
19:29yearbook quote,
19:30but then high school senior which
19:32went viral on social media and she
19:34said anything is possible when you
19:35sound Caucasian on the phone, right?
19:37If there are any black people
19:39in the audience,
19:40you know this is a thing that
19:42we do like when I pick up the
19:44phone for customer service,
19:45I like put my like best white voice possible.
19:49And all of this means that we can perform
19:52and an attempt to present ourselves in
19:55one way or another in ways that will make us,
19:59you know, more.
20:00Palatable to the people who surround
20:02us to the people who judge us,
20:04but that has that has its limits right?
20:06Because you can't like I can't kill them.
20:09Ellen, enough of my skin,
20:10but ultimately, like these,
20:11the performance can mediate
20:13right how we were treated.
20:14So any given individual may not
20:16necessarily say, for instance,
20:17another black man who was like my age and
20:19my height and the 4th year medical student,
20:22but who's like 3 shades lighter than
20:24me may not have the same experience.
20:26So a lot of what I'm going to share related
20:29to these experiences is really the average.
20:32Alright, so how I think about the sort of
20:35pillars with the medical school experience.
20:37So the first one I think of is just
20:40like the school structures, right?
20:42Just by way of how things go.
20:44So the first one is school
20:46culture and climate.
20:47The second one is the pre clerkship phase,
20:50right?
20:50We're in the classroom for most
20:52of the time we are, you know,
20:54just sort of receiving instruction
20:56from faculty and interacting,
20:57interacting with one another and
20:59building relationships, right?
21:00That's where I think most people
21:02make friends.
21:03I'm doing my school,
21:04then there's a.
21:05There are the clerkships you
21:07know where for the most part,
21:09often like the Lone Med student on the
21:11team or sometimes with another Med
21:13student and following residents attendings.
21:15And this is very much acculturation
21:17phase where we're like,
21:19you know, apprentices right.
21:21Learning how learning the culture
21:23and the ways of the hospital.
21:25Then the second pillar is career advancement.
21:29Opportunities like AOA research,
21:31volunteering, mentorship,
21:32those kinds of things,
21:34and Lastly the residency application process.
21:38So in terms of culture and climate I I
21:40think it's there is good evidence that
21:42you are so minority medical students
21:45experience a great deal of discrimination
21:47and stereotyping by colleagues.
21:49Anne Anne faculty.
21:50There is a pressure to sort of be a cultural
21:52ambassador due to being under represented,
21:55but also a pressure to assimilate.
21:57You know, a good example and some
21:59of this was a pressure but also
22:01like wanting to be part of.
22:03I mean, I guess that is pressure, right?
22:06Wanting to be part of like the.
22:08In Group and who gets
22:09included into things like,
22:10I went camping as a first year master.
22:12I had never gone camping before.
22:14You could have never told me I would ever
22:16go camping and I would have said yes.
22:18No.
22:18I went camping and then the year that
22:20followed I led the camping trip in part
22:22because I want it to be like I wanted
22:24to assimilate with my colleagues and
22:26and and and then when I decided to
22:27lead or txakoli the trip I wanted there.
22:29If in any event there was going to
22:31be a black message and who came
22:33on move that they wouldn't be the
22:35only black person on the trip,
22:36right?
22:38Is good evidence that oftentimes medical
22:40schools have a colorblind approach to
22:41student support when students have very
22:43different needs and there tends to
22:44be a frequently tense racial climate,
22:46and I think one of the good examples
22:48that many in the audience might
22:49relate to is so my first year.
22:51As far as I recall,
22:53the Dean Dean Alperin said,
22:54well,
22:54this is the most diverse cuts
22:56we've ever seen,
22:57and so oftentimes with a more diverse group,
22:59you tend to see more attention
23:00right along the lines of like
23:02what makes this group diverse?
23:03Because people tend to doubt each other more.
23:05And one thing that came up was like this,
23:08sort of like.
23:08Big disagreement along about the
23:10hunger and homelessness auction, right?
23:12Like we didn't agree with how things
23:15went or the sort of nature of the event,
23:18and ultimately we sort of split into
23:20two things and created a service
23:22learning symposium to go along with
23:24the hunger homelessness auction and
23:26that is was a manifestation of the
23:29tense racial climate at the time.
23:32Anne.
23:32So a lot of the you know the the things
23:36that happen in the pre clerkship pre
23:39clerkship phase include like you
23:42know my frequent microaggression,
23:44a lack of understanding from tears
23:47and administration faculty,
23:48social isolation and exclusion.
23:50Low social support systems and
23:52like inadequate coping mechanism.
23:54Rachel Hardeman's dissertation was
23:56about medical student mental health
23:58and race and one of the things that
24:01she found was that especially black.
24:04Male medical students had worse
24:05social support and coping mechanism,
24:07which in part has to do with the
24:08fact that
24:09you know black students are
24:11underrepresented overall.
24:12But like black men have been
24:13like super underrepresented,
24:14I think since the 90s,
24:16eight 1988 was the last time that
24:18there was gender parity among black
24:20medical students at the time.
24:23There is this concept of the
24:26conscripted curriculum where
24:27minority medical students tend to be.
24:30Unscripted and not so much invited right?
24:33Conscripted into the role of
24:34of instructor or teacher during
24:36sessions that are about inequality
24:38or race and racism in medicine,
24:40which then sort of displaces us from
24:43the learner role to the teacher role
24:45in favor of our white counterparts.
24:47Ann and of course like sometimes
24:50we sort of also sign up for it,
24:52but it isn't so much that
24:55we're signing up for.
24:56For you know that sort of
24:59teaching position because.
25:00Oh my God,
25:01I love doing this,
25:02but rather because there there is a
25:04void that needs to be filled right then.
25:07That sort of contributes to the minority tax.
25:09But then you know in any other
25:11subjects that often feels like
25:12one's contributions are not
25:14valued and which tends to lead
25:16to divestments from a divestment.
25:17From this course I,
25:18you know,
25:19I felt like in a lot of small
25:21groups like whatever I had to share,
25:23or even when I would be like you know,
25:26studying in Group with caught
25:27with classmates like if I had a
25:29thought about like some random
25:31physiological mechanism.
25:31Like that my friend my double check
25:33me Moran and even when they would
25:35find out that yeah it was right,
25:37there would be no acknowledgement
25:39of the fact that I you know my
25:42contribution was not being valued.
25:44So this is something that happens
25:45in in this and you know,
25:47I'm not just pulling it from the literature,
25:49but also like things that add
25:51experience as I mentioned here.
25:53Anne.
25:55All of this is sort of ship by this
25:58concept of like race status associations,
26:00right which inform interaction.
26:02So Cindy Dupree who is or who is
26:05in the School of Management here,
26:07wrote this paper that it's a
26:09study that showed that oftentimes
26:10people in the workplace associate
26:12blackness with lower status, right?
26:15So there's an expectation that if
26:17you're black and you're in this environment,
26:19you're probably at the sort of
26:21bottom of whatever the hierarchy is,
26:24right?
26:24Which is in part why sometimes,
26:26like I may be asked if I'm there
26:28to transport the patient as opposed
26:30to the medical student,
26:31even if I have a stethoscope around my neck.
26:34And then the different forms of
26:36like capital that we might hold
26:38also shape these interactions.
26:40And there's an interesting interaction
26:42with with like the capital like
26:44actual Capital as opposed to
26:45perceive capital. Andy slack.
26:47Race status associations.
26:48So for instance, like social capital, right?
26:50It's like who do you know?
26:52Is your dad the chief of?
26:54I don't know nephrology
26:55or orthopedic surgery.
26:56What have you right like that social capital?
26:59The network that individuals
27:00have and then cultural capital.
27:02And I think some of the the perceptions.
27:05Sort of, you know,
27:07are centered around cultural capital, right?
27:09A lot of assumptions around whether
27:10or not one might, for instance,
27:12be interested, or even knowledge
27:14knowledgeable around topics like.
27:15I don't know camping or like, you know,
27:18having a third home in the Hamptons,
27:20or what have you and you always joke and say,
27:23Luckily, like I play tennis.
27:25So like that's one form of cultural capital
27:27that I've been able to leverage around here.
27:30I organize the Med school tennis tournament,
27:32yeah, after year,
27:33and now that I've gone, you know, like?
27:35Camping in the outer endex
27:37that's like a form of cultural,
27:39cultural capital that I can take
27:40with me on to the next place.
27:43But like whether people assume that I
27:45have that capital is a different story,
27:47right?
27:47And and not ships,
27:48whether or not I get to be included
27:51in conversations around this matter,
27:52especially like you know during down time,
27:54in class or like on the words and what not.
27:57And all this leads to this the fact
28:00that many of us feel out of place right
28:02compared to many of our classmates were
28:04part of the quote unquote Doctor Dynasty.
28:07So Cassandra pill.
28:08US dissertation was specifically
28:10about this way where she studied
28:12medical students and what she finds
28:14is that there is a subset of medical
28:16students who either have parents where
28:18physicians or siblings or aunts,
28:20uncles,
28:20or grandparents.
28:21What have you?
28:22Who are physicians who are
28:23disproportionately white?
