On behalf of the AOFAS, we want to welcome you to tonight's program, AOFAS on the same page, Bias Training for Medical Professionals. Our chairs tonight are Gary Stewart and Tanya Dixon. You can find their disclosures in the program document posted in the chat box and on the On Demand Education Center. Hello and good evening. Thank you for taking your time this evening to enjoy our journal club. This is on the same page. Sometimes we do books, sometimes we do journals, and I know that this is a busy time of year for many of us. So this is going to be pretty informal, you know, looking at some journals, talking about implicit bias. So grab your beverage of choice and kind of sit back and we'll get to it for you. We're going to start first just to kind of give an overview. You know, we've talked about a number of topics this year from health care inequalities, race and women's health care. We discussed allyship in October, and today we're really going to focus on implicit bias. Now, this is something that I would think many of us know, but maybe not. And that's why you're tuning in today. And so I'm just going to give a definition of implicit bias today. It has numerous definitions in terms of how people say it, but basically it's a bias or prejudice that occurs automatically or unintentionally that affects judgment, decisions and behavior. This is not something that makes you a bad person, doesn't mean you should be stoned or something like that, but it is ingrained in our nature as humans to have an unconscious or an implicit bias. But why does that become important in medicine? Because we as physicians are entrusted to do no harm. And the biases that we find in ourselves can influence our clinical practice behaviors. So identifying implicit bias in ourselves can help us to better take care of our patients, to do no harm and to become better physicians. So without further ado, we're going to get started on our first article. Jacqueline, are you ready to go? All right, let's do it. Thank you, Amit. Thank you. Yes. OK, so my article was entitled Becoming Active Bystanders and Advocates Teaching Medical Students to Respond to Bias in the Clinical Setting. And this group basically held a one hour workshop for medical students at Vanderbilt to try to teach them how to respond to situations of bias and microaggressions. And overall, they found it to be successful. So the author started off by stating that 40 percent of medical school graduates report experiencing bias, humiliation or discrimination based on a personal trait. And I think we all know here that it's quite common, not only in all aspects of medicine, but really everywhere. And so what they did is they just held a one hour workshop for the kind of earlier med students. And they first started off by explaining definitions and some concepts, and then they went into case examples. And so just kind of some concepts that they want to emphasize was that bias and biases and microaggressions are experienced differently by individuals, but that it is a shared responsibility of everyone to foster a community of safety and belonging. And I mean, I think that's just important to to repeat again, because, you know, there's some people who think that, you know, it doesn't apply to them or or they weren't involved. But really what they're trying to teach is that everyone has a role and everyone can participate in making the culture better. And then they also they wanted to establish a learning environment, kind of like what Gary just said, not not blaming anyone or making anyone feel bad, but really explaining that we're all prone to, you know, saying biased things, even when we don't realize we are. And that the most important thing is just to recognize it and learn from it. And then also explaining that the just the term microaggression is actually really inaccurate because it's they often have a big impact on the victim. So they the the method that they used is the five D's. And so those are these are different ways in which one can respond in these situations. And so it's direct, distract, delegate, delay and display. And so going through those individually, the first one direct is responding in the moment with a direct response. So it's a verbal response. And that could be saying something like that's inappropriate, that's racist, please stop. And the key to this is to try to keep it short and succinct and to not engage in an argument or get into a debate because that's how the situation can escalate. And then you can you can say that and then kind of direct your attention to the person who is the victim. Okay, distract is the second one. And that's trying to diffuse the situation by by distracting. So either that could be ignoring the person who just said something offensive, and instead engaging with the victim. Or it could be just trying to change the subject completely. The third one is delegate. And that is, you know, delegating responsibility to someone else. So later, asking someone to someone else to kind of talk to the person who may have said something. So, you know, in our setting, that could be another attending or a program director, chief resident. Then the third or the fourth one is delay. And so that's then speaking with either the, the, the perpetrator or the victim at a later time point. And if it's if you're speaking with the victim later, it could be something like asking them if they're okay, or acknowledging that what you saw was inappropriate and asking how you may support them. And then the last one is display discomfort. And that's a nonverbal