Yale Psychiatry Grand Rounds: September 15, 2023

Transcript

• 00:00DK for a lovely introduction,
• 00:03I'm going to see if I can share
• 00:06my screen here and get started.
• 00:11Okay,
• 00:16okay, good morning.
• 00:17It's a privilege to be here.
• 00:20It's been an interesting time in history
• 00:25of the United States and elsewhere,
• 00:28especially with the
• 00:29pandemic and civil unrest.
• 00:31And one of the things that I've
• 00:35noticed is that people have responded
• 00:38differently to stressors than they
• 00:40would have in other situations,
• 00:42but with good reason.
• 00:43Each stressor we've had to deal with has
• 00:45affected each of us in a different way.
• 00:48So one of the things that's
• 00:49important to me is to understand,
• 00:50try to understand where everyone's
• 00:51coming from and try to reach a
• 00:53consensus that moves us ahead.
• 00:55And the goal is to do that as efficiently
• 00:56as possible because we know that
• 00:58there are going to be hiccups along
• 00:59the way and we have to reconfigure
• 01:01things and be strategic about it.
• 01:03And I guess this is what we're
• 01:05trying to do in forensic psychiatry.
• 01:07We're trying to look at all the data,
• 01:10marshal the evidence,
• 01:12render an opinion,
• 01:14and then advocate for that opinion
• 01:18while being cognizant that there are
• 01:20times that we may have overlooked
• 01:22something and we'll have to concede
• 01:24and and and step back and regroup.
• 01:26So my talk is pursuing fundamental fairness,
• 01:28APA's response to structural races
• 01:31of structural bias in psychiatry.
• 01:33And let me see if I can move these
• 01:36photos okay now I can see better okay.
• 01:38The objectives are to explain the
• 01:40relationship between structural bias,
• 01:42health disparities, medical morbidity,
• 01:44and mortality.
• 01:45To explain examine how organized medicine
• 01:47is addressing racial bias in healthcare
• 01:49and to describe the process challenges,
• 01:51accomplishments,
• 01:52implementation,
• 01:52and lessons learned by the Structural
• 01:55Racism Task Force and present.
• 01:57The status of the A present status
• 01:59of the APA's anti bias agenda and
• 02:02the gap is suggesting the gap and
• 02:04knowledge of how intrinsic and extrinsic
• 02:06biases in medicine affect health
• 02:09disparities and workforce burn down.
• 02:11I have no disclosures and I would
• 02:14like to open my talks with a quote
• 02:17and here's one of my favorite ones.
• 02:19Great minds discuss ideas,
• 02:23and we're going to discuss some ideas today.
• 02:25Average minds discuss events,
• 02:27and of course we'll be discussing
• 02:29some events,
• 02:29but to a lesser degree than the ideas
• 02:32and small minds discuss people.
• 02:33We're going to try to avoid that one today,
• 02:36so let's just look at some basic definitions.
• 02:39Race is a social construct or
• 02:41interpretation based on physical
• 02:42characteristics.
• 02:43Racism is a system that assigns
• 02:45value to that.
• 02:47Prejudice is a belief that is rooted,
• 02:48and often rooted in unfair assumptions.
• 02:51Discrimination is an action that is
• 02:53informed or motivated by prejudice,
• 02:56whether or not it's deliberate.
• 02:59And excuse me,
• 03:02HealthEquity is really what
• 03:05we're talking about here.
• 03:08Despite immutable traits, each person,
• 03:11regardless of station in life,
• 03:13can achieve the same level of
• 03:16health by accessing individualized
• 03:18quality care without bias.
• 03:20So it's a matter of accessing care
• 03:22based on what your needs are and not
• 03:25how much you have in your wallet or
• 03:28whether which insurance plan you have.
• 03:31OK, we're going to talk a little
• 03:32bit about microaggressions.
• 03:33I'm sure you're familiar with this term,
• 03:35which was actually coined in the late
• 03:371960s by a PA member, Chester Pierce,
• 03:40who just had a an endowed lectureship
• 03:45funded in his name. And Ezra,
• 03:47your own Irish Griffith was
• 03:49one of the people behind that.
• 03:51But he coined this term in the late 1960s,
• 03:53described how whites reacted to blacks after
• 04:01became illegal in the country.
• 04:02And it was a it was a brief,
• 04:04commonplace verbal, behavioral,
• 04:06or environmental indignity,
• 04:08regardless of intent,
• 04:09that communicated hostile,
• 04:10derogatory or negative prejudicial
• 04:11slides and insults towards a group,
• 04:13particularly culturally marginalized groups.
• 04:15Now in the late 1960s,
• 04:18Doctor Pierce used that to describe the
• 04:22relationship between whites and blacks.
• 04:24Black whites towards blacks,
• 04:25particularly in the South but
• 04:27also elsewhere and over time.
• 04:29People like Darryl Wingsu and others
• 04:32began to study this and realize
• 04:34that this is not specific to blacks.
• 04:37The relationships or or a microaggressions
• 04:39don't focus just on black people.
• 04:43So they decided it on many levels.
• 04:46It affects college students,
• 04:48It affects people and everyday life.
• 04:51There are studies that show
• 04:53that it is related to suicide.
• 04:56It's mediated by depression,
• 04:57but increased drinking,
• 04:58increased anxiety are some of
• 05:00the things that studies have
• 05:01shown that are related to this.
• 05:03So we have to be mindful of this because
• 05:05it may seem like a small incident,
• 05:08but when it's compiled and
• 05:10you compound other factors,
• 05:11this can have horrible outcomes
• 05:14for a subgroup of people.
• 05:16Micro inequities is something that
• 05:18our patients often talk about,
• 05:20but also our colleagues.
• 05:21The experience of being undervalued,
• 05:24marginalized, overlooked,
• 05:25and devalued because of someone's
• 05:27status as a minority.
• 05:29And one of the reasons micro
• 05:31inequities is important in
• 05:33Healthcare is because of how,
• 05:35because how people are perceived or how
• 05:38they feel during a healthcare encounter
• 05:41informs how they approach Wellness,
• 05:44whether or not they return,
• 05:45whether or not they comply etcetera.
• 05:48So we have an important role to play
• 05:50in in addressing micro inequities,
• 05:53being responsive in to it in our patients,
• 05:55but also being aware of it around us.