28:24And then you have students who
28:26have no ties to medicine prior
28:28to going into medical school,
28:30are far less familiar with the
28:32hidden curriculum and the sort
28:34of like ways Med school work so
28:36hard to navigate academia who.
28:38Constantly feel out of place and they
28:40are more likely to be students of color.
28:42An all of this has to do with the fact
28:45that there are huge socioeconomic
28:47differences in who gets to be in
28:49medical school and who doesn't.
28:51But also among medical students, right?
28:53What are the social economic backgrounds
28:55within the student body so nationally?
28:56More than 50% of medical students
28:58come from the top quintile of US
29:01household income and then when you
29:02break that down by race, right?
29:06There are about 1/3 of black students
29:08come from households that earn
29:10less than $50,000 compared to less
29:12than 10% of white medical students.
29:14The majority of white medical
29:16students come from the, you know,
29:18the the top quintile of households or
29:20households that earn more than $150,000,
29:22compared to about 1/4 of black
29:24medical students.
29:25But that only looks at household income,
29:27right?
29:27And as you see,
29:29there are national trends that the
29:31like household gap is sort of like.
29:34Remain either stagnant or only
29:36the you know the the racial gap
29:38in household income has remained
29:40either stagnant or in fact gotten
29:42wider in the last recent years.
29:44That doesn't account for.
29:46Net worth right?
29:47So like 2 like a black student
29:49and the white student might both
29:51come from a household that earns
29:53like over $150,000 but but the black
29:55students parents may in fact be the
29:57first generation in their family
29:59to have that kind of. King and so.
30:01And a lot of wealth in the United
30:03States is acquired either through
30:05inheritance or real estate, right?
30:07And we've talked, you know,
30:09the racial wealth gap is like a huge thing,
30:11like black.
30:12Black families are like 10 have
30:14a network that's 10 times smaller
30:16than that of white families.
30:18Hispanic families have a network
30:19that's eight times smaller than
30:21that of of white families,
30:22and that shows in like say pre
30:25medical school debt like the vast
30:27majority of US black medical students
30:29come into medical school with debt.
30:31We're sort of sorted in the buckets,
30:33where with the highest amount of debt,
30:35whereas only about 1/3 of white
30:38medical students actually have any
30:40debt coming into medical school.
30:42So all of these sort of like social
30:44economic differences, right?
30:45Like shape both the reality and
30:47also the perception of like how
30:49much capital we have and ultimately
30:51end up shaping the like our
30:53interactions among peers.
30:54But also with like residents and whatnot.
30:57So then on the words I think,
30:59and I can speak for many of us,
31:02this an you know,
31:03leaning on the evidence that
31:05there is a huge deal of,
31:07just like exclusion from like this sort
31:09of social aspects of the workplace.
31:11And I think that bleeds into being
31:12excluded from learning opportunities.
31:14A lot of us like when we would finish
31:16Clark like one given rotation here,
31:19you know,
31:19we give each other sign out and like
31:22what you find out is like this one
31:24attending who might be known for,
31:26you know, for like.
31:27I don't know letting you switch armor
31:30or whatever like might not do that for you.
31:32If you're for you,
31:33the black,
31:34Med student right,
31:35and and it's always kind of puzzling
31:37icon this isn't this doesn't match
31:38the sign out that I was just
31:40giving little things like that,
31:42which really can shape whether
31:43one has an interest or not in the
31:46given specialty,
31:46or the conversations that take place
31:48during like down time on the words between,
31:50you know whether residents like
31:52include you and I want to show you
31:54a picture of their cat like this.
31:56This you know this lettuce and
31:58like I remember.
31:58A few rotations where I had at least
32:01mild to high interest in a specialty,
32:03but feeling like the residents
32:05had absolutely no interest in
32:06teaching me whatsoever,
32:07or even like pretending that
32:09like I was part of the team,
32:11which you know contributes to
32:13stereotype threat and I'll go
32:14into that in the next slide.
32:16But there's good this study out
32:18of UC SF shall,
32:19in this cohort of medical students,
32:2182% of black Med students experience
32:23your type threat during their rotations,
32:25and then like 46% of Asian
32:26students and 44%
32:27of Hispanic students.
32:29Only 4% of white students there
32:31is good evidence that there are
32:34huge disparities in in in grading.
32:36Like you know, at the national level.
32:40Which is, you know,
32:42these disparities are further
32:44amplified when then you take into
32:47consideration that the you know
32:49clerkship directors have have have
32:51their own input which can shift.
32:54These disparities right there and this
32:55concept is called the amplification cascade.
32:58So this again, dot outer UCSF.
33:00It's called this phenomenon in which,
33:02like a small difference in
33:04assessment performance by the
33:05by the question Director right,
33:07110th of a point on the clerkship
33:10assessment Scale led to half as
33:12many honors grades across all
33:14collection for URM students.
33:15Uhm?
33:16Also,
33:16there is good evidence that on the
33:19language used in in the evaluations
33:21is gendered and racialized right.
33:23White medical students are
33:24more likely to be referred to
33:26or describe using stand out,
33:28where it's like outstanding,
33:29excellent stellar,
33:30whereas like black medical students
33:32are more likely to be used to
33:34be described using grindstone
33:35characteristics like hard worker
33:37or competent,
33:37which isn't really a compliment.
33:39An I mean I I had this thing where
33:42at least a few clerkship this like I
33:45read the evaluation and it's kind of like.
33:48If I'm feeling like I'm in the movie
33:51inception because I know I'm like
33:52aware of this evidence and I'm like see,
33:54I'm seeing it happening to me in real time.
33:57Well,
33:57like I had.
33:59I had an attending said they were
34:01afraid of interacting with me.
34:03Luckily that wasn't in the you know,
34:05whatever part of the evaluation
34:06I will go into the MSB but rather
34:08in this like submitted in the
34:10formative part of the valuation.
34:12But I thought like why would you
34:13ever be afraid of interacting
34:15with the medical student?
34:16But like this is like a thing
34:18that happens and here too.
34:20So I was talking about stereotype threat,
34:22which basically right is this
34:23phenomenon that occurs when
34:24queues in the social environment
34:26reminds you that you don't belong
34:27or that you're different.
34:29Or make your.
34:30Identity,
34:30whatever that might be,
34:31be a gender, race,
34:33****** orientation,
34:33salient,
34:34and that can lead to impaired performance,
34:36such as like decreased working memory,
34:38which is really important in
34:40terms you know when we think
34:42about individuals learning style.
34:44Also lead to individuals discounting
34:46the importance or valid,
34:47or the validity or feedback an leads
34:49to disengaging from domains that
34:51are perceived as threatening, right?
34:53That's literally why some people like
34:55choose to not go into some specialties.
34:58It has a huge impact on.
35:00Confidence and testing right
35:01that there there's been.
35:03There's a body of work that
35:05shows that stereotype threat,
35:06hasn't it has an impact,
35:08especially on minorities on
35:09standardized test performance.
35:10And there was a study that showed
35:12in the in the rare event that the M
35:15cat score over predicts students performance.
35:18That is a case in for some yarn events.
35:21It's really rare,
35:22but it.
35:23But when it does happen,
35:24it the students for whom the M cat predicts.
35:27Overpredict USMLE performance
35:29are minorities and that is a.
35:31That you know this this the discussion
35:33in this paper attributes it to
35:35the environment in medical school.
35:37Which stereotype threat contributes to
35:40worse performance on standardized tests?
35:43And then when I think about career
35:45advancing opportunities right,
35:46so airway which we don't have
35:47a chapter of here.
35:49AOA is like the, you know, the Supreme.
35:51The peak achievement that one can reach
35:53out a lot of medical school so down.
35:55But right?
35:56Who's on faculty here did the study
35:58that showed that basically black and
36:00Asian students were six respectively
36:02six and two times less likely to
36:03be inducted in airway compared
36:05to their white counterparts with
36:06similar like academic profiles,
36:07by adjusting for grades and whatnot?
36:09And I think that goes back
36:11to the point I was making.
36:13Earlier about the limits of,
36:14however, one may perform like
36:16their identity or whatever,
36:17right?
36:17Like black and Asian students are the
36:20least likely to also present us white.
36:22So like as much as like one may modulate
36:24their perform that like the performance
36:26of racial identity or whatever like this.
36:28So,
36:28so long as one does not look white,
36:31you may have all the other things that go.
36:34You know that like may go in
36:36favor of like you going into a,
36:38but like it's really interesting that those
36:40are the two groups for whom like this was.
36:43Like very strongly,
36:45statistically significant.
36:46And then research and mentorship,
36:48right?
36:49So the fact that lower faculty diverts
36:52diversity like across medical schools,
36:54Ann.
36:54It has a huge impact on whether faculty
36:56even have an interest in mentoring
36:59minority students right on there.
37:00There have been many audit studies like
37:02across fields not only in medicine,
37:04but like when you email faculty
37:06expressing interest in their work.
37:07Whether or not you have a black
37:09sounding name like impacts,
37:10you know impacts whether they're going
37:12to even respond back to you or when
37:14they realize you're black Damaso.
37:15Sorry, actually I'm busy,
37:16and I don't have time to mentor you,
37:18but like this has an impact.
37:20Also,
37:20in medical school of course,
37:22and I'm going to use one of my favorite
37:24examples will not talk about this.