way of using body language to just express discomfort in the moment. And so, so again, those are the five D's. What they also wanted to say is that there's no one superior way of responding, they're all important to just different tools and different ways in which we can respond. And they wanted to give a variety of method of ways in which to respond, because every situation is different and, you know, the relationship between the people is different and especially with hierarchies it. So having options is important. So, they, in terms of their, their results they after this one hour workshop, they found that, or they pulled the students and found that 90% of them felt more confident in being able to respond and react in these situations. And then eight months later, they again, pulled them and asked if they had used any of the tools that they had. And really the one that the students had started using was the displaying discomfort. The other four, there was no change in their use. And, you know, the other four are, they're different. It takes, it's, it's more direct, it's, it's, it takes more courage. So, they, they also stated that some of the barriers to being able to respond to these situations include the hierarchy, you know, of course, in the medical setting hierarchies quite entrenched, questioning whether the incident was important enough to report and not knowing how the victim may want the situation handled. But overall, you know, I think they were able to accomplish a lot in a one hour workshop, and the response was very positive and most of the students wanted further training. And, you know, I think this is certainly something that would be great to see in med schools, residencies, fellowships, I mean, at our meetings, basically everywhere, because I, I know, certainly for myself, I was, have been, you know, very caught off guard by these comments, and you really don't know how to respond in the moment. So I think, I think it's important to talk about it beforehand, because they often do catch everyone off guard. So my question for the group was, has anyone here used any of these techniques? And if so, how was it received? And did it lead to any change? I'll jump right in here. And just kind of say that, you know, it's interesting, because I'm here in Atlanta, and I actually see Dr. Manning walking on the belt, on our belt line, every now and then, and follow her all the time. Now that, you know, that was racist, that was sexist, that was homophobic, you know, and then I'll say, look, let's just talk about this later. And is that the right way? You know, I would think that someone who had true courage would be like, that's racist. Bye. Like, I, you know, I think it would be, I find that this is helpful because you need something to kind of follow. But I have been in situations where people have just said, that's racist. Bye. And I'd be like, wow. Thank you. And, you know, I'm working to be more like that because that's not everyone's personality to be able to do that. And I do feel like you talked about a hierarchy, right? I'm at the position now where I'm an attending and a chief of the division. And I did have to do that this summer. And I had to tell someone, you know, two people thought they were making kind of a funny conversation. It might have been funny if they were both with each other, but it was offensive to the rest of us. And I had to say, stop. And then I did contact them later and explain to them why it was so horrible what they were doing. And of course they didn't, you know, they, they, they accepted it, that particular person. But I think a courageous way would have been like, stop, leave now. And so, you know, I think that it's important to speak out and everyone has to do it in their own way, I think, to be comfortable. Gary, the only, I totally agree with you. The only thing I would worry about with that is that if, if it was truly an unconscious bias and per your definition, like this, sorry, Jacqueline's ever, who's ever, I can't remember who said the definition, then it was theoretically unintentional. And so you lose the opportunity of a teaching moment. I think if somebody says something really blatantly, you know, racist, sexist, or whatever, I actually find it quite easy to call people out where I am in my life right now. I think that oftentimes, you know, maybe I need to curtail it and again, use it as a teaching moment and say, hey, look, you know, I know you didn't mean it that way, but it could be perceived this way and you may have made this person uncomfortable and really like you need to change the way you're talking. So I agree. Sometimes people just deserve and need to be shut down. But also, if it really is unconscious bias, maybe, you know, using it as a teaching moment, you know, might work as well. Yeah, I agree with that. You know, it's definitely probably uncomfortable to do that. And, you know, as you get further on in your career and older, you know, you get that mentality of like, I don't care, I'll go ahead and just address the situation. But, you know, it is uncomfortable. And I think these skills for, you know, the students, the residents are important so that they can become comfortable. And I think the more we have these discussions, you know, the better. You know, for me, I always want to, you know, as a woman and with the microaggressions is always being called by my first name and I always, especially with the patients, I'm like, I want to be like, what possessing you to call me by my first name, but I don't say that because I don't want to