• 06:01Intersectionality, the complex cumulative
• 06:03way in which the effects of multiple
• 06:06forms of discrimination such as racism,
• 06:08sexism, ableism, and classism combine,
• 06:11overlap or intersect, especially
• 06:13in the experiences of marginalized
• 06:16individualized individuals or groups.
• 06:18For example, right before the
• 06:20Structural Racism Task Force,
• 06:22I had broken my ankles.
• 06:23So what was my intersectionality?
• 06:26African American, female,
• 06:28overweight and on crutches.
• 06:31And I can tell you, based on one
• 06:33experience when I had to travel by air,
• 06:36the treatment was horrendous.
• 06:38I was stuck on a plane for almost an hour
• 06:42because no one would help me get off.
• 06:44And that was before I was on
• 06:46crutches and I needed a knee scooter.
• 06:49I also was placed on the plane last
• 06:51and stepped up first because there
• 06:53wasn't enough staff and mind you
• 06:56this was pre pandemic not during
• 06:58the pandemic so they they should
• 06:59have had sufficient staff.
• 07:03Also it made me think about how difficult
• 07:07it is for people who are differently abled.
• 07:11Do you driving to the store and not
• 07:14being able to get a handicap parking
• 07:17spot because someone that fell the need
• 07:19to run into it to a store, etcetera.
• 07:21So these things while the everyday
• 07:24person may consider not too important,
• 07:26those cumulative perceived slides can
• 07:28have an impact on one sense of wellbeing.
• 07:33Okay, structural or systemic racism,
• 07:36also known as institutional racism
• 07:38is a combination of public policies,
• 07:41institutional practices,
• 07:44social forces and processes that generate
• 07:49and perpetuate inequities about races.
• 07:52And the key to racism is that is that
• 07:54it evolves, it's dynamic, it's adaptive.
• 07:57We can look at the the caste system,
• 08:00we can look at housing discrimination.
• 08:03Often times it's legislative, but look,
• 08:04historically we see how after slavery
• 08:08was adopt abolished, the policies
• 08:11and the laws morphed to Jim Crow.
• 08:14And then we thought that the Civil
• 08:17Rights Act of 1964 actually outlawed
• 08:21discrimination against minorities.
• 08:23But we see what's going on,
• 08:25what will happen in 2020 during COVID in
• 08:28the health inequities and other inequities,
• 08:30police brutality,
• 08:32housing discrimination, etcetera.
• 08:34And then we still see some
• 08:38in a different form in 2023.
• 08:40And as someone who has been
• 08:43subjected to housing discrimination,
• 08:44I I I think this is extremely concerning
• 08:47because when I tell people my experiences,
• 08:50I say, you know,
• 08:51I've had housing discrimination
• 08:53experiences ever since medical
• 08:55school and I overpaid for my house.
• 08:58Why?
• 08:58Because I didn't want to be bothered
• 09:00with the process.
• 09:01I just wanted somewhere to to become
• 09:04that I was comfortable with.
• 09:05But they say,
• 09:06well you know why it's experienced
• 09:08this also I said I get it and I
• 09:10believe it and I've seen it happen,
• 09:12but do they have it occur as often as
• 09:15it has happened to someone like me?
• 09:18Even when I paid,
• 09:20when I finished my fellowship,
• 09:22I went and I paid 2 months,
• 09:26two months of deposit and the first
• 09:29month's rent came back and Phil Resnick,
• 09:31secretary, called me and said
• 09:33you have to go back to Buffalo.
• 09:35Your apartment fell through,
• 09:36I said, But the money's in the bank.
• 09:38So over time, if that's impacting me
• 09:40or someone like me or one of your
• 09:42colleagues or one of your patients,
• 09:44you can see where how that
• 09:46can impact their attitudes.
• 09:47The presentation at work,
• 09:49the the perceived stressors at
• 09:51work because they have more to
• 09:54deal with that most people don't.
• 09:57And classification of of racist
• 10:02racism is based on intent.
• 10:04Now let's not forget that for 85% of
• 10:08the time that blacks have been in this
• 10:11country since sixteen 1985% they've
• 10:14lived under legalized discrimination,
• 10:16so up until 1964.
• 10:18So when you look at that,
• 10:20you see how harsh this is
• 10:23and how it can happen,
• 10:25impact on our perceptions of others.
• 10:29And it's not a matter of you didn't cause it,
• 10:31this person didn't cause it,
• 10:32that person didn't cause it.
• 10:34It's a matter of these
• 10:36things occurring over time.
• 10:37So classification can be direct or indirect.
• 10:41So direct racism is deliberate.
• 10:43It's often legislated.
• 10:43It's that policy.
• 10:44We don't allow these types
• 10:46of people in our system.
• 10:47And I I'm working with on the I MG's and
• 10:49working with residency training directors.
• 10:52One of the things that I MG's submitted
• 10:54a report to the Board of Trustees,
• 10:57GA Board of Trustees.
• 10:58One of the things they requested is
• 11:00that the APA take a position on using
• 11:03some type of filter to filter out
• 11:06international medical graduates when
• 11:07one is selecting residency programs.
• 11:10And I heard many people say we don't do that.
• 11:13But then I had two training directors
• 11:16from two different programs in two
• 11:17different parts of the United States,
• 11:19and both of them said their
• 11:22chairs had asked them to filter
• 11:24out I M g's on the first round.
• 11:26So that would be deliberate.
• 11:28Indirect is when you know it's
• 11:31wrong and you still do it,
• 11:35you still perpetuate that.
• 11:37And in post those cases,
• 11:39those training directors said that
• 11:40they told their chairman Okay,
• 11:41they do it,
• 11:42but then they didn't because they
• 11:44knew it was the wrong thing to do.
• 11:45Okay. Now let's talk about privilege.
• 11:48This is a very polarizing turn these days,
• 11:53But I'm going to talk with you about
• 11:55privilege from the perspective
• 11:57of Peggy Mackintosh,
• 11:58who was a professor of women's studies
• 12:01at Wellesley, and she wrote a paper,
• 12:05a seminal paper titled White Privilege,
• 12:11Unpacking the Invisible Knapsack.
• 12:13And what Doctor McIntosh did was in
• 12:16the late 1960s, she wrote a seminal
• 12:19paper about male privilege, and again,
• 12:21as a professor of women's studies,
• 12:24this was at Proco. But over time,
• 12:26she realized that relative to her
• 12:28black colleagues in the department,
• 12:30she had access to resources that they didn't.
