2021 Physician Leadership Virtual Journal Club: Diversity, Equity and Inclusion

Daryl Oakes: Welcome and good afternoon to the June session of Stanford CME Physician Leadership Virtual Journal Club. I am Daryl Oakes.

Ruth Adewuya: And I am Ruth Adewuya.

Oakes: And we will be your host today. The format of this series is a live facilitated webinar with pre-assigned topics and articles for discussion. Each month, we will ask the registrants to submit their questions in advance of the session, but there will also be opportunities to add to the discussion during the session via the live chat function. And really the goal of this virtual journal club program is to provide practicing physicians in all levels of leaderships and insights and management skills to help them be more effective in their leadership and their clinical environments.

Adewuya: Today's discussion will focus on promoting diversity, equity and inclusion in our organizations. And we believe that physician leaders need skills to enable equity and inclusion in their workplace. And organizations need scalable ways to ensure that their diversity and inclusion initiatives are solid and sustainable. We will begin with an overview of this month's articles, followed by Q&A panel discussion. And we're very grateful to have three expert panelists who we will be introducing to you later on in this session. With that, I will turn it over to Daryl to share her slides.

Oakes: Thanks, Ruth. We have three excellent articles today to discuss, and we have an amazing panel, as you mentioned. So I'm really excited about today's session. The first article we will discuss is by Julie Silver and her colleagues, and it is called Physician Workforce Disparities and Patient Care. And it is really looking at the question of whether workforce disparities among physicians impact patient care. And I think what is really notable about this article is that it points out workforce disparities experienced by different groups of physicians, including women, racial and ethnic minority individuals, LBGTQ individuals with disabilities and individuals who identify with multiple minority identities termed intersectional.

So first physicians in these specific groups often face significant barriers to even entering medicine. And they are notably underrepresented in our professional workforce. Women, for example, make up only 35% of active physicians. And this gender disparity is even more pronounced in some subspecialties. For instance, only 5.3% of orthopedic surgeons are women. Second, these groups experience a number of professional disparities for women and many ethnic minorities, salary compensation is significantly lower than for their non-minority group colleagues. One example of this is for women in primary care, and it has been noted that they make 18% less than their male colleagues. And this salary gap is actually not getting better, but it's getting worse over the last decade.

Other disparities that are encountered by these groups include being less likely to be promoted, less likely to attain leadership positions, less likely receive grant funding or recognition for their work. And also the physicians in these groups are more likely to report experiencing bias and discrimination in their workplace. And even if this is unintended and nothing is meant by it, these experiences can be very stressful for many individuals and have been shown to contribute to significantly higher rates of burnout in these groups. And these experiences also have a powerful negative impact on mental health. Notably rates of suicide among women physicians is 2.27 times higher than the general population. And this is compared to 1.41 for male physicians.

These physician workplace disparities, not only impact physicians, but also ultimately negatively impact patients. Physicians that are trying to manage discrimination or microaggressions in their workplace must expend extra emotional energy and time dealing with these issues. And this can potentially interfere with their professional productivity. In addition, these burdens can lead to higher rates of burnout in physicians as mentioned earlier, and this can lead to higher rates of physician turnover, which causes care disruptions for patients. Loss of these physicians from medical practice exacerbates overall physician workforce shortages and disproportionately impacts our minority communities where most of these communities are already experiencing pretty acute shortages in health care providers.

And the loss of diversity among our physician workforce really limits opportunities for patient physician concordance. And this has been shown to improve care for many minority group patients. One example of this has been underrepresented minority patients that have demonstrated increased satisfaction, increased communication, better adherence to primary prevention recommendations, improved utilization of health care resources when they have a concordant provider. And other studies have showed that women have a two to three times higher rate of survival when they present with myocardial infarction when they have a female emergency room provider.

So it's really apparent that these disparities are problematic, but the real question is what can we actually do? And Silver and colleagues actually provide a very extensive list of examples of targeted interventions that organizations can employ to address some of these challenges. And these interventions focus on a number of areas, including mitigating burnout and decreasing bias and discrimination really through increased research, education and even mandated expectations. They also encourage the fostering of cultural competency and humility as profession wide expectations as well as lifelong learning processes, rather than one off trainings.

They also encourage greater attention to patient physician communication through specific skill development for physicians to help address the needs of minority patients who aren't feeling that they're able to communicate well with their provider. They also address reducing physician debt and in part by looking at ways to mitigate the training costs for medical education and medical training, and as well as paying attention to ensuring that salary compensation is equitable for all providers, regardless of gender and or race and ethnicity. And finally, they promote efforts by organizations to show their commitment to diversity initiatives and to support the study of workforce disparities.