offend them. And then, you know, they're put off by me, you know, I get a bad, you know, review, they don't refer anybody. And it just for me just trying to understand more of why they, you know, want to call me Tanya instead of Dr. Nixon, even though, you know, my male colleague was to be in the room, it would be, you know, Dr. So and so. So I don't know if anybody has any thoughts on that one because that's what I always struggle with, because you don't want to be rude. How do you introduce yourself? Hi, I'm Tanya Dixon, Dr. Tanya Dixon. I bet if you said, because I always say hi, I'm Holly Johnson, and I sort of invite people to call me Holly Johnson and as somebody pointed out to me once that's a privilege that I get to do that. Clearly, it's a privilege to be able to be called by your for me to feel that whereas, you know, somebody was basically trying to say to me that you make it sound like it's not a big as big a deal to be where you are, but that's a privilege to be in your position. This is a whole nother discussion, but it really opened my eyes to that. Yeah. Anyways, I bet if you introduce yourself as Dr. Dixon, nobody will call you Tanya. No, I have and then they'll say, Do you mind if I call you Tanya, and then I'm like kind of stumped. Yeah, that's a good one. Well, I don't Wow, maybe is that like a Midwestern thing or something? Maybe. So I'm just like, Okay, I'm like, Sure, you know, because I don't want to be mean and I don't want to lose out on that patient, you know, and my residents are in the room like what just happened. So, it's, it's, it's a challenge but a battle I don't have the energy to fight but I'm always intrigued if someone else had a different approach to that. And my colleagues, you know, my male partners will walk in and introduce themselves the same way. They don't get may I call you, you know, Michael, it's Dr. So and so. Maybe it's not so much of a microaggression or an insult maybe it's a comfort level. Maybe, maybe they, you know, you could look at it another way where they feel super comfortable with you and it's a warmth that you give off. That could also be they're not intimidated by you. I like that. I think, I think my micro aggression is always the being that, and it's out of the work, but being transport or cleaning staff or. And, you know, it happened a lot more when I was younger. And part of it is I heard Scott Porter one time kind of say somebody thought he was a cleaning staff person he just started cleaning the room now. I'm not going to go that far. But it is one of those things where the term micro aggression when you talk to people and try to educate them on biases or whatever I just wish I had a different name, because it's not small at all. And I know they address that in this article. And for those that are trying to learn what micro aggressions are. It's, it really isn't micro but when you discuss it, it kind of makes it seem like it's a small chipping away, and I realized that it was in a paper, you know, 40 years ago and I don't think they realized when they were writing that that it was going thing they probably could have hoped it but I just wish somehow we could slowly change the term into something a little to what it really amounts to, because it's not a chipping away at you at your soul is kind of it would, it is just an offensive, it's offensive. It's just what it is. I'm reading this really great book right now that's called Just Work by Kim Scott. I don't know if anybody has read it, but it's just a fantastic book where she talks about bias, you know, prejudice, bullying in the workplace. And one of the key points I've kind of taken away from her, at least the way she describes it, and I think it's a good way to look at it, is that unconscious bias is, it is unintentional in many ways. And we all have our own unconscious bias. I mean, you sort of have to be aware of it and you're gonna say things, and we all are gonna say things sometimes that kind of reveal that. But when it's bias, unconscious bias, the author of this book asserts that it is changeable. And a person with unconscious bias is not fixed in their belief necessarily. And that's how she distinguishes bias from prejudice. Prejudice is fixed, it is a fixed belief, and you're probably not gonna change that in that person. And unconscious bias, I don't know that we can all change our biases. I mean, I guess there could be some debate around that, but we can at least manage them and understand them and be open to correction if our bias starts to show. So it's interesting, because in this book she really talks about when you are dealing with unconscious bias in the workplace, she proposes bias interruptions rather than talking. I mean, she talks a lot about being an upstander, but having it be okay to interrupt bias when it happens is way more effective than after the fact, trying to do something about it later. But she does say that it's important that a bias interruption is not a criticism. Criticisms maybe are things that feel like criticism should be kept in private, but a bias interruption should just be something where you're just calling attention to that it happened. And if you work in a workplace where everyone kind of embraces the idea of trying to reduce bias and pay attention to that, you do it in a way that everybody's like, oh, okay, that makes sense. And maybe you talk about why it hit you that way, but I recommend it to everyone, Just Work by Kim Scott, it's very good. It gives a great perspective on some of this stuff. Well, thank you. Tanya just posted the book in the