• 12:33She knew people, the networks,
• 12:35the opportunities,
• 12:35and they didn't have those opportunities.
• 12:38So even if they were equally qualified,
• 12:40their careers would not advance as
• 12:42fast because they didn't have access.
• 12:44So she uses metaphor white
• 12:46privileges like an invisible,
• 12:48weightless knapsack of special provisions,
• 12:51assembly, excuse me, Provisions, maps,
• 12:53passports, code, books, visas, clothes,
• 12:57tools and other blank checks, etcetera.
• 12:59And the key to this invisible
• 13:02knapsack is that you're born with it
• 13:04and contains these unearned apps,
• 13:07assets that you count on cashing
• 13:10in on every day.
• 13:12Now your condition to be
• 13:16oblivious to cashing in on that.
• 13:19And that is key.
• 13:20We each have different types of backpacks,
• 13:23and the backpack and our knapsack
• 13:25would vary depending on where you are.
• 13:28For example,
• 13:28if you're Jewish in New York,
• 13:30you may have a burlap knapsack
• 13:32with a lot of provisions in it.
• 13:35If you move to South Dakota that
• 13:36the fabric on that knapsack may thin
• 13:38out and the resources may thin out,
• 13:41but you're walking into a situation
• 13:43where you have a advantage and a level of
• 13:47resources that other people may not have.
• 13:50I have privilege.
• 13:51I sit on the board of trustees of the APA.
• 13:54Is that not privilege?
• 13:55That's something that most people don't have.
• 13:57So I have access to knowledge,
• 13:58resources, people,
• 13:59etcetera, by virtue of that.
• 14:02So in that situation, I have privilege.
• 14:04But when I went to pick up some artwork
• 14:07from a museum that I had purchased,
• 14:10I was accompanied by two friends
• 14:11and they asked me.
• 14:13It was a Saturday morning and they asked me,
• 14:15why are you dressed for work?
• 14:17I said because I'm going to get my artwork.
• 14:20They had on jeans and ski jackets,
• 14:22but why do you need to dress that
• 14:25way when you're picking up artwork?
• 14:27It's the weekend,
• 14:28I said,
• 14:29because I'm going to pick up my artwork.
• 14:31So we walked into the museum and
• 14:33this was the at the end of an art
• 14:35show and the three of us walked in.
• 14:37They're older white women and they
• 14:41walked right through. I got stopped.
• 14:44I was asked, may I help you?
• 14:45I said I'm here to pick up my artwork.
• 14:48Oh, are you working for one of the artists?
• 14:52No,
• 14:52I'm here to pick up artwork that I purchased.
• 14:57Well how do you think you get artwork?
• 15:01I purchased my artwork.
• 15:04So I said, here's my ID,
• 15:06which they told me to bring,
• 15:08and the woman looked at my ID
• 15:11as if she was perplexed.
• 15:13So I said, well,
• 15:14I have my passport and my
• 15:16medical license here too,
• 15:18if you'd like to see them.
• 15:20And then things changed.
• 15:22I was able to pick up my artwork.
• 15:25I was happy. We walked out of the
• 15:28museum and my friend asked me,
• 15:30how could you be so calm?
• 15:32I said I'm happy.
• 15:33Why are you happy after you
• 15:35were treated like that?
• 15:36Because I got my artwork,
• 15:38I came here to get my artwork,
• 15:39I got my artwork and I'm going,
• 15:41I'm, I'm going home.
• 15:44So they couldn't understand that.
• 15:46Why can't you be mad?
• 15:47And I explained to them,
• 15:48if I allow that to ruin my day,
• 15:51I would have more ruined
• 15:53days than you can imagine.
• 15:55So I dressed a certain way and I prepare.
• 16:00I had more ID than I needed,
• 16:03just in case,
• 16:03and it worked for me.
• 16:05I'm not going to give her and her
• 16:08ignorance the opportunity of the
• 16:09privilege of controlling my mood and my day.
• 16:13I'm happy, mission accomplished.
• 16:14And they were miserable for
• 16:15the rest of the day.
• 16:16And we still talk about that because
• 16:19they didn't realize what it was
• 16:22like until they saw it first hand.
• 16:25So let's talk about another aspect of
• 16:30discrimination, systemic discrimination.
• 16:31This is a wonderful study by Calco,
• 16:34Calfeld and Hancock.
• 16:35And what they did was they went
• 16:38to the Philadelphia court system,
• 16:40and they're linguists.
• 16:41They went to the Philadelphia
• 16:43court court system and they asked
• 16:46transcriptionists to participate in a study.
• 16:49In 27 agreed.
• 16:50And what they did was they recorded
• 16:538 native speakers of African
• 16:55American English and asked the the
• 16:58transcription is to to transcribe it.
• 17:02Those transcriptionists got 59.5%
• 17:06accuracy in terms of sentences.
• 17:09Words were transcribed 82.9%
• 17:13of the time correctly.
• 17:1582.9% of the time.
• 17:17Who, what,
• 17:18where and when were often
• 17:20transcribed incorrectly.
• 17:21Sentences were correctly
• 17:22paraphrased 1/3 of the time,
• 17:25but that was not systematically
• 17:27related to accuracy.
• 17:28So you can see where when some
• 17:31if you were in a situation and
• 17:33you were in court and someone in
• 17:36contract directly transcribed
• 17:37what you were saying and that goes
• 17:39up to that case goes to appeal,
• 17:41that can have a bad outcome.
• 17:44And I'll note that in order to
• 17:46be certified as a court reporter,
• 17:4995% accuracy is required.
• 17:50But the problem with this is
• 17:52that the transcription is said
• 17:55they want more training,
• 17:56they want more help when they are trained.
• 17:59They are trained on the
• 18:01voices of news reporters,
• 18:02judges and attorneys.
• 18:04They don't reflect the
• 18:06people that are in court,
• 18:08the general population that
• 18:10appears in the courtroom.
• 18:11So they get tested on one thing
• 18:15and then they are in another
• 18:17situation and it's hard to
• 18:22be inaccurate. But they also say that
• 18:26they were trained to tell people when
• 18:29I asked people for clarification when
• 18:31they didn't understand what was said.
• 18:34But that was quietly discouraged
• 18:35in a courtroom and could cost
• 18:37them their jobs as a subtext.
• 18:39So again these implications are profound.