So take home points are that disparities in the physician workforce exist. They negatively impact physicians of diverse backgrounds. And that burnout in the subsequent loss of these physicians from medicine negatively impact patients either by disrupting care, by decreasing the number and diversity of our physician workforce, which then exacerbates workforce shortages and limits opportunities for patient physician concordance. And this article also emphasizes that there are targeted strategies that can be implemented to improve the professional environment for minority group physicians and that these need to be addressed.

So our second article is called The Impact of Unconscious Bias in Health care: How to Recognize and Mitigate It. And this article is by one of our expert panelists today, Dr Bonnie Maldonado and her colleagues. And this article reviews how unconscious bias impacts our professional environment and also presents tools for how it can be managed. So we'll start with what is unconscious bias? Unconscious bias, and it's sometimes termed implicit bias, really describes the associations or attitudes that we all reflexively have that alter our perceptions. And as a result can impact our behavior, our interactions and our decision making. And now this tendency to make our rapid and maybe reflexive judgment may have offered some vantage in our early ancestry when we were trying to escape dangerous situations. But now in our current environments, these mental shortcuts really have unintended and often problematic results. And in the setting of medicine, these unconscious biases can have really harmful effects to our patients and to our physician colleagues.

So as a result, recognizing bias is very important and it's very important particularly in medicine. And as the authors interestingly pointed out, we may actually unintentionally encourage stereotype thinking in medical education. And this may happen particularly when we emphasize automatic associations of certain diseases with certain patient populations, but this type of mnemonics or mental shortcuts actually can hamper the overall ability to recognize disease and populations are maybe non associated. And one prominent example of this has been the often under-diagnosis of serious heart disease in women because of the emphasis of heart disease in male populations.

Now, also unintended disparities often are the result of these unacknowledged biases, and they have real consequences that be it in medical school admissions, in patient care or in faculty hiring, promotion and professional development. And it makes it important for us to recognize bias in ourselves, in our environments. And some tools that we can employ to maybe measure unconscious bias and make it more evident are tools like the Implicit Association Test, which is a test that utilizes reaction times to various positive and negative associations to help determine a person's implicit bias. And this test can help make people somewhat more aware of their unconscious biases. So hopefully, they can then act accordingly to avoid their impact.

So while it's important to first recognize that bias exists, it is also critical that we then develop real and concrete strategies to mitigate bias and hopefully decrease the negative impacts that it can have. And this is really something that requires a multi prong approach and needs to be addressed at many levels. So I think first, at the organizational level. And leadership really must commit to a culture shift. And Dr Maldonado discusses how institutions need to create capacity for change. And this really involves not only recruiting underrepresented individuals to the organization, but also recruiting critical action leaders. And these are individuals who are empowered to be change agents and are able to work to create more equitable environments in the organization.

And also diversity training though, very important needs to more than just an isolated activity. It really needs to be embedded and integrated into all of the processes of the organization. And the organization needs to encourage its members to act in ways that help promote diversity by actively engaging with different cultures and groups to minimize stereotyped thinking to practice cultural humility and curiosity, and to also actively mentor and actively offer sponsorship to individuals that bring diversity to the organization. And as an individual, one can also practice self reflection to better recognize our own personal biases. And we can also work actively to counteract stereotypes and microaggressions when we see them occur in our environments.

To manage and minimize our own personal biases, the authors have suggested some basic guidelines that can be followed. They suggest that first, we need to just be aware of our subconscious preferences, whether it's by a process of reflection or by taking something like the Implicit Association Test. Second, we need to be systematic in the way we make decisions so that we avoid having them be altered by these preconceived ideas. And third, we need to be open to new ideas and perspectives so that we can have a more equitable approach. But since we are human and there may be situations where we make a mistake and unintentionally commit a microaggression, the article also suggests ways that we can mitigate the harm when this happens. And the first step is really just recognizing that what we did, although our intent might have been different, that it may have had a harmful impact. And then we need to acknowledge the unintentional bias and the impact to the person who was affected. And finally, we need to make an effort to repair the relationship, try to rebuild trust, and also demonstrate and work to learn from the experience.

And what do we do if we see and witness stereotyping behaviors and microaggressions in our environment? How can we be active bystanders, or as some have said up-standers? The Kirwan Institute has delineated a four-step approach to what we can do in these situations. And step one really involves simply recognizing and acknowledging that bias occurred in the interaction. And step two is to make an active decision to address the bias. And this is actually a critical step in that sometimes the pain of the microaggression on the individual is at one level, but sometimes there's an additional damage that occurs when there is a lack of response by bystanders and peers, because it appears to the individual affected that everyone around them has some complicity or agreement with the behavior. And that can be very isolating for the person. So it is incredibly important to actually say something as best we can.

