Yale Psychiatry Grand Rounds: March 17, 2023

Transcript

• 00:00To. To Connecticut and for
• 00:03the kind introduction,
• 00:05I'm going to go ahead and.
• 00:07Share my slides and get started.
• 00:09Can books give me a thumbs up that
• 00:11you can see the slides? Great.
• 00:14So throughout my presentation,
• 00:16there's a QR code embedded
• 00:19at various points throughout.
• 00:21If anybody's interested in some
• 00:23of the references or specifics,
• 00:25the QR code takes you directly to
• 00:27a web page that has some key and
• 00:30seminal articles that I referenced
• 00:33throughout my presentation.
• 00:35Just a basic series of disclosures,
• 00:38I would say.
• 00:39My disclosure today is that
• 00:41I am quite sleep deprived.
• 00:44I'm also excited and nervous about the
• 00:47match celebrations this afternoon.
• 00:52So I want to start with the poem.
• 00:53This is an excerpt from a poem
• 00:56by Warson Shire. Who writes?
• 00:59Later that night, I held an Atlas in my lap,
• 01:03ran my fingers across the
• 01:06whole world and whispered.
• 01:08Where does it hurt?
• 01:11It answered. Everywhere.
• 01:15Everywhere.
• 01:18Everybody.
• 01:22I share these words to acknowledge and
• 01:24honor the fact that all of us all succeed,
• 01:27of us that have come together
• 01:28in this virtual space today.
• 01:30Are joining with various kinds of hurt.
• 01:34Today is the first grand round since the
• 01:36passing of our friend and colleague Dr.
• 01:38Fortunati, and I think
• 01:39we have to acknowledge.
• 01:41The heaviness and the complexity
• 01:44of grief as a nonlinear process to
• 01:48acknowledge the match and all the
• 01:50things that it encompasses for people
• 01:52early in their career who put their
• 01:54faith in an algorithm hoping to match
• 01:57the right place that honors them.
• 02:00But I also want to honor that the past
• 02:02few years, for many have not been.
• 02:05A time without hurt.
• 02:07It's been a time of tremendous pain
• 02:09and and challenge and difficulty.
• 02:12People rising up, speaking up.
• 02:14But also people hurting.
• 02:16So wherever you're at and however
• 02:18you're feeling,
• 02:19I encourage you to enter this space today,
• 02:22honoring your complex emotions
• 02:24and your humanness.
• 02:29So we want to start off by telling
• 02:32you a little bit about my story.
• 02:34I am the child of immigrants from
• 02:37Pakistan to Canada in the 1960s and 70s.
• 02:40I'm the child of the City of Toronto,
• 02:42where I grew up in a. Well,
• 02:44we would call it very multicultural milieu.
• 02:48And I'm the child who, in my early 20s,
• 02:51experienced the 9/11 attacks in a way
• 02:54that was a watershed moment for my
• 02:57identity as someone who's racialized.
• 03:01With the Muslim faith background.
• 03:03I would argue that 9/11 was a moment
• 03:06where many like me lost our whiteness.
• 03:09We instantly had to contend with
• 03:12the experience of being someone
• 03:14who was afraid of being harmed
• 03:16by political violence, but also.
• 03:19Afraid that someone sitting next
• 03:21to us might think that we are
• 03:24perpetrators of such violence.
• 03:26And for me,
• 03:27as a child of immigrants who watched
• 03:29my parents experience a lack of
• 03:32advancement in their careers,
• 03:34related directly to various forms of
• 03:37structural racism and colonial trauma.
• 03:40And someone who watched them
• 03:42internalize that.
• 03:43That moment in my 20s was
• 03:45a very important moment.
• 03:46And what I did back then was I went
• 03:49out into the world and became very
• 03:51interested in equity and issues globally.
• 03:55Eventually imagining myself
• 03:56is pursuing a perhaps an MPH,
• 03:59but taking the MCAT and having a
• 04:02a flyer fall into the mail about
• 04:05a new school in global health
• 04:07at Bangor University in Israel.
• 04:10I could give a whole talk about
• 04:11that experience,
• 04:12but that's where I trained and
• 04:13through twists and turns ended
• 04:15up in Rochester at a time in the
• 04:17the history and story of America.
• 04:19That was a time of hope.
• 04:21And then recruited back to Canada,
• 04:23which was a health system that
• 04:25I had idealized and held up on
• 04:28a pedestal for much of my life.
• 04:30So I found myself an early career
• 04:32psychiatrist with deep interests
• 04:34in medical education and at times
• 04:36disparate interests in global health,
• 04:39cross cultural medicine and HealthEquity.
• 04:42Having spent time with different
• 04:44forms of organized medicine,
• 04:46but then finding myself in practice
• 04:48working as a child psychiatrist in a
• 04:51busy academic Health Science center.
• 04:54And this headline is from March 2014,
• 04:57almost 10 years ago.