• 18:42I've had it happen with transcriptionist
• 18:44I found in some and and one case that
• 18:49Ebonics was included in my transcription,
• 18:52which is why I read all of them.
• 18:54It said D&D and she be doing this net
• 18:58during a forensic deposition that I gave.
• 19:03So what about medicine?
• 19:06From Martin Luther King Junior said
• 19:08in 1966 to a group of reporters,
• 19:11Of all the forms of
• 19:12discrimination and inequality,
• 19:13injustice and Healthcare is the
• 19:15most shocking and inhuman because
• 19:17it often results in physical death.
• 19:21So the AM may begin to look at this during
• 19:27the beginning of civil unrest about May 2020,
• 19:32as well as during the pandemic when
• 19:34all the data was coming out to.
• 19:36That reinforced the inequities and made
• 19:38it a reality for some people who fail to
• 19:41believe racism is a threat to public health.
• 19:44So they wanted to focus on creating pathways
• 19:47to truth healing and reconciliation.
• 19:50They want to advance equity
• 19:52in medicine and public health.
• 19:53They said something that they've
• 19:55known for years or decades.
• 19:57Race is a social construct which
• 20:00is different from ethnicity,
• 20:02genetic ancestry or biology,
• 20:03and race is not a biological
• 20:06determinant of health.
• 20:12The AM A supports ending the practice
• 20:14of using race as a proxy for biology
• 20:17or genetics and medical education,
• 20:19research and clinical practice.
• 20:20And I often get the question,
• 20:23well, if you don't use race,
• 20:24then how do you get this information?
• 20:27And it's simple.
• 20:28The AM A recommends that clinicians and
• 20:30researchers focus on genetics and biology,
• 20:33the experience of racism and social
• 20:37determinants of health and not race when
• 20:41describing risk factors for disease.
• 20:46So it seems simple,
• 20:48but to get people to buy
• 20:50into this will take decades,
• 20:52especially in research,
• 20:53because already in research people are
• 20:56screened out because they are not the
• 20:59quote UN quote ideal study subject.
• 21:02So the patients I see,
• 21:04most of the patients I see do not
• 21:06qualify for research studies for
• 21:08a variety of different reasons.
• 21:10But they they have.
• 21:11They would never check off all the
• 21:14boxes for one reason or another.
• 21:16So let's talk about social
• 21:19determinants of health.
• 21:21The county health ranking study
• 21:22was one of the first studies that
• 21:25showed that clinical care accounts
• 21:28for 16% of health outcomes.
• 21:31Some other studies showed 18 to 20%.
• 21:35But most of what happens and what most
• 21:40of what determines those outcomes are
• 21:42the social determinants of health,
• 21:44how we live, work, worship,
• 21:47are educated, our families,
• 21:49our situations,
• 21:50etcetera.
• 21:50So when we look at all of those
• 21:53lifestyle factors,
• 21:54we go back to the concern about
• 21:57the bias in these systems.
• 22:01So Metzel and Hanson Metzels in Tennessee
• 22:05and Hanson's at USUCLA came up with concept
• 22:10called structural competence and they
• 22:14said that it's the more you understand
• 22:16about structural bias in the country,
• 22:19the better the outcomes will be.
• 22:20And studies have since reinforced that.
• 22:23So they're part of being structurally
• 22:26competent is understanding the
• 22:27downstream effective policies,
• 22:29biological, economic, cultural, etcetera,
• 22:32including different forms of class
• 22:37disenfranchisement and HealthEquity.
• 22:39Despite immutable traits,
• 22:41you have access to the potential
• 22:44that have similar house health
• 22:46outcomes that can reduce internal
• 22:48and external bias and stigmatization.
• 22:51For example, when you come into a hospital,
• 22:53if you have tattoos of a certain type,
• 22:57that may explain or that may be
• 23:02telling in certain situations.
• 23:04Now these days, so many tattoos occur,
• 23:07but they still use people have tattoos,
• 23:10but you still look at these things
• 23:13and I always ask about study stories
• 23:14about the tattoos, the histories,
• 23:16the background, etcetera.
• 23:18But this is one of the things that
• 23:20has been associated with gangs
• 23:22and certain communities etcetera.
• 23:24So now a number of hospitals are
• 23:26taking on structural competence
• 23:28training as part of their orientation.
• 23:31For example,
• 23:32at Boston Medical Center with orientation,
• 23:36no healthcare professional can go and
• 23:39touch a patient in that hospital until
• 23:42they learn about structural bias and
• 23:45the things that they're going to see
• 23:48based on the community that they they serve.
• 23:52That can support culturally competent care,
• 23:55but it also promotes evidence based care.
• 23:57Because once you understand these
• 23:58things and can filter those out,
• 24:00you can look at the medicine
• 24:02and the physical,
• 24:02the the physical health and mental health
• 24:05concerns because without that bias.
• 24:07And that's going to be extremely
• 24:09important in how we proceed.
• 24:10And I'll show you a study in a few
• 24:12minutes that will reinforce that,
• 24:14but it also can reduce professional burnout.
• 24:16I had a colleague who once said I see my
• 24:21worst patients more often than others,
• 24:24and someone asked why those are the ones
• 24:27you probably don't want to see and he said,
• 24:29well, I think of it this way.
• 24:31The more I see them,
• 24:32the better chance I have of getting
• 24:34them well and not seeing them as often.
• 24:37And once they're well,
• 24:39I feel very effective and I'm
• 24:42less likely to burn out.
• 24:44So when you understand and can
• 24:47filter out the structural biases,
• 24:49the racism, and other forms of bias,
• 24:52you can look at that person.
• 24:54It improves health outcomes,
• 24:55it supports culturally competent care
• 24:57and promotes evidencebased care.
• 24:59So you do feel more confident and
• 25:01you're less likely to burn out because
• 25:03your practice seems less overwhelming.
• 25:05So here's an example in Madison that is
• 25:09interesting for a number of reasons.
• 25:10As you see, there are four, three men there.
• 25:15We have the Chala from Chadwick
• 25:18Boseman from who starred in the
• 25:20first Black Panther
• 25:24movie as well as in a number of other
• 25:28movies and was one of our bright stars,
• 25:30who died of cancer in his early 40s.
• 25:33Colon cancer, even.
• 25:34Kennedy was diagnosed with stage
• 25:374 colon cancer at age 4039.
• 25:39And Darryl Strawberry,
• 25:41who won World Series rings in New
• 25:46York's for the Yankees and Mets.