And then number three is what to say. These are some suggestions for some active strategies that can be used. So whether it's humor to defuse the situation or reject the stereotype, whether it's asking questions to clarify the intent of the situation or naming this comfort with the behavior or frankly just being direct about what has occurred. And finally, step four, which I think is often under emphasized is the importance of continuing conversation beyond the interaction. And this is to maintain the relationship with the person impacted by the microaggression and also to foster ongoing positive behaviors amongst the person who may have committed the microaggression.

So in summary, this article reviews what unconscious bias is and how these types of attitudes or stereotypes can unknowingly alter our perceptions of the world and may affect our behavior and decision making. And that these biases, even if they're unintentional, can have real and negative impacts. And also the importance of understanding that there are strategies that we can employ to mitigate unconscious bias. Many of them are multifactorial. They involve bias awareness, culture change, countering stereotypes and intentional group diversification.

And our last article is by Dr Robert Livingston, and it is How to Promote Racial Equity in the Workplace. A five-step plan. Dr Livingston is a social psychologist at the Harvard Kennedy school. And he has consulted to numerous Fortune 500 companies, private sector and nonprofit organizations. And in this article, he presents his approach to promoting diversity in organizations. And I really find this article particularly relevant to our audience here in this journal club, because many of our audience are leaders or aspiring leaders. And this is because Livingston points out that leaders have a unique opportunity to use their influence from their position to affect the norms and the policies in the workplace. And this can allow them to be powerful agents to promote racial equity.

But the caveat, of course, is that these leaders, if they want to be effective in creating change, they really need to focus on recognizing underlying issues and rather than just aiming for quick or visible fixes. And he makes a nice analogy to a medical treatment that if we only focus on the symptoms and we don't try to diagnose and cure the underlying disease, we may not actually be helping the patient.

And as Livingston points at out, the first step is recognizing that there actually is a problem. And more specifically recognizing that the lack of diversity and racial equity in organizations may really reflect the underlying problem with racism in our society. But since racism is often assumed to imply intent or overt action, it is often very difficult and uncomfortable for people to recognize. But I will quote Livingston here. He says, “Racism, defined simply as the differential evaluation or treatment based solely on race, regardless of intent, occurs far more frequently than most white people suspect.”

And I just love this image here as it really depicts so well and powerfully the impact of these different ideas, a quality, although a wonderful idea, if it doesn't address and acknowledge the differences. If it's not paired with equity, it really doesn't produce a fair result. And then the last panel, the reality that the disparities in our workplace are often so much more extreme than we would like to believe. And so in order to build racial diversity in our organization, Livingston offers a roadmap to racial equity. And he describes five stages that an organization must move through to create real change. He summarizes this process with this acronym, he calls press.

And the first stages involve P, problem awareness and our root analysis. And in this stage, organizations must first really identify the condition of the environment specifically, what is the problem and where is the problem coming from. And next, the stage E, empathy, does the organization care enough about the problem and the people at harms to provide it with sufficient motivation to move to action? And finally, the S is strategy and sacrifice. Does the organization have sufficient strategies to correct the problem? Is it willing to make the necessary sacrifices to implement those strategies? And with our final summary, leaders really can play an important role to promote change in their workplaces, but they really need to address and focus on the underlying issues of racism in their organization to do this well. And for organizations to achieve diversity and racial equity, they need to move through the processes, including recognizing a problem, having a motivation to improve and employing effective strategies that involve being willing to make the necessary sacrifices.

So with that, we get to the part of our session where we get to interact with our amazing panel and discuss these very interesting concepts. And I will turn it over to Ruth now to introduce our expert panelists.

Adewuya: Thank you so much, Daryl, for that overview. We are pleased to have… We have our expert panelists for our journal club today. We have Dr Bonnie Maldonado, who is the endowed professor of global health and infectious diseases, the professor of pediatrics and epidemiology and population health, the division chief of the pediatric infectious diseases and the senior associate dean in the office of faculty development and diversity. Dr Maldonado thanks for being with us today.

Dr Bonnie Maldonado: Thank you so much, Ruth, and Daryl as well.

Oakes: Thank you, you're welcome.