• 04:59Because what I came face to face with
• 05:02was a system where one of the biggest
• 05:04equity issues was hitting me in the face.
• 05:07That was the inequitable way
• 05:08in which we treat people,
• 05:09particularly in general and acute
• 05:12settings whose struggle with mental
• 05:16illness or addiction I've watched,
• 05:19you know,
• 05:19in my early career system where
• 05:21someone was 18 and built up
• 05:23the courage to ask for help,
• 05:25they could be waiting on a stretcher
• 05:28in a hallway for weeks before
• 05:31our bed would become available.
• 05:34But most importantly,
• 05:35I watched how many times these patients,
• 05:38these young people I served,
• 05:40were consistently dehumanized,
• 05:42blamed and shamed by those
• 05:45who work in the system.
• 05:49And I realized that the people who
• 05:52were doing this were people like me.
• 05:55In watching them, in many ways,
• 05:58I was looking in a mirror at myself.
• 06:01Someone who is becoming desensitized
• 06:03to the pressures of practice.
• 06:05And compartmentalizing more and more.
• 06:08So I did what I did.
• 06:09For moments of my life,
• 06:10I leaned into it. At the time,
• 06:13we began looking at these processes of
• 06:16bias against people with mental illness.
• 06:19We looked at the social process of
• 06:21different forms of stigma in these settings,
• 06:24and what was clear to us what was
• 06:26happening when we studied it was
• 06:28when someone walks in the door and
• 06:30implicitly will gets attached to them.
• 06:32That label though.
• 06:35Could be that they're dangerous
• 06:37and unpredictable.
• 06:38It could be that they are.
• 06:43Time consuming and a system that
• 06:46prioritizes time and efficiency.
• 06:48But what was most interesting was that
• 06:50they were labeled as being unfixable in
• 06:52a system that prioritized quick fixes.
• 06:55And because well, meaning health
• 06:57professionals like to feel useful.
• 06:59That label would lead to an
• 07:01avoidance behavior.
• 07:02People wouldn't go in the room.
• 07:03There was a discomfort.
• 07:05But of course,
• 07:06in the same research,
• 07:07we looked at how patients and
• 07:09caregivers perceived this labeling,
• 07:10and they shared that that avoidance
• 07:13feels like judgment and discrimination.
• 07:16But at the end of the day,
• 07:17everyone,
• 07:17including patients and those
• 07:19working in the system,
• 07:21felt a sense of powerlessness
• 07:24and helplessness.
• 07:25And this cycle just kept turning and turning.
• 07:31Part of what became clear to
• 07:33me in the early days of these
• 07:36different lines of inquiry.
• 07:38Was it the ways in which we talk
• 07:40about things like discrimination and
• 07:42prejudice and the current paradigms
• 07:44for teaching and training were built
• 07:47on an entirely flawed assumption,
• 07:49that being that,
• 07:50you know,
• 07:50the problem resided in another
• 07:53group that's not us,
• 07:54not the 79 of us that are here today,
• 07:57that the bad people,
• 07:59the people who might be discriminated.
• 08:02And that perhaps we intervene by putting
• 08:04all of those people in a workshop
• 08:07or forcing them to take a module.
• 08:11Without appreciating or holding up the
• 08:13mirror to ourselves and our systems.
• 08:16The problem with the that existing
• 08:18way of approaching teaching and
• 08:20learning about these topics is what
• 08:22we're seeing in many cases today.
• 08:25Burning so much energy and
• 08:29worsening polarization.
• 08:31So my work started with that simple idea.
• 08:33What happens if,
• 08:34instead of burning that energy,
• 08:36we hold up the mirror to
• 08:39ourselves and our systems?
• 08:41How can we reconcile the knowledge
• 08:43that we are part of this harm,
• 08:46but we can also be part of healing?
• 08:56So in one of our earliest studies,
• 08:57we did that. We held up the mirror to
• 09:00health professionals and looked at how they
• 09:03processed and integrated feedback about
• 09:06the fact that they indeed were biased.
• 09:08And why this study was a very
• 09:11important study, not just for me
• 09:14professionally but personally,
• 09:15is because until this study I had always
• 09:18really anchored myself to this idea
• 09:20that it was about humanizing each other.
• 09:23That if we could begin to connect to
• 09:26one another at a human level and see
• 09:28the things that we have in common,
• 09:31that perhaps these bridges can be built.
• 09:35But what we found when we held up the mirror
• 09:37is that instantly health professionals said,
• 09:39well, no, that's not even possible,
• 09:42that you can give me feedback that
• 09:44I'm biased because professionals,
• 09:46which we can't have bias,
• 09:47we're professionals.
• 09:49But at the same time,
• 09:50they said both.
• 09:51Of course we had bias because
• 09:53we're human beings too.
• 09:55And why this finding struck me so deeply?