37:26Is the case of a thesis award here.
37:29Yeah alright,
37:29so this is a study published
37:31in 2018 academic medicine where
37:33the the the Med School thesis,
37:35which is like our own kind of version of AOA,
37:38right the strongest predictor of
37:40getting honors and high responders,
37:42was having an effective research mentor,
37:44right?
37:44And so you one can think about how
37:46all the racialized components of
37:48interactions and what not end up shaping.
37:51Whether someone is going to have an
37:53effective like an effective research mentor,
37:55but also being you.
37:57You know, being you are also
37:59black Hispanic native students,
38:00you are students,
38:01had half the odds of being
38:03nominated for owners,
38:04and have the odds of getting
38:06honors an like very abysmal odds
38:08of getting hired hunters, I think.
38:10And this is a 13 span worth of the
38:12study and only like 2 URM students
38:15got Connors over that course.
38:17So even when you get rid of a
38:1908 and which is the case here,
38:21there are other ways career advancing
38:23opportunities end up being, you know,
38:26sort of distributed an unequal fashions.
38:29Then we get to, you know,
38:31applying to residency,
38:32where URM students,
38:33one having increased odds
38:34of taking leave of absence,
38:36which is kind of a red flag on
38:38residency application meets one
38:40of my classmates median just
38:42recently published this paper and
38:43also greater rate of attrition
38:45compared to non URM students.
38:47At the four year Mark,
38:49Black and native students have the lowest
38:51odds of matching into residency right,
38:53and but these are sort of like even out
38:56by by the six year mark which means.
38:59This is relevant for actually
39:01all racial minority groups like
39:03compared to white students.
39:05So all minorities have lower odds
39:08of matching at the four year mark.
39:11But then by by six years all things even out.
39:14So basically all racial minorities
39:15have to go through the match.
39:17A couple of more times compared to
39:19White to our white counterparts.
39:22And then when you look at how
39:24applications are evaluated,
39:25there is a huge emphasis on cut
39:27off scores in part,
39:29probably because program directors
39:30are overwhelmed by the number of
39:32applications which you know fuels the double.
39:35AMC's like business model.
39:37Erases their number one source of revenue,
39:40so that means that you know program
39:43rely programs will rely on numbers
39:45and ultimately there will be a
39:47select few and by select few I mean
39:50percentage wise of students who
39:52receive you know the vast majority
39:54of of say invitations for interviews.
39:57So for instance in internal medicine.
40:0012% of Addison applicants are
40:02offered the half of interviews.
40:04And they'll ultimately attend
40:051/4 of state interviews.
40:06That means there, you know,
40:08on the other,
40:09you know on the other end of this,
40:11students who aren't as stellar,
40:13like students who don't have as
40:15high as step one score and whatnot,
40:17are end up having to apply to one
40:19to apply to far more programs and
40:22have fewer interview invitations.
40:23And all of this.
40:24Why is it's like tide up with the
40:27sort of like accumulation of racial
40:29disadvantage along the course of
40:31the four years of medical school?
40:33And I'm going to use the example
40:36of orthopedic surgery where?
40:37This recent study showed that right?
40:40Like if you look at students holistically,
40:42you would find that like on average,
40:45like students from any given racial
40:47group are equally competitive
40:49for orthopedic surgery.
40:50But if one chooses to focus on
40:53again step one, Step 2, AOA,
40:55then you have.
40:56What is the current kiss right where
40:59white applicants have about a 70%
41:01rate of matching into orthopedic
41:03surgery but black applicant and
41:05Hispanic applicants have like?
41:07Less than 50% chance chances of matching
41:09into ortho and bottle like ortho,
41:11which like is among the most you know,
41:14highest training specialties.
41:15So quickly I am going to talk about
41:19these long term implications,
41:21starting with with income, right?
41:23So USMLE step one scores are highly
41:25correlated with this with a given
41:28specialties finding potential right?
41:29And also whether one has a mentor in
41:32the given specialty is a huge influence
41:35into and choosing state specialty.
41:37There's a good study that showed that
41:40medical schools that have a more diverse
41:42faculty in orthopedic surgery and
41:44more diverse residency programs are.
41:46More likely to send minority students
41:48into orthopedic surgery and so look
41:50at this correlation between step one,
41:52score an earning potential right.
41:53You have orthopedic surgeon
41:54neurosurgery right on? Turn up there.
41:56Which like are, you know,
41:58the specialties where if you don't get it,
42:00240 can sort of forget about.
42:04Forgive me. So.
42:06All of this sort of accumulates into
42:09what I call a hierarchy of medical
42:11specialties for URM students right where?
42:14Yeah, will be. Family medicine psychiatry.
42:18These are the you know.
42:22Specialties have greater representation of
42:24minorities of minority student Ann and Ann.
42:27By the way, this is residency you know,
42:30among residency programs.
42:31So which begs the question right?
42:34Especially knowing that at at Metz
42:36at the Magic relation stage, right?
42:38Like Black and native and Hispanic
42:40students express like relatively high
42:42interest in non primary care specialties,
42:44but yet you know when it comes to graduation,
42:47black and native students
42:49go into primary care.
42:51At a rate higher than anyone else.
42:54And I know oftentimes people argue right,
42:56that the reason why some people don't know.
42:59Many people have done which primary care
43:01is because of how expensive medical is,
43:03but but that's been empirically challenged,
43:05right?
43:05Like, there's actually good evidence
43:07that people who go into primary care
43:09have the highest amount of debt.
43:11In other words, people going into
43:13primary care in spite of debt,
43:14whereas people who going to say
43:16ophthalmology, dermatology,
43:17they are the least inducted at graduation,
43:19right?
43:19An which brings me back to the
43:21point earlier that, you know,
43:23it's coming from 1910.
43:24This sort of like.
43:26Juxtaposition between hygiene and sanitation,
43:28hygiene, sanitation rather than surgery.
43:30So like are we ultimately through?
43:34You know,
43:35sort of like.
43:36A slew of mechanisms in medical
43:38schools that interact with each other,
43:41sorting marginalized students
43:42into the specialties that are
43:44more sort of undervalued, right?
43:45Because of our existing arview system.
43:50And so when we look at early academic path,
43:54right, we know, for instance,
43:55that black faculty are half as
43:57likely to receive care work right?
44:00Which is funding for research.
44:01And there are half as likely
44:03to be promoted at each stage.
44:05There are less satisfied and more
44:08likely to consider leaving academia.
44:11An A is good evidence that black people,
44:14social networks actually yield
44:15fewer career opportunities right?
44:17Despite using their social
44:18networks at similar rates compared
44:20to their white counterparts,
44:22which to me always begs the question.
44:24And I always ask.
44:27People when I was you know
44:28when I get this presentation.
44:30How many black friends do you have
44:31left from medical school, right?
44:33Like how much of that social network
44:34that were that were supposed to be sort
44:37of building during medical school?
44:38How much of that actually lost
44:39and how much of it remains?
44:41You know, sort of racially integrated.
44:43And then of course the impact on Unhealth,
44:47right?
44:47There is good evidence that
44:49just experiences of racism,
44:50both interpersonal and structural,
44:52have an effect on chronic
44:54mental and physical health.
44:56Already talked about.
44:57Depression,
44:57anxiety and anxiety among among medical
45:00students and associations with the sort of
45:02like the racial climate in medical school,
45:05and especially for those students who,
45:07for whom being black,
45:09for instance,
45:10is more central to their identity.
45:12Those are the students who.
45:14On who?
45:17For whom experience of discrimination
45:19is more tightly associated with
45:21depression and anxiety, right?
45:23And the recent paper show,
45:25for instance,
45:26that surgery residents who report
45:29experiencing discrimination are twice
45:30as likely to report suicidal ideations,
45:33and especially so among black
45:36and Asian surgery residents.
45:38There's also this interesting like
45:40interaction between education and health,
45:42right?
45:42Typically we know that health
45:44is education is protective
45:46against negative health outcomes,
45:47and part of that has to do with income,
45:51right?
45:51But because there are income
45:53disparities among Blacks,
45:54say black and white people
45:56at the same education level,
45:58ultimately there is good evidence
46:00that black people actually
46:01receive shallower health returns.
46:03Compare health returns from education
46:05compared to their white counterparts.
46:07So if you think about.
46:09Like highly educated black women
46:11compared to highly educated white
46:13women an like maternal morbidity
46:15and mortality rates, right?
46:16That gap is actually higher among
46:19those who are highly educated
46:21compared to if you were,
46:23you know versus like black,
46:25low educated and white, low educated women.
46:28But all of this, of course,
46:30right.
46:30Like all of that I have listed that
46:32you know accumulates to like long term
46:34outcomes like it can be subject to change,
46:37right?
46:37And there are sources of change.
46:40I'm in the theory of
46:41racialized organizations.
46:42One of the one of the sorts of change
46:44that is highlighted as external sources
46:47that are external to the organization,
46:49be it social movements,
46:51policy changes,
46:51and organizations to which
46:53we are accountable to,
46:54and a good example is the LC ME right?
46:57That's an accreditation body.
46:58That is,
46:59you know, can yank our our right
47:01to continue to educate students.
47:03And so when the LCM we created
47:05a set of diversity standards in
47:0720 like in 2012, they saw and.