Adewuya: Next, we have Dr Terrance Mayes who's the associate dean for equity and strategic initiatives and the executive director of the Commission on Justice and Equity here at Stanford Medicine. Thanks for being here.

Mayes: Great to be here.

Adewuya: And we also have Dr Felipe Perez, who is a clinical assistant professor in the division of pediatric anesthesiology and the assistant dean for diversity and medical student education in the Office of Diversity in Medical Education. Thanks for being here, Dr Perez.

Felipe Perez: Great to be here. Thank you for having us.

Adewuya: So thank you all for being part of this discussion. And we had received a few questions in advance of this session. But I think a great place for us to start this discussion is to begin to impact why this conversation of diversity, equity and inclusion is important in the conversation of physician leadership. I'll start with you, Dr Mayes, what are your thoughts on its importance in this context?

Dr Terrance Mayes: Thank you for the question, Ruth. I'll start my first acknowledging that this has been tremendously challenging year or two, I think to say the least. And there isn't any silver lining, certainly in the racial injustices that we've seen in our country. There isn't the silver lining and the disproportionate impact of the COVID-19 pandemic that we've seen on communities of color. But what I will say and one thing that's given me hope and optimism, it is that I am seeing that we're having these much more often than we did in the past. And I think that is a good thing. We're actually talking about bias, unconscious and explicit. We're talking about racism, anti-black racism, anti-Asian racism. And I think, again, that is a great thing.

Daryl mentioned in the introduction that I am the executive director of Stanford Medicine's Commission on Justice and Equity, which was created and charged by our dean and CEOs of our hospitals to really examine our institutional culture and come up with recommendations around dismantling systemic racism that exists within our walls and outside of the walls of Stanford as well. We issued our recommendations about a month ago. And the very top, the very first recommendation was around leadership commitment. And the recommendation was that, look, if we are serious about moving the needle, we're serious about dismantling systemic racism, we're serious about creating more inclusive environments, this is going to require executive leadership commitment and really commitment throughout your organization. But we recognize that culture change starts at the top.

And what I'll say because a question that I often get, and I think it's related to your question, Ruth, is how do we convince leaders that this is the right thing to do? And I'll say this, and then I'll pass it to the other panelists. And I think with DEI, with diversity equity and inclusion, with health equity as well, just like with any other function in the organization, we really have to practice making the business case and thinking through how will this advance our organizational strategy and goals.

I would love for all leaders to be just intrinsically motivated to do DEI, to invest in DEI. I'd imagine everyone who's here today has that intrinsic motivation. But we know that it's not the way it works across the board. That's not the case across the board. And we have to answer the question what's in it for me, what's in it for the organization? And I'm not just talking about abstract diversity equals creativity and innovation, although that's important, but rather more specifically things like if we invest in recruiting and retaining underrepresented minority students, that will lead to a higher productivity, that will lead to faster graduation rates for grad students, that will lead to money saved. Things that are academic and medical leaders care about. Creating this education and training effort around anti racism, around unconscious bias will lead to fewer discrimination cases, which will lead to money being saved. Again, what's in it for me? What's in it for the organization? That's the business case that we need to make.

Adewuya: Thank you. Dr Maldonado, Dr Perez, any additional comments to what was just shared?

Maldonado: So I've been in this office now since 2014. And I have to say that when I first took this on, nobody encouraged me to take this office on. Nobody. They said, “It's not good for your career, you're going to be pigeonholed,” all kinds of interesting comments about what would happen to me personally if I did this. Now, I had to think a lot about it. Unfortunately, my career has been pretty robust over the years. I'm a full tenured professor and have done a lot of work in my area of infectious diseases and global child health. But it was an area that I felt encouraged, because I did feel that our leadership was committed. And obviously it's taken now seven years at least in my time here. And before that, Hannah Valentine, who really started the office under Phil Piso.

So I would say that it does take a lot of leadership commitment and it does take your recognition of what it might be doing to your career as well if you're going to launch this, because you really need to have the backing of the institution. And I think it's really just something that every individual just needs to put some thought into. What am I going to do? And who's going to be, not only my ally, but who's going to spa answer this work and make sure that it has teeth, that it has real meaning, that people are committed at the institutional level? And so far I have to say that over the last seven years, things have gone, I think very well. But I think over the last year, because of the tragedies that we've seen over and over again, the commitment has only really been amplified.

I do think that everything Terrance said I would agree with, but also have to recall that strategically, you should really think about what your path is going to be, because you want to make sure that you have some specific goals in mind when you go into this.

Adewuya: Excellent. And Dr Perez, I saw you nodding when Dr Maldonado was talking about people telling her to think about taking this on. It looked 0 you had a similar experience.