• 09:58Was that it highlighted
• 10:01that compartmentalization,
• 10:02which at times could have been an
• 10:05adaptive defense mechanism in many
• 10:08ways has become quite maladaptive.
• 10:11If you know we believe that humanizing
• 10:13one another is part of the way,
• 10:15we move forward to heal.
• 10:18This research helped me appreciate that
• 10:21there's something about our culture,
• 10:23particularly in medical and health education.
• 10:28That actually encourages us.
• 10:31To dehumanize ourselves.
• 10:34And compartmentalize our independence
• 10:36that perhaps there's something much
• 10:39deeper that we have to contend with
• 10:41before we can do anything else.
• 10:45So as we began to engage deeper
• 10:47and did further research,
• 10:49we held up the mirror to people like
• 10:52us who actually work in mental health.
• 10:55And we held up the mirror about our
• 10:57biases about people with mental illness
• 10:59because we wanted to understand when
• 11:01someone really prides themselves on
• 11:02being of service to a certain group or a
• 11:06certain identity or certain population.
• 11:08And they have to come to terms with the
• 11:10fact that they may not be so special.
• 11:12How do they work through that?
• 11:16So through this series of studies we did,
• 11:18we found something very fascinating and it
• 11:20was a paradox in the feedback literature.
• 11:22Now there's a a broad literature
• 11:24on feedback in medical education.
• 11:26And what it highlights is that
• 11:28we're not supposed to give people
• 11:30feedback about themselves or anything
• 11:32that relates to who they might be.
• 11:34We are encouraged to give
• 11:35people feedback on what they do.
• 11:37And the reason for that is
• 11:39because there's a long standing
• 11:40research which highlights that.
• 11:42Any feedback?
• 11:43About someone that relates to what they
• 11:46think about themselves or the self.
• 11:49Actually hijacks the feedback process.
• 11:51It's so difficult to reconcile that it
• 11:54leads people to question the credibility
• 11:57of any such feedback and not perceive
• 12:00feedback about the self as action.
• 12:03But what we found in our work
• 12:05was that actually feedback about
• 12:07bias was a form of feedback that
• 12:09people question the credibility.
• 12:11They tore it to pieces.
• 12:13Yet for some reason it was
• 12:16still perceived as actionable,
• 12:17and that's something that's very
• 12:19important for us to consider.
• 12:23Overall,
• 12:23much of that early work highlighted
• 12:26that how we talk about these
• 12:29issues that have proliferated and
• 12:32become buzzwords in healthcare
• 12:35and education today matters.
• 12:37If we continue to treat learners in
• 12:40a manner that pushes them towards an
• 12:43impossible version of themselves.
• 12:45Maybe there's going to be unintended
• 12:48consequences if we continue to load
• 12:50more and more and more different
• 12:52things like modules or exercises,
• 12:55without consideration of the
• 12:57cognitive and emotional load that
• 12:59this plays on individuals,
• 13:01ultimately our efforts may not be successful.
• 13:07The other thing that we learned related
• 13:10to how individual education and social
• 13:13processes of discrimination and prejudice
• 13:16relate to systems and structures.
• 13:19In this study, we followed individuals
• 13:22longitudinally within a specific clinical
• 13:25learning environment after raising
• 13:27critical awareness about their biases.
• 13:30So in this context,
• 13:32which was an emergency department,
• 13:34where we know that there's a quick fixed
• 13:36culture and an implicit assumption that
• 13:38people with mental illness are unfixable
• 13:41with an implicit avoidance behavior
• 13:43and helplessness and frustration.
• 13:45Just making people aware of their biases.
• 13:51Actually, might not be the greatest thing.
• 13:54And that's because increasing recognition
• 13:56or awareness of such biases actually
• 14:00creates a significant amount of dissonance.
• 14:03And helplessness.
• 14:05That contributes back to the helplessness and
• 14:09frustration that underpins this whole cycle.
• 14:12If all we say to people is yes,
• 14:13there may be ways in which you enact harm.
• 14:16And that might be unconscious,
• 14:18and that might be something
• 14:19you might not be aware of,
• 14:21or you might be trying to address
• 14:23and it might not be enough.
• 14:25That simply makes people likely
• 14:28to check out and say, well, what?
• 14:31What's the point then,
• 14:32if there's nothing I can do about this?
• 14:35However.
• 14:36If you couple that with active skill
• 14:41building and behavioral strategy,
• 14:43something different happening.
• 14:44So many of these participants and you
• 14:46know this is all great and we recognize
• 14:48that there's a moral imperative to do better.
• 14:51But you know we're metrics and there's
• 14:53all these structural region reasons
• 14:55why this won't be sustainable.
• 14:56Yet when we encouraged specific
• 14:59behavior change and in this case
• 15:02it was encouraging engagement and
• 15:04empathic engagement and being.
• 15:06Prior, prior,
• 15:07pre aware of that tendency to avoid.