• 25:48He was diagnosed with colon
• 25:51cancer at age 36. So you have
• 25:57all that diagnosed with
• 25:59colon cancer before age 40.
• 26:01Now we also know that the steepest
• 26:03increase in colon cancer is in
• 26:05people ages 20 to 39 years of age.
• 26:07And also there is increased
• 26:09incident in women.
• 26:10Blacks are 20% more likely than whites
• 26:12to be diagnosed with colon cancer,
• 26:15and they're 40 to 50.
• 26:16Blacks are 40 to 50% more likely to die.
• 26:18So this seems to be a real concern,
• 26:21especially since it's
• 26:22being diagnosed earlier.
• 26:24But the requirements that I think
• 26:26they came out in 2020 or thereabouts
• 26:30recommend colonoscopies start at age 45.
• 26:35So you're overlooking a population
• 26:37of people systematically who have a
• 26:40worse prognosis and are more likely
• 26:42to die and to have the disease.
• 26:45So this is another example
• 26:48of systemic or implicit bias.
• 26:50Now let's look at some other examples.
• 26:54In 2018,
• 26:54I opened a newspaper and saw that
• 26:57a hospital emergency department
• 26:58found that there was a flaw in their
• 27:02algorithm for contestive heart failure.
• 27:04All things being equal with
• 27:06the severity of symptoms.
• 27:07If you were white,
• 27:09the algorithm told you told the
• 27:12doctors to hospitalize the patient,
• 27:14and if that patient was black,
• 27:18the hospital was called,
• 27:19the instruction was to send the person home.
• 27:22So somebody put program that in
• 27:25the algorithm. The question is why?
• 27:27And how was it somebody who did it By
• 27:29an error, the wasn't tested properly,
• 27:32etcetera.
• 27:32So when you're looking at computers and such,
• 27:34again,
• 27:34it depends on what we put in it and
• 27:36not everything we put in it is equitable.
• 27:38So we have to look at the data
• 27:40and do test runs before we use
• 27:42this to make life the data,
• 27:44the programs to make life or death decisions.
• 27:47And we also look at cystic fibrosis.
• 27:50Blacks are diagnosed an average of four
• 27:53years later with cystic fibrosis than whites.
• 27:56Why?
• 27:56Because in medical schools often people
• 27:58are taught that it's a white disease,
• 28:00so people don't look for for it.
• 28:03And I've had four patients,
• 28:04black patients with cystic fibrosis and
• 28:07it was consistent in all the cases.
• 28:09It was four years,
• 28:10regardless of age,
• 28:11from from teens to early 40s.
• 28:16The perception of pain has been
• 28:18shown by the national study from
• 28:21the National Academy of Sciences.
• 28:23They surveyed medical students,
• 28:25and they found that they,
• 28:28like their counterparts in society,
• 28:31not nonmedical professionals,
• 28:32believe that blacks have a
• 28:35higher pain tolerance.
• 28:36There's also some studies that suggest
• 28:39that pain perception is disregarded or
• 28:41outcomes are worse if the person is less.
• 28:44Lacks English.
• 28:45The parent lacks English proficiency,
• 28:47and there's one study looking
• 28:49at appendectomies.
• 28:50Now,
• 28:50a couple of other studies have
• 28:51come out and they have found
• 28:53it a little bit different,
• 28:55but the studies were not duplicated,
• 28:57so we'll have to wait to see
• 28:59what happens with that.
• 29:00But we do know they were less
• 29:02likely to get imaging studies,
• 29:04and they went to the the operating room
• 29:10for an appendectomy at a later stage
• 29:13of severity. And then we know
• 29:15about schizophrenia which is
• 29:17disproportionately diagnosed in blacks
• 29:19relative to whites regardless of age.
• 29:23And and this is profound,
• 29:25even when semi semi structured
• 29:29clinical interview tool was used,
• 29:33still blacks were diagnosed with
• 29:37schizophrenia more often than whites.
• 29:39And that has a lot of implications
• 29:43about treatment seeking prognosis
• 29:45and other forms of care and
• 29:47longterm outcomes and equity.
• 29:50So let's talk a little about
• 29:52resident burnout and racism.
• 29:54And this is an extremely important
• 29:57study that came out in 2019, Derby,
• 29:59Heron and Wes and colleagues,
• 30:02it was a Co-op study and they looked
• 30:05at over 3000 non black second year
• 30:07resident physicians and they did gave
• 30:09them the mass like burnout inventory
• 30:11which was basically two questions.
• 30:13And then they did a hard sort for implicit
• 30:16bias and a feeling scale for explicit bias.
• 30:18And what they found was secondyear
• 30:21residents who were stressed out,
• 30:22more more likely to engage in,
• 30:26was more likely to be associated
• 30:29with implicit and explicit
• 30:31bias against black people.
• 30:33So when blacks came into the
• 30:35clinics or the hospitals,
• 30:37the bias was implicit,
• 30:40meaning they may not have been aware of it,
• 30:42or it was unintentional,
• 30:45perhaps, and explicit meaning
• 30:47deliberate against black people.
• 30:49So if you're one of those black
• 30:51people going to a hospital and
• 30:53counting one of these residents,
• 30:54you're not going to have a good experience,
• 30:56or you're not going to have as
• 30:58good experience as you should,
• 31:00all things being equal.
• 31:01Now the interesting thing is
• 31:03they found that in 3rd year,
• 31:04the same residents were less stressed,
• 31:06and when they were less stressed,
• 31:08they were less likely to
• 31:10engage in explicit bias,
• 31:11intentional bias against blacks.
• 31:13But the implicit bias persisted.
• 31:18So what about the experience
• 31:20of racism and psychiatry?
• 31:21We talked a little bit about that, but
• 31:28there are other areas in
• 31:31which there's discrimination.
• 31:32And we talked about schizophrenia.
• 31:35Let's talk about antipsychotic prescriptions.
• 31:37Blacks are more likely to get
• 31:39first generation antipsychotics,
• 31:41then then second and that study was
• 31:45from 2004 and it's been repeated
• 31:47now we see all the metabolic
• 31:49concerns that are related to
• 31:552nd generation antipsychotics.
• 31:56So you've got to look at the balancing act,
• 31:58but we also look at the opioid crisis
• 32:00in terms of pain perception. Blacks,
• 32:02usually you see a condition like this,
• 32:04it it affects all sorts of people.