Perez: I think at the time that I've become now the assistant dean, it's been more accepted as a potential to grow in an area of academia. And I think it's becoming more recognized, but I did start working on diversity efforts back in 2015. And at that time, it was not popular to be working in this area. And it just wasn't things that were being recognized as academic as people's worth of time and definitely the minority tax [inaudible] tax is something that was placed and burdened on minorities to continue that work without it being recognized.

Adewuya: Excellent. Thanks for highlighting that. Let's jump right into some of the questions from the articles. And I'll start with you, Dr Maldonado, about the article that you wrote with your colleagues. And the question is that in your article, in that article, it mentions that intent and impact are distinct. And so in our very culturally diverse society, it can happen so easily and quickly that someone can feel discriminated against or negatively impacted without the intent or even the notice of the offender. How can we foster a culture in our organizations which acknowledges this, but also does not break down or judge the person who has committed that microaggression without intent?

Maldonado: That's a great question. And I do think there's a lot of trust involved here. I think really building the trust across the entire enterprise, meaning the hospitals, the medical school, among trainees, staff at both hospital and medical school, as well as the faculty, that trust really needs to be built. And it doesn't happen overnight. It really does require a bottom up and a top down approach. I don't think you can do just one or the other, because it is true that many of the microaggressions that occur are really not, as we talked about in our article, they're unconscious. People may not really realize what they're saying or they may actually think they're doing something positive when they say what they do.

And we cannot pretend, first of all, to be all things to all people. That's just not going to happen. And it shouldn't. I think everybody has to acknowledge that we are all coming… We have to try to build a position where we realize that we can try to communicate with one another our similarities and our differences and be honest about, look, I may say something that might be not acceptable to you. I don't know that. I just need to be honest. And it is by talking about these things with you that I will learn what your sensibilities are and you can learn what mine are. And so I think that needs to be a bidirectional approach and it takes a lot of work. But building the overall culture of trust that it takes to get people to that point is important.

And in addition, breaking down the walls of anger and resentment on all sides, and those are hard to do as well, because there can be anger and resentment on both sides. People feeling that person's getting a break that I'm not getting, actually from both sides, let me say that, and realizing that's really not what we're trying to do here. We're to make sure that people get the opportunity to be their best self, no matter who you are. And that may mean different things to different people. So this is where these DEI groups can really be helpful and the leadership can be help in promoting that and making sure that, that it is safe to express your own feelings, but recognizing that you may not get it right. And for the other party to recognize that they should be able to be open minded and just express in a nonjudgmental way, this is how you're making me feel and how am I making you feel. So having it truly be bidirectional is really, I think the aim. And putting up walls at this point is just not going to be productive.

Perez: Yeah, that's a great question, Ruth, that you're being up. And Bonnie, I completely agree that it's a top down and bottom-up approach. One of the culture changes that we recently seen in medicine has been the issue of patient safety. I remember in medical school going through medical school, and that was not a topic that was discussed or taught at that time. ACGME requires us to all be trained in patient safety and quality improvement. I still remember as a medical student being afraid to stand up and be an up-stander when a medication error was about to occur as an anesthesiologist. Or once it did occur, it was not allowed to be shared with the patient or the institution.

Now, institutions have created top-down approaches where it's very safe to report of safes. Actually, that's what they're called, where we report errors. And then Bonnie said it the best all human being are, but they are frequently and in predictable pattern ways. And they came out with the Institute of Medicine about how we can prevent errors and near misses. In the same way that we've been able to see a culture change in medicine and where a nurse feels comfortable speaking to a surgeon saying, “Hey, that's the wrong site surgery or hey, anesthesiologist, have you given the antibiotics.” The same way that we can be up-standers in our operating rooms as anesthesiologist in our clinics, in the hospital floors and we are able to speak up.

And I think as long as the hospital system creates a system of reporting and support for the offender, as well as a person who witnessed it and so that we can all grow together, I think that's the way that we're see change occurring. But it does involve leadership investing in hospital committees, systems and officers the same way they did for patient safety.

Mayes: Just really quickly add to what Felipe said, because really the quote that you pulled from Atul Gawande, that we all air and we all air predictably. What I found in doing this work is that one of the biggest barriers to creating inclusion and understanding and listening across difference is really guilt and shame. I think we sometimes get stuck in shame. And if someone tells us that we did or said something that they perceive to be micro aggressive, we immediately hear that as you're calling me racist or you're calling me sexist or homophobic or you name the oppressive type of individual. And it's difficult for us to separate the intent versus the impact, which was your question.