• 15:11That engagement led to critical
• 15:13reflection about these assumptions
• 15:15and really push and foster the idea
• 15:18that mental illness was a shared
• 15:20responsibility across all systems.
• 15:22But what we saw longitudinally,
• 15:24that was really fascinating,
• 15:25was that if people began to
• 15:28share an explicitly role model,
• 15:30a different kind of behavior.
• 15:33They begin questioning structural
• 15:35factors in the system itself.
• 15:38And in this particular study,
• 15:40they actually began questioning things
• 15:42like the triage policy and the tools
• 15:45and the scales that were being used,
• 15:47and began to argue and advocate
• 15:49that those be changed because the
• 15:51system and the structures themselves
• 15:53were actually stigmatizing,
• 15:55and that those structural determinants
• 15:57reinforced stigmatization of
• 15:58the individual level.
• 16:02The model that came out of our
• 16:04research really highlighted that
• 16:05none of this work is a checkbox or,
• 16:07you know, a module. Like I say,
• 16:09it has to start with the acknowledgement
• 16:12that we can strive to do it as
• 16:14best as we can, but at the outset,
• 16:17acknowledge and embrace the fact that
• 16:19we will stumble more than we strive.
• 16:22And that we just have to keep working on it.
• 16:25And pick ourselves up and keep going.
• 16:28But it also recognizes this is an arduous
• 16:30cycle that includes holding up the
• 16:33mirror and includes critical reflection.
• 16:35But it actually includes changing what we do.
• 16:38Doing things differently.
• 16:41Yet at the heart of it was that
• 16:44this work resonated and stuck in
• 16:47certain settings and not in others.
• 16:49The secret sauce was how we
• 16:52looked at our teams.
• 16:54If teaching and learning happened
• 16:56with people across disciplines,
• 16:58with people who work together,
• 16:59learning together.
• 17:00And if that team opened up,
• 17:03their ability to be open and vulnerable
• 17:06about wanting to be better than
• 17:08members of the team actually became
• 17:11social reinforcers for change.
• 17:16So that's how I kind of started tiptoeing
• 17:19into these topics academically. But I
• 17:22wanna also tell you why I'm really here.
• 17:26I want to bring in now Doctor Javeed Sukhera.
• 17:29He is the Chair of London
• 17:31Police Services Board,
• 17:32and we've reached him in London.
• 17:34Doctor Sequeira, thank you
• 17:34so much for joining us, Sir.
• 17:37Thank you so much for having me.
• 17:38Let me begin by saying, of course,
• 17:40that we are all so deeply sorry
• 17:42for what your community is going
• 17:44through and how you've been forced
• 17:46to to deal with this tragedy.
• 17:48I wonder, with the people that you're
• 17:50speaking with and and in your role,
• 17:52what is the conversation like right now?
• 17:56It's tough, it's unfathomable.
• 17:58I think, for for me personally,
• 18:00our our family had a personal
• 18:02connection to the deceased,
• 18:03which takes this to a whole other level,
• 18:05the kinds of conversations I have
• 18:07to have with my young children.
• 18:09But also the conversations
• 18:10we're having as a community.
• 18:11I think there's an outpouring of
• 18:13love and support and solidarity,
• 18:15which is great,
• 18:16but I wish to remind my friends and
• 18:19neighbors to not look away from the hate
• 18:22that contributed to this incident. I.
• 18:27On the evening of June 6th,
• 18:302021 it was a warm summer day
• 18:32where I used to live in London ON.
• 18:34And family, friends of ours,
• 18:36one of the first families
• 18:37we met when we moved there.
• 18:39Family with a young son that was
• 18:41similar to my son and a daughter that
• 18:44was similar to my daughter in age.
• 18:46Kids who played together.
• 18:47Went out for a walk.
• 18:51And that. Individual in a black
• 18:54pickup truck who was driving
• 18:57through the streets of the city.
• 18:59And explicitly espoused a white
• 19:03supremacist agenda is looking for
• 19:05people who look like us to kill.
• 19:08He ran over our family friends,
• 19:11killing four of five of them,
• 19:13three generations.
• 19:14And horrific hate crime that
• 19:16took place not too far from my.
• 19:21Waking up the next day due to
• 19:23the role that I had at the time.
• 19:25Working and civilian
• 19:26oversight of police services.
• 19:29Knowing that something horrible
• 19:30and tragic had happened.
• 19:32Feeling my own gut react in
• 19:35ways I had never experienced,
• 19:38but then learning from my
• 19:40daughter who was 13 at the time.
• 19:43That one of the people who
• 19:44were killed was her friend.
• 19:48I want to bring I'm not here
• 19:51simply because this is an academic
• 19:55exercise or a topic that relates.
• 19:59To scholarly publications or grants.
• 20:02I am here because this is a topic
• 20:05that is deeply personal to me.
• 20:09And many. In our communities.
• 20:13And I think we have to contend
• 20:15with that fact if we are to
• 20:17talk about it with anybody else.