chat. So thank you, Tanya, for that. It's on my list for books to read. So I love having more to continue the education. Might be a book club book. Right, right, for next year. Yeah, it's a good book. It's like, she's a woman who's been in the tech industry, but I honestly read the book and I was like, Kim, have you been following me around? Have you been like spying on my life? I feel like so many of these things are exactly what's happened. Like I've experienced so many of the things in the book. So it was affirming, felt good to read and really good to think about your own biases and the way those come out in the workplace. Yeah, I think a lot of times we're focused on how unconscious bias affects us, but I think we also have to be aware that any of us, no matter who we are, we have our own unconscious bias and we have to have to think about that. Thank you all for that discussion. Connie, would you like to move on to your article? Sure, so I had the JAOS article, the training room entitled, Dear Program Director Solutions for Handling and Preventing Abusive Behaviors During Surgical Residency Training. I mean, I think most, you know, the bad rep of surgical residencies is that they're hard. There's a lot of bullying. And I think that goes for all specialties, you know, not just ours. But this article talks about how Speak Up Ortho on the social media platform that was founded on a culture of how ortho may dissuade women from going into orthopedics because of the harassment, bullying, whatnot, that's been notorious in the path. And it talks about, you know, the barriers, you know, female and, you know, I read this and was like, you know what, some males, you know, experience bullying, discrimination, harassment, or sexual harassment. And it's not reported due to, you know, fear of retaliation. It may be because surgical specialties may be associated with normalizing this bad behavior. I'm sure that many of us, you know, or have family members who think of surgeons as, you know, having this bad rep because of, you know, the harassment that they give to nurses, you know, trainees, et cetera, or, you know, that, you know, people just don't report because of lack of trust of the reporting process. I mean, who wants to, you know, say something bad happened to them for fear of they're going to look bad upon, how is that going to reflect their career choice? You know, because these are, you know, oftentimes it's hierarchical. And so it's, you know, faculty members, program directors, chairmen who are doing this bad behavior. And you're like, okay, this person holds a critical piece to my career. And so what they did in the article, they did an online survey and asked, or grabbed 200 orthopedic resident stories where they were able to respond to either one of four statements, talking about, you know, any awareness, reporting experiences, advocacy, and action. And they analyzed this information and found that the five most commonly reported abusive behaviors were sexual harassment, bullying, harassment, sexual discrimination, and microaggressions. The offenders, of course, were attendees, senior residents, program director, chairman, nurse, or the patients, you know, themselves. They stated that they did not report due to fear of retaliation, detriment to their career, or fear of being judged negatively. And then those few people who reported that they had reported, but had a negative experience with their reporting was due to lack of confidentiality. So it was found out that they were the reportee. Lack of accountability, or nothing was done to the offender. And this is one where, you know, even in my own institution, not myself personally, but one of my former female attendings was harassed by, you know, one of her male partners, and, you know, was told, and nothing was done about this. It was kind of just like brushed off. He's just being himself, you know, and that's the type of thing that we need to change. And I love that this article offered up 12 solutions of how to improve this bad behavior and make it better. So the first thing that they offered was the culture of the program, you know, right? It comes from the top down. And thankfully I can say that this type of behavior is not tolerated at my institution anymore. We actually just matched a all-female class, and there was some kind of disgruntlements talked about among some of the residents. And our chairman took those residents in and said, hey, it's not gonna be tolerated. If you keep this up, you're out. And I think that was awesome because it shows that, you know, number one, it's coming from the top down as this article stated. And two, there's a consequence, right? You know, I think the article says that there's not a, what's gonna happen if this behavior continues? You know, it actually, he firmly stated that there is a consequence to this bad behavior. Unfortunately, you know, I have not heard of anything lately. So I'm hoping that things are changing because our chairman is not tolerant of this bad behavior. And it was, you know, said to the residents, but also to my partners as well. They talked about number two was defining and educating. So, you know, continuing these discussions, these dialogues, you know, having training every year that talks about, you know, what is harassment? I'm sure we all have to do this for our institutions, but making sure that that's an important, critical part of training. I know I have to do it every year, but it had me thinking of, is this something that the residents have to do every year? I know I have to do that