47:10Almost immediate reversal in the trend
47:12of representation of both female
47:14metric tons and black matriculants.
47:15And so if you look closer that
47:17has to do with the basically
47:19specifically a change in favor in
47:21the representation of black women.
47:24And you know in those years.
47:27There are also internal sources of change,
47:30right? So conscious efforts like within,
47:32say, the student body.
47:34The faculty can lead to altering processes
47:36and so can social movements within right
47:39so I could talk about next ysm here,
47:42which as I continued to
47:45push the administration.
47:46And has the you know led to some change.
47:49Like we we have hired faculty to lead a
47:52HealthEquity thread in our education here.
47:55Among some you know,
47:56among many changes associated
47:58with what with what next,
47:59why some started?
48:00When I look at other institutions like
48:03a pen and Highland Highland emergency
48:05medicine and the work that they've decided
48:07to do and how they're doing emerge.
48:10You know,
48:11recruitment for residency is another
48:13good example of internal source
48:14of a change which has yielded
48:17more diverse classes.
48:18For the years that they've done this,
48:21another good example is these format
48:23pizza program that have completely
48:25reshaped how they do recruitment,
48:27right?
48:28So they're blinding airway status.
48:30They're really emphasizing numbers,
48:31but if in addition to that
48:34they have invited non physician
48:36interviewers into into their
48:38process to really share power right?
48:40In terms of like who gets to shape
48:43the incoming class of residents
48:46within within the institutions?
48:48Another good example that I
48:50like to think about is the UCSF
48:52Differences Matter campaign,
48:54which is a school wide $10 million
48:56commitment and I don't know you know.
48:59In practice what $10 million means.
49:02But like 'cause that's a lot of money,
49:05but I've never seen.
49:06But the $10 million can like explicit
49:08commitment to addressing diversity
49:10and inclusion within the institution,
49:13right?
49:13Like I think that speaks to the need
49:16for these commitments to be backed.
49:19With like institutional support
49:20by and from different members of
49:22the institution and financial,
49:24and especially financial support,
49:26I do think when, for instance,
49:28standards like the LC.
49:30MEA standards are put into place,
49:33that they should be more.
49:35They should especially be specific, right?
49:37For instance,
49:38so the the onset of knew diversity
49:41standards has not, for instance,
49:43addressed the fact that right
49:45that black men are like one,
49:48have continued to make up like 1/3.
49:51Of black medical students like
49:52since the 1990s,
49:53which is a gap that's like not the case
49:56in just about any other racial group.
50:00And I just want to.
50:00Take the plug that the kind of
50:03sustainability that one may expect from
50:05increasing diversity is not promised,
50:07and in fact,
50:08as good evidence that when a when
50:10an organization when a student
50:12body becomes more diverse,
50:13there is a backlash that people call
50:16white lash sometimes and you see
50:18it in America after Barack Obama
50:20became president, there was quite
50:22the whitelash in this country.
50:24So because of the sort of
50:26perceived threat to status, right?
50:28So initiative diversity initiatives
50:29that lead to diversity need
50:31to sort need to also come.
50:33With efforts to to ensure right
50:36that that belonging for all
50:38members is affirmed such that there
50:41that we don't so such that one
50:44organization does not end up with.
50:47But but the sort of backlash that that
50:49is often seen across institutions.
50:51There's good evidence, for instance,
50:53that we tend to forget the
50:55right is for this quote,
50:57unquote theory of racial ignorance shows
50:59that and it's been born empirically, right?
51:02Like, for instance, today,
51:04the majority of white people
51:06misperceive the degree to which
51:08there has been little to no change
51:10in terms of disparities in and say,
51:13like, the racial wealth gap,
51:15those kinds of things right there.
51:17We forget,
51:18and so there's the reminders are
51:20important right reminders of purses,
51:23but but Interestingly enough,
51:24some of those reminders end up altering
51:27individuals perception of the past.
51:32So. I think the point of of some
51:36of some of this recent evidence in
51:39social psychology is to say that it
51:42that changed outcomes is not easy
51:44and it is not easily sustainable.
51:46So it takes a tremendous amount
51:48of work and commitment.
51:49And so I think ultimately what that
51:51means is that we there's a strong need
51:54for redistributing resources, right?
51:56Such that power is shared hierarchies
51:58or flat, and we need to remain.
52:01And if we're not yet become accountable to.
52:04Many of the organisations and
52:06surrounding communities to which
52:08we owe or to wish that we serve.
52:11And one of the things that I always
52:13block is the need to invest in getting
52:1612 education if we think we're ever
52:18going to become more diverse, right?
52:20So I think here, for instance,
52:22we have a lot of student LED initiatives
52:24that are invested in K through 12 education.
52:26But we here y'all can take a page
52:28out of schools like Morehouse and
52:30Charles Drew that have larger
52:32financial investment in surrounding K
52:33through 12 education for broadening
52:35and deepening the pipeline.
52:36Because at the end of the day there's
52:39only but so many of us to go around like.
52:42You know,
52:42once we medical school only so many of
52:45us can go into a given specialty an I
52:47think also internally medical schools should,
52:50if they are committed to this matter,
52:52apply pressure on the external.
52:55Forces and systems that
52:56perpetuate inequity is right.
52:58So the US news Ranking is a good example.
53:00So many medical schools are reticent.
53:04When it comes to say,
53:05like you know,
53:06letting in students with a mid
53:08range and got score and what not,
53:10because like the average uncut score,
53:11and you know among your student body
53:14like affects the ranking so that so.
53:16She should medical schools be asking
53:18right of the US news record or U.S.
53:21news ranking to have an equity metric or
53:24to remove the M cat or just to abolish
53:27the US News ranking for instance?
53:29So there's a,
53:30you know,
53:31the sort of internal external
53:33pressure dynamic that needs to also
53:35be sustained within medical schools.
53:37And with that I'll stop and
53:39I'll take any given questions.
53:42Sorry, I went a little over time.
53:47I can't hear anything you're saying,
53:48doctor my career. Here we go.
53:50That's fine. You hear me now.
53:52Yes yes terrific.
53:53OK, well thank you very much and
53:55we've got some time for conversation
53:56now we've got about 1/2 hour.
53:58I want to invite you folks to
54:00submit questions through the Q&A.
54:05Let me just start here with the one
54:07that was a definition question.
54:09The definition of culture as you
54:10defined it, or the OR the author
54:12please you mention this is early.
54:14In the talk you talked about culture.
54:17Yeah, let me just go to
54:19that slide again, sorry.
54:22This is Clifford Geertz culture.
54:26Here a system of inherited conceptions.
54:32A system of inherited conceptions
54:34expressed in symbolic forms by
54:36means of which people communicate,
54:38perpetrate and develop their knowledge
54:40about and attitudes towards life.
54:42That's Clifford Geertz,
54:43Clifford, Geertz, GE RTZ.
54:45That's the the anthropologist who.
54:47I mean, there are many definitions.
54:50That's just one that I liked.
54:52That was good
54:53sufficient. Thank you.
54:55Yeah, the next question, please.
54:58About cultural competency,
55:00do you think that cultural
55:02competency should be thrown out
55:04or anything structural company?
55:05And do you think that structural
55:08competency enhances cultural competency?
55:10I'm not sure.
55:13I mean, they're very different concepts,
55:15right? Like the I mean the idea of
55:18of cultural competency I think is
55:20a bit fraught in that like I mean,
55:23how quote unquote competent can
55:24one be in in the in the different
55:27cultures and and and and from that
55:29perspective I like cultural humility.
55:32More. That means basically, right?
55:33Just kind of assume that you
55:36don't know and you like, right?
55:38Like assuming and not not making any
55:40assumptions based on an individual's like.
55:43Their racial group or culture
55:44just because of, like you know,
55:46existing stereotypes.
55:47So if you forced me to choose,
55:50I would say yes.
55:51Cultural competency should be
55:52thrown out in favor of structural
55:54competency and cultural humility.
55:56Cultural humility.
55:57That's
55:57an excellent point, Max. Thank you.
55:59I have a question for you.
56:01Talked about isolation during clerkships,
56:03and I think that's really important.
56:05Then of course you've just recently
56:07gone through clerkships here
56:08and possibly elsewhere as well,
56:10and that this leads to exclusion
56:12from learning opportunities.
56:13That, I wonder if you could talk
56:15a bit more about that about the
56:17isolation that that you experience
56:19that others might experience on our.
56:21You know, in our hospital on
56:23our our services.
56:25Yeah, I mean, I think it depends,
56:27so and sometimes sometimes I,
56:29I think generally the clerkship
56:31experiences is isolating for all medical
56:33students right by virtue of like,
56:35especially if you're like on it on the team,
56:39by yourself and like you know,
56:41everyone's senior and and you,
56:43you know you get pummeled question,
56:45but I think there is a uniqueness and being
56:48minority student right which I talked
56:50about stereotype stereotype threat earlier.
56:52Or sometimes you may even be on a team.
56:56With another student who like for me,
56:58I've been on teams where I'm with
57:01a student who is not black, right?
57:04And who is either white or or or.
57:08I don't know South Asian East Asian.
57:11Where have you an?
57:12I felt like sometimes like my residents
57:14will be more invested in their learning.