• 20:21So why are we here?
• 20:22Why are we? As a department,
• 20:26as a community talking about this right now.
• 20:30This moment in history,
• 20:31when we know that the heat of these
• 20:35fires has been burning for centuries,
• 20:37why are we here now?
• 20:39Why does it matter?
• 20:42I would argue that we are here
• 20:46because we have to awaken.
• 20:48From the illusion.
• 20:51Of our separateness.
• 20:55The fires that are burning,
• 20:57that are being fanned and flamed
• 20:59in this country and many others,
• 21:01they're reaching our front doors.
• 21:04Many of us have already been burned.
• 21:07But if we think that we are different
• 21:10or special or unique or that we
• 21:13somehow have figured this out.
• 21:14We really.
• 21:16Need to critically reflect
• 21:19on those assumptions.
• 21:20For many in racialized communities.
• 21:24There's a different form of trauma when
• 21:27you know that your humanity doesn't matter.
• 21:30And then you watch people you
• 21:33know awaken to your humanity
• 21:35when they see people like you.
• 21:38Being murdered.
• 21:43And if we think about how we've
• 21:46talked or addressed topics such as
• 21:50these within our hallowed halls,
• 21:52our systems, and our settings,
• 21:54including the place I now work.
• 21:57We have to recognize that there
• 21:59are many individuals who have
• 22:01experienced consistent gaslighting,
• 22:03meaning being told that their experiences
• 22:07of discrimination aren't real or true.
• 22:09And what I would call consistent
• 22:12toxic positivity being demonized
• 22:14and denigrated for simply breaking
• 22:17up the topic of things like racism.
• 22:21And watching while the racism
• 22:23itself continues to go unchecked.
• 22:28As these words and topics become buzzwords.
• 22:32It's essential for us at this
• 22:35moment to recognize the difference.
• 22:38Between fostering diversity
• 22:41or fostering inclusion.
• 22:44And the ideas related to
• 22:47liberation and justice.
• 22:49The ability for members of our communities
• 22:52to come into clinical learning and
• 22:55working environments in their full self.
• 22:59Without having to consistently code switch,
• 23:02we're self censored.
• 23:04And feel embraced,
• 23:05just as they would if they were
• 23:07part of the social cultural norm.
• 23:12There are two studies that we
• 23:14participated in that I want to draw
• 23:16your attention to that highlight some
• 23:18of these tensions and challenges.
• 23:20The first I was senior author on and
• 23:23we did a critical discourse analysis
• 23:25of statements that were put out after
• 23:28the merger murder of George Floyd from
• 23:31academic medical units organizations,
• 23:33including medical schools,
• 23:35hospitals and different organizations
• 23:37in the US and Canada.
• 23:40Not surprisingly,
• 23:42our analysis showed that most of
• 23:47such statements included pictures
• 23:49of smiling Deans.
• 23:51And a consistent kind of self
• 23:54congratulatory rhetoric about how
• 23:55great that department or unit
• 23:58or hospital was at these issues.
• 24:00Many read like laundry lists
• 24:03of accomplishments.
• 24:05But what was fascinating was.
• 24:08That historically black colleges
• 24:10did not read like that.
• 24:13And in healthcare,
• 24:14the statements pointed to racism
• 24:17and policing is a problem,
• 24:19with very few actually holding
• 24:21up the mirror acknowledging that
• 24:24people die in our hospitals every
• 24:26day because of racism.
• 24:29The other study on the right was one
• 24:32where we did a critical discourse
• 24:34analysis of discrimination and
• 24:36harassment policies in medical
• 24:38schools across Canada.
• 24:40The implications of this work are
• 24:42really helping reshape the way higher
• 24:44education is approaching these issues,
• 24:46because what we learned was that
• 24:49existing policy based approaches
• 24:51to addressing these issues
• 24:53largely center the self protection
• 24:55of organizations themselves.
• 24:57And the language includes largely
• 25:01self protective discourse with
• 25:03some discursive tensions.
• 25:06For example,
• 25:07policies described how everyone
• 25:09has a shared responsibility to be
• 25:12free from discrimination without
• 25:14really specifically holding people
• 25:17with structural leadership roles
• 25:19in such organizations accountable.
• 25:21This course also puts an onus of
• 25:25responsibility and credibility
• 25:26on people who complained.
• 25:28Putting undue burden on individuals who,
• 25:31not surprisingly,
• 25:32tend not to report such instances
• 25:34because they haven't found trust
• 25:36in systems to support and react.
• 25:41So if we think about the context
• 25:42in which we do this work,
• 25:44we have to recognize the cultural
• 25:47norms of medical education
• 25:50and training really are.
• 25:52A system where professionalism means
• 25:55subservience within a hierarchy.
• 25:57And the perfectionism I spoke of earlier,
• 26:00the dehumanization and subservience,
• 26:02essentially contributes
• 26:03to a culture of silence.