And I think one thing that I would like to see organizations do as we're rolling out more trainings and development around microaggression is really focus on leveling the playing field. We all commit microaggressions. I think that's really important to acknowledge even those of us who are people of color, women, everyone commits microaggression, and it's because we all live in a society in which stereotypes exist. And so unknowingly, even we begin to absorb those stereotypes. And so I think when we level the playing field and acknowledge that microaggressions, aren't reserved just for the cisgender male, we all do it. That allows us to separate again the intent versus the impact and approach, just a place of humility and wanting to learn. And I think when we commit a microaggression and we're confronted, it doesn't feel good. It's not supposed to feel good, but we should use that as a learning opportunity. We should apologize. We should use it as a learning opportunity, and then we should move on and try not to do it again.

Adewuya: That's great. And in line with this thread of conversation, and I'll start with you, Dr Mayes, Robert Livingston in his article does talk about this promoting safe spaces for people who experience racism, where they can share experiences. And the question is how do we create, number one, and sustain interest in bringing everyone to this space so that they can listen and share and develop empathy and apologize as you mentioned?

Mayes: Yeah, again, thank you for the question. It's a tough one, because I think when you're talking about things like racism and racial trauma, these are really sensitive topics. And for many of us, they're really personal topics. And I can only feel comfortable revealing my trauma to organization if there is mutual trust. Dr Maldonado talked about this. And I think the mutual trust needs to ideally be established pre-trauma. And so we shouldn't wait for there to be a national crisis to begin having these conversations. I think if we're creating a culture of belonging, a culture of inclusion, we're always having these sometimes called difficult conversations around race and other forms of social identity. So I think creating the environment in which this is just commonplace discussion is the first and most important step. But then I think accountability is critical as well. If I come to you again, organization is that you and I share a grievance, I share an experience. That needs to be treated with the utmost respect, dignity, and humanity. And the moment that does not occur, it's really difficult to regain that trust.

Oakes: I just have something to respond to some of those comments, because I think in medicine, we often are very uncomfortable with mistakes, just aren't acceptable. And so I think I'm wondering also then tying into what you said, Felipe, about what we did in the safety realm, we made it about the process, not the person. And I'm curious if there's an opportunity in this environment to emphasize the process rather than the person to make it safe for people to acknowledge when they've said something that hurt somebody.

Perez: Thanks, Dr Oakes. I think that's a great point. And I think we've seen it within our anesthesiology department this year, where we've focused on the process of how can we move forward to make a safe environment for our colleagues and our patients, and to have an area of discussion. Anesthesiologists are perfectionist. And if we make an error, it can definitely harm individuals. So we don't like mistakes. So we have created systems in place such as morbidity and mortality conferences, where we discuss situations that have led to harm at a time or prevented a near miss or potential harm that could have happened to our patient.

So we used actually those systems that we have currently in place to allow for discussions of racism. And we saw in our pediatric anesthesiology division use morbidity and mortality report conference, where we discussed a situation where a patient felt that they had experienced racism. And we used the processes of safety to go through the process of how we could improve and implement safety measures, not for safety of the patient, necessarily in the same way that we think about medications, but rather a cultural change that we needed to change and adapt within our systems. We also used the safe report system to use it as a newsletter. And we reported out the same way that we report incidents of harm that we reported out this incident of racism.

So I do see as a potential system based issue where we could create systems that would improve the situation. However, there are some things that we shouldn't tolerate. And we do need to focus on the patient education or on the coworker education part. And so we definitely need to focus and definitely include that part into our systems that we are creating.

Adewuya: Thanks for sharing those insights. Going back to the idea of unconscious bias and explicit bias, Dr Maldonado, I have a question for you around this. And it starts with a statement of seems like to some degree, unconscious bias is more difficult to experience and manage than explicit bias. And so oftentimes, individuals spend a lot of cognitive energy trying to decide if their negative experience of a moment or behavior is real or warranted. And then in addition, the individual will then need to decide if and how they want to respond. So now here's the question, how can we address this additional mental burden that we place in our minority group physician colleagues? I'm curious to get your thoughts on that.

Maldonado: Yeah, that's a tough one. Frankly, I think there is going to be a continued burden on the minority population or the population who's at most risk in general. That's just, unfortunately, the way I view the path to equity is just going to be a disproportionate one. I do think this is where up-standard training has been quite helpful. I do think that people are really starting to understand what that concept of bystander moving to up-stander training will be. And the more we can really infiltrate those thoughts into the majority group, whatever that might be defined as, I think the more we can lift that burden.