• 32:07But early on in the early 2000s
• 32:09when we began to see the the
• 32:11casualties due to the opioid crisis,
• 32:12they were disproportionately black, white.
• 32:15Only recently have blacks been catching up.
• 32:17So while many blacks suffered
• 32:20unnecessarily with pain back then,
• 32:22it may have saved a number of lives.
• 32:24So it's a mixed bag there.
• 32:26But it shouldn't be occurring.
• 32:29When substance shoots,
• 32:30treatment is prescribed.
• 32:32Blacks are less likely to get substance
• 32:35use care that is cutting edge or
• 32:40medication assisted therapies when
• 32:42they are discharged from hospitals,
• 32:45and these are individual studies.
• 32:46I have the references if you'd like.
• 32:48When they are discharged from hospitals,
• 32:50they're less likely to be
• 32:52referred for psychotherapy,
• 32:53They're more likely to be secluded
• 32:55or restrained in hospitals and other
• 32:57settings and they're more likely to
• 33:01complain about perceiving discrimination
• 33:04in the hospitals in terms of the
• 33:07ratings that hospitals feedback
• 33:09studies that have been occurred.
• 33:11So there may be a number of reasons
• 33:14about that when you look at the resident
• 33:17study that shows that there's some bias
• 33:19and that's a significant part of it.
• 33:22Now,
• 33:22one of the things we do in medicine
• 33:24and psychiatry is prescribed lithium.
• 33:27And one of the things we look at is
• 33:29the glomerular filtration rate and the
• 33:31estimated glomerular filtration rate change.
• 33:34How we look at the range for or what
• 33:38the threshold for kidney disease or
• 33:41renal failure is in black versus white.
• 33:43So Dorothy Roberts is a law
• 33:48professor at Upenn,
• 33:49and when she was a Robert
• 33:51Wood Johnson's fellow,
• 33:52she looked at the history of the
• 33:55difference in a range for a renal failure,
• 33:58cut offs in blacks versus whites.
• 34:01She traced it back to about the 1930s and
• 34:04discovered that it was a case of IPSI Dixit.
• 34:07Because I say so,
• 34:09So for generations,
• 34:10because some person said so.
• 34:12We trained psychiatrists and
• 34:15other physicians,
• 34:16healthcare professionals,
• 34:17generations of them to say to
• 34:20to believe that the glomerular
• 34:22filtration rate range acceptable
• 34:24range was different based on race.
• 34:27That difference is as much as 21%,
• 34:31which means that blacks were
• 34:33less likely to be diagnosed at
• 34:36an early stage of renal failure,
• 34:38which affected morbidity and mortality.
• 34:40So it wasn't race that it was said
• 34:44that blacks have a worse outcome.
• 34:45It was because of the Gomera
• 34:48estimated gomerial filtration
• 34:50rate and not because of race.
• 34:52So that also meant that blacks
• 34:54were less likely to be eligible for
• 34:57placement on the renal transplant list.
• 35:00And in February 27th,
• 35:022023,
• 35:03the US Oregon Procurement and
• 35:06Transplantation Network made an
• 35:08effort to make that equitable.
• 35:10They said that they were going
• 35:12to look at every black person on
• 35:15the renal transplant list and see
• 35:17when they how long they had been,
• 35:23how long they had been delayed treatment
• 35:26because of the estimated glomerular
• 35:28filtration rate because now the systems
• 35:30are more equitable and you there
• 35:32are many papers coming out etcetera.
• 35:34Although three years ago people would
• 35:36fight tooth and nail against us.
• 35:38So what they decided was that they
• 35:40were going to look at how long
• 35:43the diagnosis of renal failure was
• 35:46delayed and they would compensate
• 35:48blacks for at least up to 19 months.
• 35:52In other words, you go back and if
• 35:55you were misdiagnosed for two years,
• 35:57they would move you up 19 months ahead
• 36:00on the transplant list in an effort to
• 36:03come create some semblance of equity.
• 36:06And so the wait listing times had
• 36:08to be backdated.
• 36:09And this is to it's intended to repair
• 36:14damage due to structural racism.
• 36:17The While it sounds good,
• 36:21it doesn't happen enough.
• 36:23This is one of the first efforts
• 36:25to do some type of correction,
• 36:30attractive action for medical
• 36:32bias on this level.
• 36:34And we also look at ADS.
• 36:35This is a 1974 ad from the Archives
• 36:39of General Psychiatry and some
• 36:42of you may recognize this.
• 36:45This is an ad that says assaultive
• 36:47and belligerent cooperations also
• 36:49often begins with hallow paradol,
• 36:52a first choice for starting therapy.
• 36:54And what you see in the picture
• 36:56is the angry black man.
• 36:57Now that is one of the things that people
• 37:02used to justify diagnosing schizophrenia.
• 37:06Incorrectly,
• 37:06so of course,
• 37:07but if it's an angry black person,
• 37:09an agitated black person,
• 37:11they're more likely to be diagnosed
• 37:13with a psychosis spectrum disorder
• 37:15rather than a mood disorder.
• 37:18So, and this comes when you're taught this,
• 37:20you're trained this to think this way.
• 37:24That passes on to generations too.
• 37:26And that impacts how we treat African
• 37:29Americans who come in or psychiatric care.
• 37:34Now, what can we do to remedy this?
• 37:37Well,
• 37:37clinician bias and burnout and
• 37:40structural bias or discrimination in
• 37:44healthcare can be diminished by health.
• 37:49Cultural humility.
• 37:50Let's start with cultural competence.
• 37:52Cultural competence means that you
• 37:53go and you study and you learn more
• 37:55about different cultures, etcetera.
• 37:57But it the word competence
• 37:59suggests that it's finite,
• 38:01but it also can introduce bias.
• 38:04I've read about how you people function,
• 38:06so therefore I know what's best for you.
• 38:08Or this is how you do things.
• 38:10Or in your hospital.
• 38:12This is the culture.
• 38:14So when you use cultural competence,
• 38:17there is a sense that you have
• 38:20gained proficiency and you risk
• 38:22telling people about who they are
• 38:24rather than listening to them
• 38:27and learning about who they are.
• 38:29But what you can do is use
• 38:32cultural competence to inform your
• 38:34approach to cultural humility.
• 38:36For example,
• 38:37I once worked on A at the Navajo Nation,
• 38:41the hospital there for it
• 38:43defines an Indian hospital.