• 26:10So I'm not here to just talk about
• 26:12where we've been, where we are.
• 26:14I'd also like to share a few insights about
• 26:17where we can potentially go from here.
• 26:22We want to break the silence.
• 26:24We have to speak up,
• 26:25but advocacy conducted within our settings
• 26:30is generally perceived as disruptive.
• 26:33In this study by my colleague Dr.
• 26:35Ladonna and others,
• 26:36they looked at how patient
• 26:39advocates view health advocacy
• 26:41compared to physician advocates.
• 26:44And what was fascinating in this
• 26:45work is that for patient advocates,
• 26:48advocacy was seen as essential.
• 26:50It was about their lives.
• 26:53Whereas physician advocates viewed
• 26:55advocacy as inherently disruptive.
• 26:58And they were acutely aware that
• 27:00by speaking up or advocating,
• 27:02they were going against a
• 27:04culture and taking a risk,
• 27:06which is why many do it
• 27:08largely in the shadows.
• 27:12I should say a trigger and content warning,
• 27:14but I want to share for you some of.
• 27:17What was disruptive about my
• 27:20speaking up vocally about anti
• 27:22Muslim prejudice both before and
• 27:25after the tragedy that I described,
• 27:28giving everyone example of the large
• 27:30amounts of hate that get directed
• 27:33towards individuals who speak up?
• 27:35And this is nothing compared
• 27:37to what women experience,
• 27:38particularly racialized women who
• 27:42encounter largely disproportionate amounts
• 27:45of hateful backlash for speaking up.
• 27:48For contributing feedback.
• 27:53So if we think about where we go from here.
• 27:58I think we can anchor ourselves
• 28:01into the richness of some of the
• 28:04work we do and some of the diverse
• 28:06ways in which we see the world.
• 28:09Much of what we do in psychiatry
• 28:12has often been focused on coping.
• 28:14But we also know about healing.
• 28:17We know that if things are to transform,
• 28:21there has to be a dialectic
• 28:24where we hold disruption.
• 28:26And dialogue in each hand as we move forward.
• 28:32And I recognize that this is a private
• 28:34approach that that resonates with me.
• 28:36And I recognize it does so because
• 28:38I've always been an insider in a system
• 28:41in many ways as a positive, deviant,
• 28:44pushing and advocating for change while
• 28:47working with and alongside communities,
• 28:51particularly activist communities
• 28:54outside of powerful organizations.
• 28:57Ultimately,
• 28:58change at a neurobiological level
• 29:02has to be informed by science.
• 29:06And I would argue as a as
• 29:09an education scientist,
• 29:10it has to be informed by social
• 29:13and behavioral sciences.
• 29:15If all we do is fall back
• 29:18into a coercive cycle.
• 29:20We're power becomes intoxicating,
• 29:22and we seek only to surround ourselves.
• 29:26With similar thinking or similar
• 29:30approaches and don't seek to Co
• 29:33create or Co construct solutions,
• 29:35I would argue that we aren't
• 29:37simply going to move forward.
• 29:40But if there's anything that my work
• 29:42does far has taught me above all else,
• 29:45it is about the importance
• 29:47of self compassion.
• 29:48All of us live and work in cultures
• 29:51where sleep deprivation is often
• 29:52held up as a metal where we can
• 29:55tend to fall into cycles of self
• 29:58cleaning and self guilt so easily.
• 30:01So if we want to change systems,
• 30:03we really have to learn about
• 30:05our own boundaries.
• 30:06Learn about the importance and
• 30:09the revolutionary power of rest.
• 30:11But it requires consistently
• 30:14practicing self compassion,
• 30:16self forgiveness,
• 30:17and self validation as an
• 30:20essential ingredient of this work.
• 30:25Two areas that we're working on
• 30:26here that I want to share with you
• 30:29include feedback and role modeling.
• 30:31As I shared earlier,
• 30:32looking and understanding how we have
• 30:35feedback conversations is a big part of
• 30:37of the model that we initially explored.
• 30:40More recently, we've been conducting
• 30:43a study funded through the Royal
• 30:45College of Physicians in Canada,
• 30:46which is like the ACG ME here.
• 30:49Where we've been looking at how we
• 30:52have feedback conversations that are
• 30:54emotionally charged about equity.
• 30:55Discrimination and prejudice in
• 30:58different professional cultures.
• 31:00And we're exploring it in teaching,
• 31:02education, pre service teachers,
• 31:05nursing education and medical education.
• 31:09What's been very fascinating about this
• 31:11work is that there may be similarities
• 31:14about teaching and learning or such
• 31:17conversations at a surface level.
• 31:19But as we dig deeper into the deeper and
• 31:22more implicit aspects of this pedagogy,
• 31:25there's clear differences.
• 31:28Conversations that are emotionally
• 31:30charged about equity.
• 31:32In health,
• 31:33professions largely exist with
• 31:35an emphasis on boundaries.