training as a staff or University of Cincinnati, but I don't know if it necessarily, the residents, you know, have to do it. Having a clear code of conduct, you know, it's kind of sad to say that, you know, we have to have these, it feels like common sense, you know, ways to behave, but, you know, having a clear written out code of conduct is necessary. Knowing the Title IX mandatory reporting, you know, making sure everyone is aware of that. I'll be honest, I did not learn about any of that until I, you know, came as a resident. You know, it's not really something talked about, I feel, in undergrad or in medical school, but, you know, continuing this constant dialogue I think is important. Having a reporting process and implementing and maintaining confidentiality. I think that is one of the biggest things that people fear. They can't report because of the consequences that's going to happen to them, but we, you know, we need to know so that we can change this behavior, but we also want them to be able to remain anonymous. Having a designated resident advocate, I think this is a interesting way of, you know, identifying a resident or two that would, what, number one, be, you know, a confidant that the resident could go to, a medical student could go to if they had this issue, and then bring it up to the higher powers to address the issue and make sure, you know, it's, number one, addressed, that they reach out to the, you know, the individual if they happen to say it's okay to talk to them, because of course they need to maintain confidentiality, but ensure that this gets resolved and the offender reprimanded. Having an ombuds person, I, you know, wasn't, this wasn't something on my radar, but I looked to see, and yes, the University of Cincinnati has an office where you can call if you have, you know, an issue like this and report it so that even, I liked it, if you're having these thoughts of, did this actually happen? You know, how does this make me feel? Someone to talk to, to, you know, see if what you're going through is actually, you know, a problem, you know, and trying to just listen to them and see what kind of solutions they have. And then, of course, this person is not related to the department, you know, not related to any, any, you know, aspect of their career, just more of someone who's there to be an advocate on their behalf. And, you know, when they wrote this article, they listed in 2015, there were only 35 medical schools that had an ombudsman office. And so hopefully there's been more since that. You know, having defined consequences, if you were to be found guilty or, you know, of being an offender, support for the victims. I think that's one of the, you know, the things is, you know, they feel not heard. They don't feel supported. So it leads to depression, anxiety, you know, poor sleep, you know, change in health, eating, and this can have some detrimental effects on their mental health, you know, and possibly, you know, worse is, you know, leading to suicide or something that we want to try and prevent. Bystander intervention, simulation training, you know, so these are some of the things that we've already talked about. I know we haven't done anything like that, but I think just having repeated, you know, trainings and discussions and having these journal clubs, I think is important for permitting the change. I liked this one, vetting leaders, you know, so asking them, had they ever been accused or, you know, any form of harassment, you know, that was filed against them. And of course, you know, the article says they probably won't be honest about it, but asking that question will kind of let them know that it's not tolerated. And so I think that was a great question and maybe something we even ask, you know, residents during, you know, residency interviews, like, you know, because they're just as much an offender as attending. So, you know, maybe it's something to ask our resident applicants. And then lastly, they talked about in this article was, of course, if there's someone who's repeatedly, you know, has this issue, or if residents don't wanna talk about a certain rotation or a certain individual, that might be a red flag for you to investigate more and then pulling residents from that service, that attending. Don't allow the residents to interact with an individual. And we recently had to do that with one of our faculty members. And I loved that the department was like, okay, we're not doing this anymore. Enough is enough. Cause it was, you know, oh, this is just how he is. That he's a high producing, high money maker for the department. But we said enough is enough and pulled the residents. So I think the, I'm witnessing it in my own department and I think that's great. So my question to all of you are, are there any ways your institutions are doing any of this or anything different that wasn't discussed in the article that might be, you know, worthwhile for us to bring back to our institutions? I think it's all well and good that they put that in the paper, but is it really being implemented? I mean, I guess that's what your question is. I can tell you with 100% certainty that it is not at my former institution, but, you know, I think that that's the question is how do you implement this and how do you know it's being implemented? But I don't know. Yeah, that's a tough one. Yeah, I definitely, just to follow up on what Holly said, you know, all of these mechanisms, reporting mechanisms, code of conduct, they're only as good as the institution in which they are made. And if the