• 38:44So what I did was I read a lot
• 38:48about native culture and then
• 38:51I asked questions about it.
• 38:54Can you help me understand this?
• 38:56Is this a customary or how
• 38:58should I think about
• 39:00this? And they really enjoyed
• 39:02the have having discussions.
• 39:04They sent me to a sweat lodge and the
• 39:07next day they had a debriefing and I
• 39:10learned so much about indigenous culture
• 39:13that it was a a a profound experience.
• 39:16But had I gone in and said, you know,
• 39:18all I I've read in these books and
• 39:20use that and not ask questions,
• 39:22not been looking at critical selfreflection,
• 39:25where am I being biased?
• 39:26Am I shutting myself to be open
• 39:28on to this and to learning,
• 39:30then the outcome would have been different.
• 39:32So a cultural humility involves
• 39:35critical selfreflection,
• 39:36openness, nonjudgment, curiosity.
• 39:37And it's been shown to have
• 39:39benefits and treatments such as
• 39:41strengthening the therapeutic alliance
• 39:43and improving health outcomes.
• 39:45So what about a PA?
• 39:48Well, APA strategic initiative since
• 39:532015 has been to advanced integration
• 39:56of psychiatry and healthcare,
• 39:58supporting research,
• 39:59supporting and increasing diversity
• 40:01within the APA and education.
• 40:04And I put in yellow here and a larger
• 40:06type support on the supporting
• 40:09increasing diversity in the APA.
• 40:11And the rest of it says serving
• 40:12the needs of evolving, diverse,
• 40:14underrepresented and underserved
• 40:15patient populations and working to
• 40:17end disparities in mental health care.
• 40:20OK,
• 40:21so Apa's response to structural
• 40:24racism was multifactorial.
• 40:25And I will say that the task force,
• 40:28I'm going to tell you how that came about.
• 40:30In March 2020,
• 40:31we were in the board room debating
• 40:33whether or not we're going to have the
• 40:35May meeting because the pandemic was there.
• 40:38And I brought up a concern that we were
• 40:41not following the OR fulfilling the
• 40:43diversity initiative or requirement
• 40:45or goal of our strategic initiative.
• 40:47And after bringing it up a couple of times,
• 40:49President Bruce Schwartz said let's
• 40:50look at that. And then his term ended.
• 40:52And then Jeff Geller,
• 40:54term open began and as president of a
• 40:58PA and he said we're going to look at this.
• 41:01And once he looked at it further,
• 41:05he was planning a a study or
• 41:09study group on this.
• 41:10And then after George Floyd's death,
• 41:13he changed it to a task force and made
• 41:16it the focus of his presidential year.
• 41:19Now back to a PA's response
• 41:22to structural racism.
• 41:23They did make some announcements about
• 41:25COVID-19 and health disparities early on.
• 41:28They denounced racism and police brutality.
• 41:30And some of this had occurred before 2020.
• 41:34In July 2020,
• 41:34the Board had a round table
• 41:36discussion and everyone participated.
• 41:38I think it was about two hours long
• 41:40about each of our views on race.
• 41:42And they realized that the APA has does
• 41:45not have definitions for minority and
• 41:48representative and underrepresented.
• 41:50And so there was a whole work group on
• 41:52that and then they did more studies.
• 41:54And so the findings have been taken,
• 41:57sent to the minority and underrepresented
• 42:00groups and they had focus groups
• 42:02and discussions about that.
• 42:03So that's still an evolution.
• 42:05We hired consultants and this
• 42:07was one of my big
• 42:11request. I said that we don't
• 42:14have the expertise to say whether
• 42:17or not our board is biased or
• 42:21conforming practices for boards.
• 42:23We need someone who knows
• 42:25how boards function etcetera,
• 42:28look at what we're doing and give
• 42:30constructive feedback about what
• 42:32we're doing well and helping us
• 42:34understand what we need to do to
• 42:36improve in those other areas.
• 42:37So there was also a call self and
• 42:39looking at structural bias in a
• 42:41PA's or diversity equity inclusion
• 42:43in a PA's headquarters.
• 42:44And the board underwent A sixhour
• 42:47training with the Barkwell
• 42:49Group adversity training.
• 42:50And while it seemed to be a
• 42:53drop of sand in the water,
• 42:55it actually got us on a common ground
• 42:58because everybody had a similar baseline
• 43:01for discussion and the discussions
• 43:03began to change in a positive way.
• 43:06The CEO was appointed A diversity
• 43:08coach and he found that extremely
• 43:11helpful and I noticed that his
• 43:14language and his perspective,
• 43:15how he processed or presented
• 43:17I should say how he presented.
• 43:19Things changed and the tensions actually
• 43:23diminished when with certain groups
• 43:26that were perceived to be slighted.
• 43:29The APA's foundation does pipeline
• 43:32programs and programs about
• 43:34psychiatry for high school students,
• 43:37Historically black colleges and universities.
• 43:39There are many fellowships for
• 43:41residents and some of you may
• 43:43be a PA Foundation fellows.
• 43:44And then there was a Chester
• 43:46Pierce Human Rights Award,
• 43:47which I mentioned before beyond
• 43:49the Structural Racism Task Force.
• 43:51Also our publications took it upon
• 43:54themselves to look at the matter
• 43:58and introduce areas of reform
• 44:00or areas to expand diversity.
• 44:02Now President Geller appointed
• 44:04Structural Racism Task Force
• 44:07and here are all the members.
• 44:10There were five
• 44:13members, experts and then
• 44:16there was Doctor DK.
• 44:18And Doctor DK was a special ask on my
• 44:20part because of his experiences as
• 44:23an international medical graduate,
• 44:25his experiences in Forensic Psychiatry,
• 44:27because I wanted a systematic
• 44:29and unbiased approach to this,
• 44:30and because he was chair of the Ethics
• 44:33Committee and that was very important.
• 44:35Or or acting cochair, I forget the,
• 44:38I forget the position and I
• 44:40apologize for that Charles.
• 44:42But he joined without hesitation.
• 44:46So the goals were providing
• 44:48education and resources on APA,
• 44:50psychiatric history regarding
• 44:51structural racism,
• 44:52explaining the current impact of
• 44:53structural racism on the mental health
• 44:55for our patients and colleagues,
• 44:57developing recommendations for
• 44:59change and providing reports.