• 31:37And a desire to keep things under control.
• 31:41And it's taught by imparting
• 31:43knowledge and skills while seeking
• 31:45objectivity and neutrality,
• 31:47with the idea that expertise
• 31:49in equity is challenging.
• 31:51Whereas in teacher education,
• 31:53there's general appreciation of
• 31:56creating and Co creating space,
• 31:58creating knowledge it's enacted or taught
• 32:01by shifting or influencing interpretation,
• 32:04and there's consistent questioning
• 32:07of the myth of neutrality.
• 32:10It's interesting that teachers always
• 32:13believe that experience or live
• 32:16experience are part of expertise.
• 32:18Nursing educators say,
• 32:19well,
• 32:19we we need to bring equity experts
• 32:21because we don't have equity experts.
• 32:23So let's bring external people who
• 32:26are experts in equity to teach.
• 32:28And Medicine reckons with the
• 32:30fact that we're so used to being
• 32:33experts at everything we do.
• 32:35That we don't even know where to start
• 32:36if there's something we're not an expert.
• 32:40One of the most fascinating findings of
• 32:42this work is about the role of emotions.
• 32:45We're finding that in nursing,
• 32:47emotions tend to be avoided or neutralized.
• 32:52In medicine, motions on the surface
• 32:54are validated and normalized,
• 32:56but still perceived as something
• 32:58that's an obstacle to learning.
• 33:00Whereas in teacher education,
• 33:01emotions are an intrinsic
• 33:02part of teaching and learning.
• 33:06The other area that we're
• 33:08continuing to do some work is
• 33:10around the idea of role modeling.
• 33:12And on that note, what I want to share
• 33:14with you a little bit of what it's been
• 33:16like for me in the past 18 months,
• 33:17taking on this very fascinating,
• 33:19interesting role that I never imagined
• 33:21I would ever do in my career,
• 33:23I was working 50% protected as
• 33:26a scientist and scholar activist
• 33:29and 50% clinically in a pediatric
• 33:31chronic pain program when by accident
• 33:34someone forwarded my information
• 33:35to the folks here in Hartford.
• 33:38And it took me a long time to be
• 33:41convinced to uproot my family.
• 33:43But as you can see with these images,
• 33:45there's something a little bit
• 33:47different about me compared to
• 33:49some of my predecessors.
• 33:51And I think that's something that I
• 33:53speak of very openly with my teams
• 33:55and those that work in the organization,
• 33:58which is an acknowledgment that
• 34:00this beautiful office and and shelf
• 34:02ladder behind me.
• 34:03Is a space that someone that looks like
• 34:06me simply would not have been welcome.
• 34:08Not that long ago.
• 34:10So in this context,
• 34:12when I've been afforded as the
• 34:15opportunity to take some of this work
• 34:18and research I've done and really
• 34:20translate it towards implementation.
• 34:22Much of our work really highlights
• 34:25that moving forward requires.
• 34:27A few key ingredients.
• 34:30One is enhancing agency's choice and
• 34:33the ability of people to be informed
• 34:35and make decisions without feeling coerced.
• 34:38But the other is role modeling vulnerability.
• 34:42And really making sure that there's
• 34:44space to talk about teaching,
• 34:47learning,
• 34:47and humility without getting in trouble.
• 34:51And the third is Co designing interventions
• 34:54and evaluation with everything you do.
• 34:59We translated some of this work,
• 35:01I can't get into detail,
• 35:02but into a framework that we called
• 35:05shared humanity that's available
• 35:07online@sharedhumanity.ca which
• 35:08actually works through some of
• 35:11these areas looking at trust,
• 35:13power and humanity and
• 35:15clinical learning environments.
• 35:16And it's work that is evolving
• 35:18in a good resource,
• 35:20for example for medical and other
• 35:22health professions learners.
• 35:25One of the examples of what
• 35:27we've been doing here has been on
• 35:29the topic of microaggressions,
• 35:30which I know is an area that the
• 35:32Yale Department has prioritized,
• 35:33and I've had a chance to go through
• 35:35some of the incredible work,
• 35:36including the modules that have
• 35:38been developed in this area.
• 35:40What I would argue,
• 35:41and what we're trying to do with the AOL is,
• 35:43is to recognize that that is extremely
• 35:46important, that we're educated,
• 35:47that we understand what this
• 35:49is and what to do,
• 35:50so that we don't remain silent.
• 35:53But we also need to think about prevention.
• 35:57So based on some research,
• 35:59by now a PhD student doctor,
• 36:02Justin Bullock,
• 36:02who had the honor of being
• 36:04one of his supervisors,
• 36:06we're implementing something
• 36:07called the pre brief conversation.
• 36:10The pre brief is a preventative
• 36:13conversation in clinical working and
• 36:15learning environments where members of
• 36:18a team are encouraged to acknowledge
• 36:21that microaggressions do happen.