57:16Like I remember being on a rotation with
57:18a friend of mine an I was interested
57:21in the subject and she wasn't.
57:23She hated it. In fact right?
57:25But like she would be told.
57:26Oh you would make such a great
57:28insert specialty.
57:29You would,
57:30but like I who expressed some interest
57:32right would not get any of this and or
57:35even felt like I like I will not be at,
57:38you know like called upon.
57:39For a given learning opportunity,
57:41right?
57:41So it's both socially isolating and
57:44that like sometimes like residents are
57:46friendlier to two students who are not my,
57:48you know or not,
57:50black or not black men,
57:52but also isolating in that.
57:53I feel like I am losing out
57:56on learning opportunities.
57:58You know, I I I I,
58:00I think that I've certainly
58:02heard the same concern raised it.
58:04Certainly during my generation and
58:05likely still now to some extent.
58:07But certainly during my generation
58:09coming up through training when a
58:12much larger majority of the of the
58:14medical students were meant that the
58:16that the women who are going through
58:18the rotation certainly felt that
58:20isolation and may still now as well.
58:22So aside from making the faculty and
58:25residents more aware of it, is there.
58:27It's also outside.
58:28Easy answer,
58:29So we start by making people aware of it.
58:31So perhaps if it's unintentional
58:32they can address it,
58:33but is there something else we
58:35can do to to alleviate that?
58:36Isolation is as you make a good point next,
58:39which is that just being a medical
58:40student on the team is kind of an
58:42isolating experience in general because
58:44the rest of the team they may have,
58:45you know they were from the same Department.
58:47Commonly they they've been together
58:49in various settings for months and
58:51months you show up for your two
58:52weeks or four weeks or six weeks,
58:54and so already in isolation,
58:55just based on that.
58:56And then this could potentially
58:58exacerbate it. Yeah, I think.
59:02So some of what makes the
59:04experience isolating right is the
59:05power dynamics that are at play,
59:07and so I think even when I've been on
59:10teams where I'm the only black person
59:12when the attending is like an attending,
59:15who you know, like cracks,
59:17jokes with the team or just doesn't
59:19isn't like you know, I don't know stuffy
59:21or for lack of a better term, right?
59:24Like that contributes to just
59:26general comfort for all team members.
59:29Man, that's one thing right the the
59:31way that the steeper the hierarchy
59:33the and the more sort of like power
59:35concentration there is at the top, the more.
59:38And this is actually evidence base,
59:40the more there's like that's like
59:42element of stereotype threat, right?
59:45And an so that's one thing,
59:46just being relaxed with the with the
59:49students and the residents and as opposed
59:51to being like known as the intense attending.
59:53Where like you hear Mark Mercurio is the
59:56overnight attending and you just kind of
59:58start shuffling ahead of rounds, right?
01:00:00Like? And I'll just pick your
01:00:02name 'cause you're in front of me,
01:00:04but I got no feelings Max,
01:00:06don't worry bout so that's
01:00:08one thing an and some of it.
01:00:10I mean yes.
01:00:11Residents being aware helps write
01:00:13that and being given feedback an and
01:00:15some amount of accountability, right?
01:00:17There are some departments here
01:00:19where like semester after semester
01:00:20they receive the worst like evil
01:00:22like the residents from State
01:00:24Department received like the worst
01:00:25evaluations from medical students.
01:00:27And there is I I don't think
01:00:29that there's any accountability.
01:00:31I mean nationally, right, we know.
01:00:33And I'm just going to call, you know.
01:00:35I mean I can.
01:00:37I can say this because this
01:00:39is a national thing, right?
01:00:40That like whenever the
01:00:42graduating questionnaires,
01:00:42those medical school questionnaires get
01:00:44published and the studies come out, right?
01:00:46Surgery?
01:00:47And Obi-wan nationally,
01:00:48are this are the specialties where
01:00:50medical students report the most
01:00:52abuse and discrimination and so?
01:00:54Like there has got to be some
01:00:56kind of accountability within,
01:00:57you know a given Department like a resident.
01:01:00If medical students complain over
01:01:01and over and over about what's
01:01:03going on and like nothing changed,
01:01:05then maybe people don't care,
01:01:06right like that resident or Med
01:01:08student feedback doesn't matter.
01:01:09I don't know.
01:01:12Now here is. So let me let me
01:01:13get another question first.
01:01:15Just a quick comment from one of
01:01:16the one of the senior members
01:01:18of the faculty factor, Mr.
01:01:19Diaco. Such an important talk.
01:01:20I wish you all the best
01:01:23from this point forward.
01:01:24From a friend of mine's senior
01:01:26pediatric faculty member.
01:01:27During orientation and early in the
01:01:29first year, there is diversity training.
01:01:31To what extent does it hit the mark?
01:01:33How might you like to see it improved?
01:01:36How? How good is our diversity training,
01:01:38and what can we do better?
01:01:40Yeah, I think you know it's actually
01:01:43not bad like I Pro is I think is that
01:01:46what he's referring to ipro is? I mean,
01:01:49I've reviewed the entire curriculum right?
01:01:51Because I wasn't that committee that let that
01:01:53eventually came up with recommendations.
01:01:55I think the first two weeks of
01:01:57Med School is probably where you
01:01:59sort of get the most of it right?
01:02:02Like you get to a whole lot and it's very.
01:02:05I think it's it's decent.
01:02:07During high pro. I just
01:02:09for the for the. Those who aren't
01:02:11in the medical school here is the
01:02:13introduction of the profession
01:02:15of concentrated two week course,
01:02:16which I think Dean angle off is
01:02:19kind of spearheaded that she kind
01:02:21of lead and created and let it.
01:02:23It's a concentrated two weeks,
01:02:24about two week course right
01:02:26at the very beginning, two weeks.
01:02:27So that's, you know, if you looked
01:02:29at a heat map of the curriculum,
01:02:32at least as far as I recall, right,
01:02:34like from being on this committee,
01:02:36ipro is where a lot of this happens.
01:02:38There are other opportunities for it
01:02:40for this to sort of be longitudinal.
01:02:43I have thought about leveraging the existing
01:02:44structure of our curriculum, right?
01:02:46So for instance we are split
01:02:48into groups for a lot of things,
01:02:50right for anatomy, for for team based,
01:02:52learning for Physiology,
01:02:53what have you for a bunch of things we
01:02:56are split into groups and as far as I
01:02:59understand it a lot of the split as
01:03:01random and I think it could be more
01:03:03intentional and this is something
01:03:04that's done in Business School actually.
01:03:06So business schools,
01:03:07when you start the school for an MBA,
01:03:10your assign like a learning family, right?
01:03:12Or learning team?
01:03:13What have you?
01:03:14And I'm not necessarily saying
01:03:16that this needs to be like a rigid
01:03:18like cohorting process where you
01:03:20have the same group along the way.
01:03:22Although here a lot of times I've
01:03:24ended in similar groups because
01:03:26some of the sorting is alphabetical,
01:03:28so then I end up with the same people
01:03:30whose last names start with P or whatever,
01:03:33or N you know like.
01:03:35But I think we could be more intentional
01:03:37in how we create the groups such
01:03:39that groups are always both racially
01:03:41like racially and gender diverse,
01:03:43but also.
01:03:44Actually, I think that if there
01:03:45is any intentionality happening,
01:03:48it is that the group tend to always
01:03:50be gender.
01:03:51You know, like gender even,
01:03:53but they can be more racially like
01:03:55the groups that are formed right?
01:03:57For these launch general experiences like PR,
01:03:59the professionalism and ethics and
01:04:01responsibility was negative.
01:04:02That sure, right?
01:04:03Those groups should be more racially
01:04:05diverse and with intentionality.
01:04:06And then besides that,
01:04:08so something else that's done in
01:04:10Business School right there.
01:04:11They make their make students take
01:04:13like you know.
01:04:14Personality and ideology test.
01:04:16And then you create groups that are
01:04:18diverse from that perspective as well,
01:04:20because there's sort of like
01:04:22surface level diversity and deep
01:04:23diversity an all like right you can,
01:04:25you could choose to make it only
01:04:28racially and gender diverse,
01:04:29but then you miss all the nuances that
01:04:32go into like who an individual is.
01:04:35An that fosters right there.
01:04:37There's a you know,
01:04:39contact theory quite literally right.
01:04:41Being launched in a cohort of of
01:04:44diverse colleagues has a positive
01:04:46impact on as long again as long
01:04:49as that that it's a positive.
01:04:51But you know that the that the grouping
01:04:55then fosters positive interactions
01:04:56and that they are lead or Co lead
01:04:59by faculty who are actually skilled.
01:05:02You know sustaining some of
01:05:04these efforts then yes that.
01:05:06Ends up having a positive impact on.
01:05:12UNE students attitudes right towards
01:05:13racial and ethnic minorities in
01:05:15terms of like even patient care.
01:05:17Yeah,
01:05:17so at Yale now
01:05:19'cause you mentioned PR briefly.
01:05:20That's the professional responsibility
01:05:22course, which of course,
01:05:23Karen Jamaican Jack Hughes I have have
01:05:26led for a long time and that within
01:05:28that course there's a groups of 12 or
01:05:31so students and it's been a strange.