leadership of a department does not have a commitment, and Tanya, I loved what you said, this came up in that book too, that the leadership has to be committed to saying, we're not doing this. And regardless of how high a producer someone is, or if they have NIH funding, or if they have all these things that seem valuable to the department, if they're detrimental to a culture of inclusivity and belonging, if they don't follow the code of conduct, you have to say, you're out, you're done. We're not going to have you here. And being willing to get rid of those people who have previously, you know, based on metrics on paper, looked like people you want to keep to say it's not worth it. Because in the end, it's going to drag us down and make us less productive to have those people in our midst. So I think, you know, all these things are well and good, but, you know, like Holly, I've seen places where, yeah, they might have some of these things in place, but it's not like they're effective because the leadership as a whole does not support, you know, the overall initiative. Thank you, Tom. Oh, go ahead, Rob. Maybe a little bit far field but I'm just wondering if, if, if leadership in different organizations. You know starts to act along this way I wonder are. What will other people know about it, because if it becomes essentially an HR issue I don't know if you've had the experience of people getting removed or escorted out very frequently. We never, you never get the details of why or what the person did. And so I wonder if there will be. You know there'll be teaching moments because we may. I mean, you know, you may you may hear from the grapevine what happened, but for the most of the time when there's official action, it's very private and and confidential. And so, you know, someone might, you know, they're, they didn't meet the standards of the organization and now they're not here anymore. And I think that's always a frustration. When, when you, when you see someone make a misstep, and maybe not be able to understand what what they did and how you could self correct behavior. Yeah, I think that's kind of tough because, you know, are they doing it to maintain confidentiality and protect that individual. But then at the same time, are you saying to the person who was abused that okay they're gone but we're not gonna say why, because we're trying to protect them and I feel like it's a kind of a bit of a battle. Thank you, Tonya I think that that was very good in terms of discussion, just like it seems when you have a physician that's in trouble for any number of things, they may be dismissed from an organization or they can resign. And then, you know, maybe they travel across the country and get a new job. And then they, you know, sometimes continue that behavior and don't learn much. But the lesson can be learned for the people that are there. And so, if there are no further questions on that. I'm going to move on to the next article, which is med ed portal article from the AMC journal of teaching and learning resources. Primary office, author and corresponding author is Christina Gonzalez from D and med. And it's how assumptions and preferences can affect patient care and introduction to implicit bias for first year medical students. And so what this particular paper is doing is they describe basically a two hour session in which they are teaching implicit bias to first year medical students. And they go over, basically saying this study was discussed, discussing a design to progress learners to accept implicit bias within themselves, and its potential to influence future clinical practice behavior. It's also can be used as we go through this we'll see in terms of faculty development. And so, they have a number of appendices that you can use to try to do this program yourself and help faculty in the structure of implicit by instructing. The way they approach this was to like I said first have people accept that implicit biases within themselves, and for the many of us on this call. It may seem kind of innate that we have implicit bias we've maybe read about it and understand, but for some people that really goes to their core of who they may have their being is to find out that they have biases against other people. And so just allow people to understand that so that they can then try to correct it, because I do believe the literature says that with work, you can address your biases. They kind of did it through a very kind of educational PhD kind of methods in terms of it was designed and what they call transformative learning theory, and that learning theory has four components, which would be an experience, which is this particular moment in their teaching this to our moment, critical reflection guided discourse and behavior change. Now they did say that they're not really weren't really able to see behavioral change, but they did come up with methods to kind of analyze this. And what they highlighted was they really wanted to do this in medical students, before they kind of had their professional identity, kind of when you're really going in, you're wide open, you're really eager to learn new things, and really highlighting implicit bias not as a kind of personality fault, but a component of professional development, which I thought was good just like anything else that we learn in medicine, as we're nascent in the field and just trying to absorb anything. And the goal was to safely and respectfully introduced to med students to the concept. The facilitators had about two and a half hours of training. The