Yale Psychiatry Grand Rounds: March 17, 2023

March 17, 2023

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"Bias in the Mirror"

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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.