01:05:33It's been a strange year,
01:05:35certainly in terms of us,
01:05:36a physical togetherness and lack thereof.
01:05:38But nevertheless,
01:05:39the idea that there's a dozen dozen students.
01:05:42To meet weekly for a long time or
01:05:44or more than that and and talk about
01:05:46talk about issues in professionalism
01:05:48that go beyond trying to remember
01:05:51whether it's the type one or Type 2
01:05:54pneumocyte that does this or that so.
01:05:58The the the question I have is aside
01:06:00from the professional Responsibility
01:06:01course which is just for that one
01:06:03year part of that one year are there
01:06:06currently at Yale School of Medicine?
01:06:07Any of those lanja tude no
01:06:09groups that you're talking about
01:06:10that yeah we have the so I remember
01:06:13we had a Physiology right?
01:06:14The Physiology group.
01:06:15I mean it's Physiology,
01:06:16so we're not talking about like they should,
01:06:18but like there's Physiology there
01:06:20are cohort we're we're in like 4
01:06:22kind of houses like in Harry Potter
01:06:24with our different advisors, right?
01:06:25I mean, there are so many.
01:06:27There's anatomy. There's.
01:06:28There's PR team based learning
01:06:30which is a group of six typically.
01:06:33Uhm? I mean, I, can you know,
01:06:36rattle off like for every six
01:06:38week block you're you.
01:06:40You tend to be in a small
01:06:42group for workshops, right?
01:06:43And the workshops happens like I don't know.
01:06:46Three times a week or something like that.
01:06:49I don't remember,
01:06:50but I think there are many many
01:06:52existing like structures through which
01:06:54we can be intentional about creating
01:06:56diverse groups in order for us to
01:06:58not be like, you know, so segregated.
01:07:00I mean literally, in my class,
01:07:03when I was a first year.
01:07:05Anyway, it was so apparent, right?
01:07:06There was almost like a hierarchy
01:07:07and how we sat in the auditorium.
01:07:09I don't know if you've ever
01:07:10noticed the white.
01:07:11The like wasp white people
01:07:12sat at the very front row.
01:07:14The black woman sat at the far back and
01:07:15people were like kind of racially ambiguous.
01:07:17I didn't make it.
01:07:18I mean, it was like fascinating to observe.
01:07:20And this was like a running joke.
01:07:22Like are you,
01:07:22are you a left side Aurora?
01:07:24You're right,
01:07:24Sider was a question that someone
01:07:26asked me one day and it was coded
01:07:27for what are you doing here?
01:07:29You're not one of us on the right side.
01:07:33That's fascinating,
01:07:34so a comment and then some more questions.
01:07:38Trainees at all levels must feel that
01:07:39it's safe to call out transgressions.
01:07:41It's so easy to feel that if I point
01:07:43out a transgression that I will kill my
01:07:45chances for a good greater recommendation,
01:07:48and I think that's something that
01:07:49so many of us so many students and
01:07:51trainees have commented on all along
01:07:53that it's it's not risk free to call
01:07:55out transgressions and so it's it's.
01:07:57This is again from a friend of mine
01:07:59on the senior faculty who you know,
01:08:01so it's it's a it's on us on the faculty
01:08:04to try and set a tone in a culture such
01:08:06that people feel it is safe to call it out.
01:08:09When there's a transgression,
01:08:11here's a specific question for you.
01:08:13Where do you see opportunities to
01:08:15foster discussions about race?
01:08:17For example, rounds devoted to
01:08:19this topic with minority students,
01:08:21fear raising racial issues would
01:08:22adversely affect evaluations and how
01:08:24my structural changes mitigate this.
01:08:26Yeah, I think so.
01:08:28People
01:08:28have started to do a sort of like
01:08:31like how if I could, Umm, and in some,
01:08:34maybe Eminem is in the right term
01:08:37because it's not mortality or morbidity.
01:08:40But like under that format right where
01:08:42you sort of discussed like incidents
01:08:44and incident that occurred and like
01:08:46how could we have better handle this?
01:08:48That kind of stuff so it can be right?
01:08:51I mean we do this as a Qi project for around.
01:08:54Like you know quality of care and we can
01:08:57do that the same thing around like culture.
01:09:01That's one one right.
01:09:03Having a sort of like conferences
01:09:05that are dedicated to this and.
01:09:08Yeah, I, I think that that's
01:09:10one way I think yes,
01:09:11people would probably be afraid
01:09:13of being adversely evaluated,
01:09:15and some people might not.
01:09:18An there being a mechanism for
01:09:20an annuity is always one way
01:09:23to allow for people to express.
01:09:26You know how they feel about certain issues
01:09:29without having to face repercussions.
01:09:31Or like an ombudsperson or another
01:09:34student knows more outspoken who
01:09:36doesn't care about repercussions.
01:09:41Is a question do you worry about biased
01:09:43evaluations in the other direction,
01:09:45namely students or residents holding
01:09:47faculty of color to different standards?
01:09:50We talked about, Oh yeah.
01:09:53Different standards leading to worse
01:09:55evaluations compared to the white faculty,
01:09:57thereby negatively impacting
01:09:58prospects for promotion, is that it.
01:10:00CERN is that something that's been reported,
01:10:03or a racist issue? Yeah,
01:10:04this is definitely a thing
01:10:06in college violation, right?
01:10:07Women and Faculty of color and anwer,
01:10:09like teaching matters alot right?
01:10:11When you teach the teach in
01:10:12college or in those evaluations.
01:10:14And I, I see, I follow a lot of
01:10:16like social science faculty on
01:10:18social media who always sort of
01:10:20like expressed their like you know,
01:10:22their discontent with the quality of the
01:10:24evaluations and feel like things are unfair.
01:10:26This is definitely a thing I.
01:10:28I don't know how much evaluations maturan
01:10:30for Med school faculty, honestly. Anne.
01:10:33But they, but it's a thing, it's done.
01:10:36They do matter for motion.
01:10:38I've been told that only research matters,
01:10:41but only what?
01:10:42I I'm jokingly saying I've been
01:10:44told only research matters, but
01:10:47well, there's no question that in different
01:10:49tracks we don't need to do this now,
01:10:52but yes, evaluations,
01:10:52teaching, teaching does matter,
01:10:54and obviously research productivity
01:10:55in certain tracks matters a great
01:10:57deal as well. No doubt.
01:10:58But but perhaps one could certainly
01:11:00argue that teaching should matter more.
01:11:02I think my friends who are focused mainly
01:11:04on medical education would argue that
01:11:06teaching should get even more attention,
01:11:08and everybody feels that their
01:11:10area needs more of it.
01:11:11Certainly that that that that good
01:11:13teachers need to be rewarded for that.
01:11:15No doubt, I
01:11:16agree, so yeah.
01:11:17Absolutely think that is an issue.
01:11:19I don't know that it's necessarily
01:11:20been studied in medical school,
01:11:22but I know if you know
01:11:23if it happens in college,
01:11:24those are the same people who then go
01:11:26to Med school and continue to evaluate.
01:11:29You know faculty,
01:11:29so I would not be surprised
01:11:31if that was the case.
01:11:33Another question please,
01:11:34how would you suggest that group
01:11:36diversity is best created when
01:11:38we often only have access to self
01:11:40reported identities which are
01:11:42also voluntary? Yeah, that's a
01:11:44great question so well.
01:11:45First of all, right?
01:11:47Most people don't lie on those.
01:11:49I know some people do,
01:11:51but most people are honest about
01:11:53the identity that they report
01:11:55and so you could sort of just
01:11:57make do with whatever data that
01:11:59is available, right, I think.
01:12:03You know it's funny.
01:12:05I actually just read a paper recently that
01:12:08most people who click other right who
01:12:10don't identify a given race are white.
01:12:13Uh, so you know, besides the people
01:12:15who for the most part you know,
01:12:18opt into saying other out of not
01:12:20wanting to identify race, I think.
01:12:22The data isn't bad, and I mean also.
01:12:25I don't know you could look at the picture.
01:12:29Is there is good evidence or like in
01:12:31in in the fields of like sociology
01:12:33and social psychology and economy
01:12:35and ikkicon they actually look at
01:12:37pictures and names and I know it's
01:12:39fraught because theoretically in
01:12:41this country we say race is a.
01:12:44Is a self identified matter.
01:12:45But like when you see me,
01:12:47you don't let me tell you that I'm black,
01:12:50right?
01:12:50I am almost immediately raced as
01:12:52Black an that has true implications
01:12:54for how people treat me like people
01:12:57don't let me say I'm not black like
01:12:59even if I did say that like you
01:13:01would not believe me right? And so.
01:13:05As much as it is quote unquote,
01:13:07like self reported and voluntary,
01:13:08there's a truth to the fact that.
01:13:12Especially if your dark skin,
01:13:14like if you're black people will see
01:13:16that you're black and treat you as such,
01:13:18so yeah.
01:13:21OK come. Did you observe others
01:13:23doing bystander interventions to
01:13:25protect the learning environment
01:13:26when microaggressions happened in
01:13:28front of you during clerkships,
01:13:30the couple, did you see some
01:13:32bystander interventions?
01:13:33Yeah, I thought
01:13:34something like this when I was on pizza.