• 36:23And that.
• 36:24We strive to be aware and sensitized by them,
• 36:28but what the previous provides is
• 36:30for a teacher and learner at varying
• 36:33degrees of power in that dynamic
• 36:35to acknowledge our humanness and
• 36:37how we may be affected by such
• 36:39microaggressions and how we would
• 36:41want team members to respond.
• 36:43A microaggression pre brief can
• 36:45be as simple as you know.
• 36:47We know that this happens and this is
• 36:49a topic that makes me very uncomfortable,
• 36:52but I will strive to send to you.
• 36:54If there's anything that happens,
• 36:56and I want to acknowledge that this
• 36:58is the kind of space where we have
• 37:00to be open and honest about it.
• 37:01Two, you know, explicitly someone saying no,
• 37:05I'm a faculty or I'm this,
• 37:06and these are things that part
• 37:08of my personal identity.
• 37:09And so if there are any microaggressions
• 37:12that didn't denigrate me,
• 37:13would humanize me.
• 37:14Related to this,
• 37:15I'd like my my ask of you as a team
• 37:17member is to simply not look away and
• 37:20acknowledge it and let me take the lead.
• 37:23What we've been doing is
• 37:25researching the implementation of
• 37:26these individual conversations,
• 37:28really understanding about how
• 37:30do we respond to microaggressions
• 37:33in a preventative way.
• 37:35And what we've found from this work
• 37:37we're writing it up right now is it
• 37:39is so dissonant and discordant for
• 37:42so many people in a department of
• 37:45psychiatry with 132 bed facility.
• 37:47To be encouraged to talk about
• 37:51what makes them who they are.
• 37:53It's so not normal.
• 37:55That even the process of implementing
• 37:58these types of conversations
• 38:00has to contend with how big of a
• 38:04culture shift it is from some of
• 38:06the norms that exist.
• 38:10The other area that we're doing
• 38:11a lot of work in trying to build
• 38:14further capacity is connecting and
• 38:16understanding the ways in which racial
• 38:19trauma or minority stress accumulate,
• 38:21leading towards heightened arousal
• 38:23systems and adversely impacting
• 38:26well-being and functioning.
• 38:29Overall at the Iowa,
• 38:30our vision and plan is to acknowledge that,
• 38:34you know, we're a 200 year old place
• 38:37that has been founded on the simple
• 38:40idea of centering the humanity and
• 38:43dignity of people who are suffering.
• 38:46But at this cross section in history,
• 38:48we are recognizing that in
• 38:49many ways we have gone astray.
• 38:52That we have normalized various
• 38:54forms of coercive practices.
• 38:56And what we do?
• 38:58And that our system is largely
• 39:01a coping focused system.
• 39:03So our plan and vision.
• 39:06Is to move from this idea of moral treatment
• 39:10to what we're calling radical recovery.
• 39:13We're in the final stages of sketching
• 39:15out our road map for change,
• 39:16so I wanted to give you a sneak peek.
• 39:20We've got 12 strategic goals.
• 39:22And as you can see,
• 39:24the center one really is under the
• 39:27theme of liberation of this came
• 39:29from extensive internal and external
• 39:32engagement within our community.
• 39:33And actually the theme as it came through
• 39:36and got went through analysis was coercion.
• 39:39The topic was coercion,
• 39:40but not going to make a theme
• 39:42that's coercion.
• 39:43So when I looked at different words
• 39:45that would capture the essence of the
• 39:47liberation was the one that came to mind,
• 39:49but it's also.
• 39:50Sorry, that made people very,
• 39:52very uncomfortable.
• 39:55Part of what we are seeking to do is to
• 39:57ground all of our work in code design,
• 40:00empowering the patients,
• 40:01families and communities as partners.
• 40:03We're beginning to do this
• 40:05through a participatory,
• 40:06inclusive approach to policy design,
• 40:09everything from visitor
• 40:11policy to passes and food.
• 40:14We're also partnering with the
• 40:16World Health Organization's Quality
• 40:18Rights Initiative to develop a
• 40:21scorecard around corset practices
• 40:23that we will publicly monitor
• 40:25and report with a framework that
• 40:27we hope others will follow.
• 40:29And going beyond the buzzwords
• 40:31in terms of well-being and DE I,
• 40:33really to continue to be a place
• 40:36that builds and fosters personal
• 40:38and professional development.
• 40:41And digs deep to think about how.
• 40:45We want to be while translating some of
• 40:49these aspirations into walking for long.
• 40:54So that's that's what I was hoping to share.
• 40:57I shared why I'm here,
• 40:58why we're here as a collective.
• 41:01And I hope that as we
• 41:02have a chance to to chat,
• 41:04discuss and and be in Community with
• 41:06one another that we can think about why
• 41:09you're here and why this topic this work.
• 41:13Is important to you and and how we
• 41:16work together, support and uplift
• 41:18one another as we move forward.