I think coming back to the issues around defensiveness and perfectionism and feeling lack of mistakes, et cetera, I like to go back and I know it's been somewhat controversial, but Malcolm Gladwell's book, Blink, and to a certain extent, talking to strangers. And then Daniel Kahneman's book on Thinking, Fast and Slow. We're scientists. So I think for all of us in the health professions, in the scientific community, at least we can try to think about it in that way, because this is what we're supposed to be. We're quantitative beings, and more than anything else, we try to look at evidence based.

And when you look at it that way, it's much easier, I think in some ways to construct the motivations of unconscious bias and maybe to lessen the burden on one person, at least by understanding that it's just a natural phenomenon. Now, granted at a certain point, I remember going back years when I was a junior faculty member and watching different films and speakers talk about the, we call them the ton of feathers. And that really resonated with me. I was a young faculty member trying to get tenure. I had three little kids. I have a very supportive spouse, but still you're the mom. And there's just a lot going on in, and just trying to do all of that on top of having to face these issues and not knowing am I just making it up? Is it all in my head? Is it just me? Am I just the bad person? Or is this something that's happening to all of us? And then you have to talk about…

I'm bringing a lot of issues in here, obviously. I want to catch them all before we get to the end. But then there's intersectionality. You're a woman of color. So is it because I'm a woman or a minority or both or is it just me? There's all of this self-doubt and imposter syndrome comes into play. I think I'm throwing it all at you at once, but that's essentially why I think it's still going to be hard for people who are in these situations. The LGBTQ aspect, for example, if you're on top of that or even just alone, dealing with issues around gender and how we just haven't really embraced that yet. I don't think we mean to, it's just built into who we are. We're a binary society. It's either one or the other. It's very difficult to understand what's not binary.

And I think some of these books, at least help me understand how people think. And it helped me in my office deconstruct how we do that in an institutional practice. For example, in hiring, in selecting candidates, in doing evaluations. When you pre specify a template, you can then lay it out in a way that pulls you away from that automatic binary thinking, whatever the binary is. And so we really need to think and build that into our systems, because that will lessen the burden on the individual. And in the meantime, we need to support those people, because it's ongoing. It's amazing.

And when I first learned about imposter syndrome, I was a resident a long time ago. I won't tell you when, but a long time ago. And it's still extremely pervasive and we should be developing the tools to help everybody deal with that. And it's not a snowflake issue. This is stuff that's happened forever. We just all were told to just buck up, get strong and deal with it. And yes, we will do that, but I think how much more productive we could be if we didn't have to deal with those issues. So it is a learning process.

And one thing I could say about this particular time is through all of the strife and the angst and the death and the destruction that we're seeing in the last year from the COVID pandemic as well as the recognition of the racism that's institutionally based, that we can at least come out of this with some constructive learnings that we can use to really pivot our societal approaches to race, ethnic and every other-ism that we're facing in this, that we've always faced. And really learn how to think slow and carefully about these things so that we can build not only a more equitable society, but to really lift that additional burden that any group that feels oppressed is going through.

Oakes: Those are all excellent points and there are a lot of them there. And I think one that stuck out to me too, is the tendency to feel isolated when these things happen. And I think the recent moment of recognization that many people are recognizing and there's been heightened awareness, I think has allowed people to network better and hopefully eliminate some of the isolation that people feel when these things occur. And the tendency to assume it's that person, it's them as opposed to recognizing and seeing the patterns. But I think building structures where people are more connected so that they can be productive about their responses as opposed to just feeling like it's them and then dropping out.

Mayes: Yeah, a lesson I just pulled from Bonnie's remarks when she was describing her experiences as a young faculty member and juggling a lot of different things, she said, “I had a strong support system.” And I think faculty, other leaders, aspiring leaders, particularly those who come from underrepresented backgrounds, it's critical that we have strong support structures, whether it's our families, our colleagues, mentorship. Bonnie didn't talk about mentorship, but I'd imagine she had strong mentors at that time. And I know for a fact that she serves as a mentor for many others, including myself. I cannot overstate the importance of mentorship, sponsorship as a means of counteracting the real effects of the minority tax.

Adewuya: Wow. Excellent. Dr Perez, do you have additional comments to those insights?