01:13:37I was like the most sort of
01:13:39positive role modeling I saw,
01:13:41and I wonder if she's in the audience.
01:13:44I'm going to call her out.
01:13:46Jasprit loyal was my attending
01:13:48on on General Peets.
01:13:49Anna Patient asked my attending,
01:13:51or I mean said to my.
01:13:53Resident was a black woman.
01:13:55Oh, I thought you were the nurse even
01:13:57though like she knew like this was a
01:13:59senior resident and my residents say no.
01:14:01I'm just a resident in a very sort of like
01:14:04quiet way and they're tending went she.
01:14:06She's a doctor and she's one of our
01:14:08best and Ann that was like the most sort
01:14:11of like Stern an and and just positive
01:14:13role modeling I've seen on the words,
01:14:17probably.
01:14:17Yeah, so I mean it helps right?
01:14:20Like in terms of affirming that this
01:14:22person who is being sort of like
01:14:24singled out by by a patient in that
01:14:26instance belongs right Ann and isn't
01:14:28out of place for lack of a better term.
01:14:31And I've seen the opposite where patient
01:14:33asked me if I'm patient transport when
01:14:35I walked in with the team, you know,
01:14:373:00 o'clock in the morning, in the Ed.
01:14:39With my stethoscope around my neck and
01:14:41like that ending doesn't introduce me.
01:14:43And then they say nothing when the
01:14:45patient asked me that question.
01:14:47So I think it helps when when,
01:14:50when the bystander sort of like
01:14:52moment occurs,
01:14:52but at the same time I,
01:14:54you know,
01:14:55sometimes just kind of let it roll,
01:14:57but I guess not that much since
01:14:59I still remember this well.
01:15:01I think the fact that you still remember
01:15:03Doctor Loyals positive intervention.
01:15:05Helpful intervention suggests that
01:15:06that it does have impact on somebody.
01:15:09If you still remember to. Yeah yeah, yeah.
01:15:11Doctor wise. She's awesome.
01:15:13She was awesome. Yeah, she's
01:15:14pretty awesome. Max.
01:15:15Your talk is excellent.
01:15:16I know we need to work on
01:15:19how we prepare faculty.
01:15:20For inclusive teaching,
01:15:21do you have suggestions how we
01:15:23can work with students to help
01:15:25educate the residents and faculty?
01:15:26So how can we work with students to
01:15:29help educate the residents and faculty?
01:15:32You know, I think there is for sure a
01:15:35role for students and at at the first
01:15:37thing I will say is is that if students
01:15:40do this they should be compensated right?
01:15:42So that it doesn't feel like being like
01:15:44conscripted into a teacher into a like.
01:15:47Voluntary, but not quite
01:15:48voluntary teacher role, right?
01:15:50I think students who take on those
01:15:52kinds of responsibility in other domains
01:15:54tend to be compensated and should be
01:15:57the case for this subject as well.
01:15:59I think you know leaning on.
01:16:02Exists, I mean, there's decent evidence,
01:16:05especially coming from like
01:16:07social psych on social site.
01:16:09And like you know, educational psychology.
01:16:14On sort of how one students can
01:16:16help with simulations, right?
01:16:18That's one good way where you know,
01:16:20be sort of like standardized, not patients.
01:16:23But like you know,
01:16:24participants in simulations or or
01:16:26conversant for lack of a better term
01:16:29is one way you know residents and
01:16:32faculty is sort of like practice.
01:16:34You know,
01:16:35like addressing certain types
01:16:36of may be difficult encounters,
01:16:38that kind of stuff,
01:16:39and some of us like spend a lot of time
01:16:42reading and engaging with this with,
01:16:44you know, with this literature,
01:16:45and so then potentially,
01:16:47you know he could have a team of
01:16:49students who are like very likes
01:16:51deeply engaged with the subject.
01:16:52That can also help come up
01:16:54with curricula and like so as
01:16:56research assistants and what not.
01:16:59Thank you.
01:17:02Another issue is student
01:17:03patient interactions.
01:17:04Is there a place where you can talk
01:17:06through racial incidents with a mentor?
01:17:08So if you have a some of the some of
01:17:10the comments that you received from
01:17:13patients which you've already mentioned,
01:17:15is there a setting it aside
01:17:16from the resident or attending
01:17:18you're working with there?
01:17:19Is there a place where you can
01:17:21actually talk through these things?
01:17:25Besides, I mean I think we have,
01:17:28so this is another thing about the
01:17:30existing structure in our curriculum,
01:17:32right? We have like,
01:17:34for instance scenario began clerkship.
01:17:35We have this thing called power hour where
01:17:38we come together and and like discuss
01:17:41like different kinds of abuse of power.
01:17:43Most of the time during power hour.
01:17:46I think people like talk about like what
01:17:48say a resident or attending or whoever did.
01:17:51But I think they're being
01:17:54a space for reflecting.
01:17:56Is useful power hour is unique to begin.
01:17:58I don't think it's a thing
01:18:00in all the other clerkships,
01:18:02but unless it's become a thing since
01:18:04I left the words but another like the
01:18:07reflective writing workshops that.
01:18:09That's sorry that happened under
01:18:12the program for Humanities and
01:18:14Medicine is another space for
01:18:17those conversations to happen.
01:18:19Not something that happens sort of
01:18:20like across the words and and some
01:18:22of the questions that I remember
01:18:24being asked in the reflective
01:18:25writing workshop where things like,
01:18:27oh, you know,
01:18:28right about a time where you were
01:18:30made to feel like you didn't belong or
01:18:32write about a time where you you might
01:18:34have potentially like abuse or power.
01:18:36That kind of stuff.
01:18:37So yeah, I think it's a great space as well.
01:18:40Don't forget
01:18:41the program for biomedical ethics.
01:18:42They have some fashion here we
01:18:44go. Here we are. Alright,
01:18:47here's a question for you.
01:18:49Please acknowledging this structural
01:18:50racism is undeniably at play in
01:18:53every clinical setting at Yale
01:18:55and other medical institutions.
01:18:56It is equally inevitable that
01:18:58URM's might misinterpret some
01:19:00comments actions by other team
01:19:02members as microaggressions
01:19:03due to experiencing president.
01:19:05How can you arrange distinguish
01:19:07between the two?
01:19:09You know that's a good question and this
01:19:12basically this question gets at this
01:19:15matter of like intent versus impact,
01:19:17and there is good evidence that like you
01:19:20know empirically at the national level,
01:19:22depending on one racial group,
01:19:24like for instance, why people tend
01:19:26to put more value on intent and black
01:19:30people tend to put more value on impact,
01:19:33and that probably has to do with how
01:19:35often one experiences discrimination.
01:19:37And so I think.
01:19:40Well, this gets out whether a
01:19:43comment as well meaning or not.
01:19:45I don't have an answer for that like if
01:19:47if if it's well meaning and doesn't land
01:19:49well and someone says that wasn't cool,
01:19:52you can just apologize.
01:19:53I I guess I don't.
01:19:54I don't know how.
01:19:56Well,
01:19:57when so I mean tick tick tick to
01:19:58give an example of this potentially.
01:20:01And that I've that I've seen and
01:20:02having read and heard that that
01:20:04getting people's names wrong is
01:20:06something that can be offensive
01:20:07or be seen as a microaggression
01:20:09confusing one student for another.
01:20:12And I work in a clinical setting
01:20:14where there are just so many young
01:20:15people that people are constantly
01:20:17getting everybody's name wrong,
01:20:18and this is clearly more hurtful
01:20:20to some people than others.
01:20:21Based on experiences that they've had.
01:20:24Yeah, exactly right or being
01:20:25confused for the next black
01:20:27student or or whatever it it's.
01:20:29I can't read the next verse.
01:20:31I can't read the potential perpetrators,
01:20:33perpetrators mind,
01:20:34so it is hard to actually distinguish, right?
01:20:36I think the most I mean the most
01:20:39that one can do is like give people
01:20:41the benefit of the doubt.
01:20:43But right?
01:20:44But like when you are someone who is
01:20:46like pummeled with with microaggressions
01:20:48like day in day out it is.
01:20:51It can be hard to do that.
01:20:54And again it depends on each one,
01:20:56sort of like I don't know agility
01:20:58with giving the benefit of the
01:21:00doubt or letting things go.
01:21:02It's not, it's not a,
01:21:04it's a hard thing to answer it.
01:21:05It's in order to think.
01:21:07To distinguish I,
01:21:08I guess you'd have to be able to read
01:21:10someone's mind or the other part of it
01:21:12is like how like how well you know someone,
01:21:14right?
01:21:15And so then you you assume,
01:21:16I know you well enough to know that
01:21:18you would have meant it that way.
01:21:20But like if I don't know you, then I can't.
01:21:23I you know,
01:21:24I may choose to give you the benefit
01:21:26of the doubt because I'm gracious,
01:21:28but I think that's a really
01:21:29good point in the course of our setup.
01:21:31In the clinical setting is of course a
01:21:33set up for, even for even more of that.
01:21:36Which is to say that it's very hard to
01:21:38get to know people very well when you do
01:21:40a rotation here their rotation there,
01:21:42whereas potentially the residents in
01:21:43a Department, hopefully over time,
01:21:44and the fact that they get to
01:21:46know each other better.