• 45:02And
• 45:05and these these programs need
• 45:07quality insurance because you have
• 45:09to go back and follow through.
• 45:10Did we do this right? Did we not?
• 45:12What can we do to do to what
• 45:13can we do to get back on track?
• 45:15Because they often fall off track.
• 45:17We have so many other competing
• 45:19interests and I didn't learn until
• 45:21after the task force meeting that
• 45:25I mean task force ended that that
• 45:28each task force is usually given
• 45:30one staff member to work with.
• 45:32I was rallying them all and we
• 45:35had 15 and they were fantastic and
• 45:37helped us make the work go much more
• 45:41smoothly and much more efficiently.
• 45:43They heard about what was going on,
• 45:44they were interested and they
• 45:46were fantastic and we couldn't
• 45:48have done it without them.
• 45:50So my personal goals were to be
• 45:53bidirectional and collaborative.
• 45:54We did surveys and other things
• 45:55and I read every survey answer
• 45:57to understand what was going on.
• 45:59And one of the things,
• 46:00reasons we went and looked at the APA
• 46:02was because the survey responses were
• 46:04don't look at it in the psychiatry,
• 46:06look at it within the APA.
• 46:07So just proportionately we got that feedback.
• 46:09So we did what the members wanted.
• 46:11We wanted it member driven.
• 46:12So we did have groups and meet
• 46:13with groups and talk with groups
• 46:15and it because it takes a village.
• 46:16This is it's a member driven organization
• 46:19and we cannot relook the needs and
• 46:21concerns of our members and it needed
• 46:23to be transparent and balanced.
• 46:25So we had all of these different work
• 46:28groups as well as I mentioned the
• 46:30publications looked at things from
• 46:33their own and DS M5 as you see in
• 46:37DSM5T R there are that was edited to
• 46:40reflect on structural bias and racism.
• 46:43So the text, if you look at it,
• 46:45it's different in a TR version
• 46:47than the five outcomes.
• 46:48We had 19 action items.
• 46:50I knew one was not going to pass
• 46:52and justifiably because of what we
• 46:54learned from our from our consultants.
• 46:56But we had a historic 18 accepted
• 46:59by the Board of trustees.
• 47:01They voted on 18 and accepted them.
• 47:03Now usually they just accept the
• 47:05report and it sits on a shelf.
• 47:07And my research before I got started
• 47:10with the task force showed me that
• 47:14we have the consultants we had.
• 47:17We have now have a section in the
• 47:19medical director CEO's report that
• 47:21describes all of the anti racism
• 47:23and equity and inclusion initiatives
• 47:27in one section.
• 47:28Because it turned out we were doing
• 47:30a lot of things that we weren't
• 47:32aware that we were doing.
• 47:33But once you compile them,
• 47:35you can see that as a body of work,
• 47:38we reviewed on the strategic
• 47:40initiative at every board meeting and
• 47:42everybody has a plaque in front of
• 47:44them to remind them of what they are.
• 47:47And one of the survey questions after
• 47:49board meetings were did I include diversity,
• 47:52equity,
• 47:52inclusion in all of the deliberations.
• 47:55Also did the group and did the
• 47:57chairman or the president of
• 47:59the APA who chairs the group.
• 48:01We had several town halls work
• 48:04group meetings and we also concern
• 48:06firm that a PAAPPN is looking at
• 48:09specific readings and diversity,
• 48:11equity, inclusion,
• 48:12structural racism or and made
• 48:15to include in maintenance
• 48:18of certification readings.
• 48:21We removed the
• 48:25the likeness of Benjamin Rush.
• 48:26It had already been moved but removed.
• 48:28But he owned slaves, among other things,
• 48:31and so now people have an option
• 48:34to turn in their own old fellows
• 48:37medals and badges and to get the
• 48:39new one with the brain on it.
• 48:41And they were two resident projects and
• 48:43we are extremely proud of our residents.
• 48:45Under Doctor DK's leadership,
• 48:47they developed a model curriculum
• 48:50for A on structural bias, diversity,
• 48:52equity, inclusion and a database
• 48:54for resident concern.
• 48:56So now when you go to an APA meeting
• 48:58on there is a way to report when
• 49:02you experience bias and they're
• 49:03looking at that and the trends to see
• 49:05what's going on and if there are any
• 49:07patterns how they can approach that.
• 49:09So in terms of ally ship,
• 49:11this is what I leave you with.
• 49:13If you see something wrong,
• 49:14say something,
• 49:14be accountable to yourself and
• 49:16look with them.
• 49:17Don't forget cultural humility
• 49:19because those concepts are we are
• 49:22taught in psychotherapy training,
• 49:24but they also can apply to
• 49:26other aspects of our lives.
• 49:27Focus on self-care to reduce
• 49:30extrinsic bias because we know
• 49:32that extrinsic bias and influences
• 49:35how we treat our patients,
• 49:38especially certain groups of patients
• 49:40or certain class of patients.
• 49:42Equity councils can help but don't
• 49:44overburden your colleagues because they
• 49:46don't want to be the expert on black people.
• 49:48There's not one black person,
• 49:49but they don't want to be the
• 49:51expert on people who have physical,
• 49:52who are differently abled or who
• 49:55speak Spanish or what have you.
• 49:57And don't forget about the invisible pack.
• 49:59Pack privileges situation specific
• 50:01and we must be cognizant of that
• 50:05and and everything we do.
• 50:07So basically now where are things we
• 50:09have the structural racism accountability
• 50:10committee they're required to report
• 50:12to the board and every board member.
• 50:15Looking at those 18 action items,
• 50:18we've gotten some of them completed and
• 50:20closed but we're still working on other
• 50:22ones and that is charge of work committee.
• 50:27But in 2023,
• 50:28it was moved to the membership
• 50:30under the membership committee.
• 50:32So we look forward to seeing at our next
• 50:34board meeting in October how far it's
• 50:36gone and what we need to propel things ahead.
• 50:39And I'd like to end with this
• 50:40quote from Barack Obama.
• 50:42You can be completely right and you
• 50:43still are going to have to engage
• 50:45folks who disagree with you.
• 50:46So don't try to shut folks out.
• 50:47Don't try to shut them down,
• 50:48no matter how much you might disagree
• 50:50with them.
• 50:51And thank you for your time.
• 50:52And I was able to add a couple of
• 50:54slides I had limited because you're so
• 50:56gracious with your time and I'm going to.