Perez: Yeah, no, I think Bonnie and Terrance says it very well. And thanks to Terrance's report for highlighting a lot of the changes that could occur at institution level to allow for these institution and push our leadership here at Stanford heard. But I think something that is true is that leadership in creating those areas of support can come definitely from the administration in terms of funding resources and providing those safe places. So when things do occur, you do have the support you need. And then within the bottom up we talk about how do we create that support system? And I think I just encourage people to look outside their own division, outside their own departments, and really collaborate across different departments, different divisions within their organizations, because that's where you can sometimes find very supportive individuals who are struggling with the same things that you might be.

Adewuya: I want to pivot to another angle at this, because it came up in advance of the session and it came up again today in one of the questions, which is the fact that in our conversation we've been talking about inclusion and equity in the health care, but the angle of when the problem is from the patient and how clinicians have to deal with the issue when the racist behavior is patient initiated and it impacts physicians minority female and all of that. Dr Perez, can you talk about that concept when it is patient initiated behaviors, what are some strategies or how can organizations and physician leaders respond to that?

Perez: I think it's great to be an up-stander in those moments, especially if it's happening to a colleague. I think demonstrating that our institutions have a zero tolerance for that behavior is very important to have that leadership. And you see it described in pamphlets or information that are posted around the hospital where our values are demonstrated to our patients, that, that behavior is not tolerated here at our institution. However, if it does occur, I think that again, talk about the support system that is required to support the individual that went through it is very important. And so at the moment you have to have people trained so that they can speak up and support the individual and then provide the support that's required to help them navigate coming back to work, because it is scary for individual who has to continue encountering that patient over and over again.

And so by providing a support network that allows for clinicians to support each other is very key to make that change. So I think the institution needs to have a zero-tolerance policy and share with patients and then your institution has to have the support system to help your providers through it.

Adewuya: Excellent. I know that we could continue this conversation for a long time, but we are at time. And so I would like to… You'll indulge me with one final thought as leaders in this space at the university and Stanford Medicine, what is a parting thought that you can provide to physician leaders, whether they're early in their career or aspiring? And I'll start with you Terrance, then Felipe and go to Dr Maldonado.

Mayes: So this has been a great discussion. Thank you again for having me, for having us. I guess my parting thought would be to recognize that we are all at different places on our journey towards becoming more inclusive, more anti racist. We're all on a journey, but what's important is that we're on the journey.

Adewuya: Excellent. Thank you. Dr Perez?

Perez: Yeah, I think my parting words would just be that same as Atul Gawande that error is human and that we need education and we need systems in place. And as leaders, we need to educate ourselves, make sure our medical students are educated. So changing curriculum even at the medical student level, our residents need to be educated and our faculty need to be educated as well as our patients. So through education and systems change, we'll get to where we want to be as long as we continue to analyze it and make the appropriate changes that we need to see the future that we want for our patients and for our colleagues.

Adewuya: Excellent. Thank you. Dr Maldonado?

Maldonado: Yeah. Again, I want to echo what Terrance said and thank you for having this session. I think we're at a critical moment in our history for a number of reasons. I do think that this issue might not have been brought to bear with the force and impact that it has without all of the other things that have happened to us in the last year and a half. And I want to make sure that we move forward in a very deliberate way, in a very metric driven way so that we have a sustainable change. I don't want to see this fall apart as soon as things go back to “normal” because normal wasn't that great. So I think we want to build a better normal and we have this opportunity and we don't want to forget. We want to institutionalize, but flexible opportunities to really interact with each other in ways that can make us all a much more collaborative and productive colleagues and friends. The sustainable piece of this is just super important.

Adewuya: Excellent. Thank you very much.

Oakes: Thank you to all of you. Thank you, Ruth too. This is just an amazing discussion and I so appreciate us getting to have it. And obviously, there's more to be said. Just was so impressed with the conversation.

Adewuya: It was fantastic. Thank you all so very much for sharing your insights with us today. Thank you again very much for participating in today's session.

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Authors

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Daryl A. Oakes, MD

Clinical Associate Professor of Anesthesiology, Perioperative and Pain Medicine

Stanford University

Course Director, Faculty

Nothing to disclose

Yvonne Maldonado, MD

Senior Associate Dean, Faculty Development and Diversity, Taube Professor of Global Health and Infectious Diseases, Professor of Pediatrics (Infectious Diseases) and of Epidemiology and Population Health

Stanford University School of Medicine

Faculty Member

Terrance Mayes, EdD

Associate Dean for Equity and Strategic Initiatives

Stanford Medicine

Faculty

Felipe D Perez, MD

LEAD Steering Committee, Clinical Assistant Professor

Anesthesiology/Stanford University School of Medicine

Faculty

Ruth Adewuya, MD

Managing Director, CME

Stanford University School of Medicine

Faculty, Planner