01:21:47But for students coming through,
01:21:48there really isn't for the most
01:21:50part that much time and exposure,
01:21:51so everybody tends to be.
01:21:54Pretty new to each other on these rotations,
01:21:56and so that that could potentially add
01:21:58to that problem that you point out.
01:22:01Another question please.
01:22:03Have there been any reported suggestions
01:22:06on how to prevent white lash?
01:22:08And you could tell us again,
01:22:10the definition of Whitelash
01:22:11had been reported.
01:22:12Suggestion that high prevent whitelash?
01:22:14Or should we just assume that
01:22:16this is an inevitable event
01:22:17after progression of diversity,
01:22:19equity and inclusion?
01:22:21Yeah, you know, that's that work is ongoing.
01:22:25Anne, here there's a phenomenal group here,
01:22:28like in social Psych and
01:22:30Oregon behavioral scientists.
01:22:31I, as far as I know, there hasn't been
01:22:34like evidence on like how to quote,
01:22:37unquote, prevented,
01:22:38besides people having to confront.
01:22:41The reality that that white supremacy
01:22:43should not be a thing by a white
01:22:47lash as a reminder is basically
01:22:50the sort of like negative reaction.
01:22:53Which is almost kind of reflexive
01:22:55to increasing diversity or.
01:22:57When there is like a new person
01:22:59in a position of power,
01:23:01who is a person of color?
01:23:04So yeah, I I haven't seen any evidence
01:23:07that suggests that it's like something
01:23:10that's like entirely preventable.
01:23:13I, I mean it,
01:23:14it literally takes,
01:23:15you know,
01:23:16embracing or giving up the sort
01:23:18of you know wages of whiteness
01:23:20as as social scientists call it.
01:23:22And I don't know that's a lot of work.
01:23:25It's maybe a big ask for America.
01:23:27I don't know.
01:23:30Maybe? Here's a comment.
01:23:32Let's put this in Jasper's file.
01:23:34Yeah, let's put that in Jasper.
01:23:36It's final. That's doctor loyal.
01:23:38Who you complemented on her intervention?
01:23:40OK, now we have.
01:23:41Please comment on whether or how
01:23:43relations with patients of different
01:23:45race or culture by students and faculty.
01:23:48Affects training and evaluation,
01:23:50so comments on whether or how
01:23:52relations with patients of different
01:23:54race or color by students and faculty
01:23:57affects training and evaluations.
01:24:00Hi so there is some evidence
01:24:03around how patients like you know,
01:24:06patient mistreating either students
01:24:09or residents ends up affecting
01:24:11like residents like you know,
01:24:14like engagement with the.
01:24:17Resident engagement with would like
01:24:19the rest of the clinical team,
01:24:22so I suspect that depending on how
01:24:25one experiences and reacts to. 2.
01:24:28Discrimination or a micro aggression
01:24:30from patients and also depending
01:24:32on how the team then addresses it.
01:24:35That probably has an effect on
01:24:36how the team continues to interact
01:24:38and then maybe a downstream
01:24:40downstream consequences there.
01:24:41But then on the flip side and this is
01:24:44something I feel probably should be
01:24:46taken into consideration more often,
01:24:48like when I've had black patients
01:24:50who are like so so so incredibly,
01:24:52just like grateful for the fact that I'm
01:24:54part of their clinical team and may eat,
01:24:57I mean, and even sometimes.
01:24:59Not even back,
01:25:00just like patients who are very
01:25:02appreciative of like whatever I've like
01:25:05contributed to their care during during
01:25:07my time and they make great comments.
01:25:09Sometimes that does end up in my
01:25:11that has ended up in my evaluation
01:25:14like oh like a family member.
01:25:16Like said great things about Max like
01:25:18that kind of stuff so I think it can
01:25:20work in both direction like patients
01:25:22are grateful for for one student
01:25:25participation and it ends up in the in
01:25:27your eval or you know when patients.
01:25:30Are not cool with you being part
01:25:33of their team and it's sort of an,
01:25:35especially if it doesn't go address.
01:25:37Then it creates more distance
01:25:38and tension within a team.
01:25:42Thank you Sir, you know so the the
01:25:44time went by very quickly and then
01:25:46we had lots and lots of questions.
01:25:49There's lots of questions that I
01:25:51didn't get to but I want to save.
01:25:53I've got one minute here left an I
01:25:55want to use a little bit of it to
01:25:58remind the folks who are watching that.
01:26:00We have several more excellent
01:26:02programs coming up.
01:26:03Please do check the website,
01:26:04but about this talk.
01:26:06I want to absolutely thank you
01:26:07Max for this for this presentation
01:26:10for this conversation.
01:26:11And certainly wish you great success
01:26:12as you head to Boston briefly for
01:26:15residency before you come back.
01:26:16Here, you know with us down the road,
01:26:19and in the meantime,
01:26:20perhaps if you'd like 'cause we
01:26:22talked about the ethical case for
01:26:24structural change and you have
01:26:26made a good case for structural
01:26:28change and given us very,
01:26:29you know, several good examples.
01:26:31But I I want to ask you this,
01:26:33if you could say.
01:26:34And I don't mean to put you on the spot,
01:26:38but that's my job.
01:26:39Here is modern railway OK?
01:26:40If there's one thing?
01:26:42That you would like to see.
01:26:44The faculty now I'll speak
01:26:46for the faculty for moment.
01:26:47Here's one thing I wish the faculty
01:26:49would address to move us Tord.
01:26:50Improving the situation.
01:26:51Tord structural change is there
01:26:53one thing that stands out for you,
01:26:54and you do not see that?
01:26:56Sorry, that's not fair.
01:26:57I see that.
01:26:58Look on your face, say, give me a break.
01:27:00If there's one thing.
01:27:01For example,
01:27:01if you want to say you guys should
01:27:03pay the bioethicists a lot more.
01:27:05I mean,
01:27:05I think that's one thing that
01:27:07you might want to suggest,
01:27:08but there might be other
01:27:10things as well.
01:27:10You know this is OK, I I don't know,
01:27:13this is necessarily specific to the faculty.
01:27:15It may be just like a medical school white
01:27:17thing and I'll send it account, yet right?
01:27:20So if you looked at the match list last week,
01:27:22you know beautiful phenomenal match list.
01:27:24I am the only one out of 91 people
01:27:26who match into a primary care track,
01:27:29and I'm not even sure that I want
01:27:31to be a primary care provider.
01:27:33I I just liked I applied both
01:27:35categorical and traditional internal
01:27:36medicine and and will be going and
01:27:38ended up liking the just like what
01:27:40was presented to me on Interview Day.
01:27:42More on the primary care and
01:27:44a lot of the primary care.
01:27:46Programs one right versus I don't know
01:27:48nine people going to optomology and
01:27:51seven people going into dermatology
01:27:52and and and so 6-7 people going
01:27:55into a orthopedic surgery.
01:27:56So I think specific to here.
01:28:00I feel like as a medical school we really
01:28:03need to rethink like what is our like?
01:28:06What do we owe society right?
01:28:07Like graduating almost 100 medical students,
01:28:09an one person going into primary
01:28:11care and who doesn't even know they
01:28:14want to be a primary care provider
01:28:16and the implications in terms of
01:28:18like as I mentioned earlier,
01:28:19right earning potential those kinds
01:28:22of things like an what it means for
01:28:25like the Community which we serve.
01:28:27We really need to rethink right?
01:28:29Like we don't have a family
01:28:31medicine Department.
01:28:32We we make almost no effort in terms
01:28:34of like letting students know that like
01:28:37primary care is something that you
01:28:40should consider pursuing right like.
01:28:42That's something that's been on my mind.
01:28:44There are many more things,
01:28:46but that something that is like very stark.
01:28:48But I thought
01:28:49I should share. If you know very good.
01:28:51Thank you very much and thank
01:28:53you so much for tonight.
01:28:55In in closing I do want to mention,
01:28:57as you know somebody who's been
01:28:58an important part of the bioethics
01:29:00scene at Yale, and in fact,
01:29:02nationally and internationally.
01:29:03Who is our friend Robert Levine,
01:29:05who passed away recently and
01:29:06many of people on this call.
01:29:08No doctor Levine.
01:29:09He was very helpful for this
01:29:10program getting started.
01:29:11Very helpful to me as I was
01:29:13getting started in bioethics.
01:29:15But people all over the country
01:29:16and all over the world are familiar
01:29:18with his work related to clinical
01:29:20research and even things that we
01:29:22study going way back to the Belmont
01:29:24Report and things that we look back.
01:29:26And in the very early days of
01:29:27bioethics in the United States,
01:29:29Doctor Levine Play an important role
01:29:31and helped so many people here at Yale.
01:29:33Now the positive impact on our
01:29:35field and on so many patients
01:29:36as a result of his work.
01:29:38So I certainly want to take a
01:29:40moment to acknowledge Doctor Levine
01:29:42and for his kindness and for his
01:29:44great contributions and to express
01:29:46our sympathies to his family.
01:29:48And with that,
01:29:49I wish you all good night Max Jordan again.
01:29:52Thank you so much and we wish you
01:29:54terrific success and will see you
01:29:56folks again in a couple of weeks.
01:29:58Goodnight
01:29:58to my career.