students had no required knowledge that there was no reading or anything beforehand they just had to show up. And so what they use was second, third and fourth year med students with a faculty member to co facilities facilitate small groups. And so they have a one hour session that was done by the in this particular case the primary author, who has done research in this field, and then they had smaller groups for the following hour and we'll go into a little bit and how they did that. The idea of using second, third and fourth year students as well as with a faculty members that they felt that, and do their research that near peers would be able to kind of give them a level of comfort. So the first hour of this two hour session, done, kind of in their orientation week. Introduce the concept of implicit bias. Many people don't even know what that is. And then they normalize it kind of normalizing it. And when we are I've given implicit bias letters and maybe some of you have is just, hey, it's, it's okay, you know, this is something that we all have the stigmatize it. This is this kind of going through and educating people at the beginning of this one hour lecture discussed its ubiquity, that it's all around us all of us display it doesn't make you a good or bad person. Clarify the association between implicit bias and racism. And if you've done any work in some of this in a racial space. Once you start talking about race sometimes people just shut down or become very offended and then you can't really make any headway. And then the relevance to clinical care, which when we're talking to especially orthopedic surgeons and even trying to qualify why we have a DEI committee, our society and some of our other trade societies, is that this is really about patient care. How it relates. So the author did this in this one hour lecture. And if anyone's interested to see what this lecture is they have actually the slides because they hoping that you may want to do this. And they have it I believe in Appendix B. And then take a 15 minute break, which really isn't that long a break when you think about it. And then they break the students into small groups. They assign the students randomly because they didn't want to go in alphabetical order because then you'd have certain surnames that would be for certain ethnicities if you go in alphabetical order so they tried to do this randomly. And as I said, they'd have a second, third, fourth year student with a faculty member. And in this small group during the hour they would be debrief kind of discuss what the thoughts were of people in this small group from the larger lecture, the one hour lecture that was given to the whole group. They had some honest inquiry, honest reaction, explored some personal narratives and develop strategies to become aware of when their biases are activated. Some of the things they changed along the way were that instead of what they used to do at the medical school was that they'd give a morning session like this and then the two hour session and then they do an afternoon session. But they decided to do everyone at once because if you can remember kind of orientation week you're meeting people and the people that have to go in the afternoon might have lunch with the people that went in the morning and then they were kind of coming in defensive, you know, coming in hot, as you will, this kind of not as responsive to it so they just did one big lecture, and they would do like a word cloud kind of anonymous polling that they just stopped because when they would put that word cloud on the screen it would influence people and so that's kind of as they were talking about what they were doing, they change. They also talked in this article, a little bit more about how they did their facilitator training. The second, third and fourth year students. They usually were people that have taken a healthcare disparities elected from their school. The faculty were small group facilitators that were kind of teaching and courses that were with communication skills and professionalism, their trainings again about two and a half hours. If this is something that you're interested in doing an appendix D and outlines our goals they're learning objectives a timeline for the sessions, and how to deliver this content. The trainings were structured so that facilitators could experience the group, like the students so when they structured this way they kind of wanted to give a feel so that they know what their students would be going to. Now with anything you have to do some type of evaluation. And in their evaluation this got a little bit of PhD in education, he first say that they use this Kirk Patrick's educational outcomes. And this was a modification and that they had a level one which is a learner reaction a level two. which was modification of attitudes and perceptions and acquisition of knowledge and skills and it was just how they decided to kind of measure this was more qualitative in a mess, where they analyze strategies that were provided by some of the students, and they analyze responses to a prompt and an example of the proper be, you know, identify one strategy you can use to become aware of when you are making an assumption that may lead you to jump to a conclusion about something someone else. That's essentially you know if you're able to do that. You have to understand what a piece of bias is you have to be able to define it you have to identify it in yourself. And you need to have some way to kind of respond to that. And so, you know, they use that method to kind of test and evaluate. So how do they go about their results in this article. So they demonstrated knowledge as I said from that Kirkland kind of educational outcome by identifying the strategies that students came up in response to that prompts or certain prompts. And that analysis resulted in certain themes and these things were humility reflection and partnering, and I thought that was, you know, you know, I thought that was kind of interesting and they gave kind of a quote of what humility would be. And humility would be kind of approaching this encounter with an intellectual humility and in that is, you know, a cognitive realization of your own limitations. Who are you, and what are your beliefs remaining inquisitive during interpersonal interactions, possibly instead of judgmental wanting to immerse in yourself in new experiences, and as you're, you know, when they talk about trying to change your biases. Those are some of the things that suggests like hey, you know, have you ever been in a room where you were the minority will try it. Okay. And so, then there's a reflection piece, you know, own, you know, your own behavior, and really kind of seeing the meaning and the interactions that may be related to bias in you, and then this thing called partnering, which was recognizing verbal and non verbal behaviors of the other person in our category would be patients that may have jumped to a conclusion due to their own, you know, do your own biases so if you're sitting in a room you walk into the room and you see someone, you may have these biases, you have to buy your biases you have to realize what they are, and try to address them. And you can sometimes guess when you get into the room and you may have said something. And you can see kind of the body language of the patient. Well, we're teaching no medical students clinical skills now. And these are some things that some of us are very empathetic some of us have that emotional kind of quality about us that we're able to read some of us need to be taught some of that. And that's what they're doing. And so what they also did in the results was identify certain pitfalls successive things that went well, and future opportunities. When I was looking through this, what I really was taken taken by that this is such a different approach you know this is you know social science sociology science. And some of the things that they are measuring you know isn't the LF as score or what have you. But it's just as relevant. You know, when I talked about the humility theme. They said you know ask questions have a genuine curiosity about you. When you're trying to go through implicit bias, take time to reflect. Note when a negative thought pops up don't you know stab yourself in the eye and when you kind of have a prejudice first response, acknowledge that and deal with it, where does that come from. And as you put that you know on the patient or person you're working with partnering meaning that, you know, you have people that are your patients and kind of try to do better about reading what they're doing. And so what I got from this is that I was pretty amazed that I think that, you know, we kind of go over this implicit bias, we're trying to teach people about it. This is what this is about today. But they have a two hour session, they give you slides that they seem to show was effective, especially in early learning. And so that's a way that we could possibly do something like this, and possibly even teach others to teach others about implicit bias and so I thought that they gave the tools and slides and the tendencies for us all to use. I think they did a very good job of looking over their six years and kind of changing things from 2015 to 2020. They even discussed how in 2020 they went to a zoom format because of COVID, and they discussed how we can all do that as a zoom format. And so, this was a different kind of article wasn't necessarily trying to. I would say highlight anything but kind of educate on how we can educate others on implicit bias. And so they also kind of discuss some things that they may have done differently in terms of the first year students, where some of the students that were from underrepresented minorities felt like everyone were kind of looking at them to kind of teach, and those from privileged backgrounds felt like they were being blamed. They didn't really have a solution for that. I bet some of that is a byproduct of this type of work and takes patience and empathy and explanation and time that this two hour session is just a start. I think this is this is a start, and all of this is a start so as we go through this article. My question would be to the group. Does anybody think they'd want to try this in their organization, or can they see a way to kind of try doing something like this. I think as we're as we're experiencing right now it's a matter of getting getting folks to show up and participate right so it's it's hard to get people to sit down for, you know, even even an hour or two and have some introspection and, and get that type of education, especially when it's, it can be uncomfortable, but certainly where our organization has been pretty good is things like communication and having difficult critical conversations that type of thing we've, you know, we tend to push education in that regard and that, that there's certainly awareness of implicit bias and, you know, there's in Michigan there's state training that's part of your medical licensure that has to go on, you know, to check the box. But in terms of, you know, interaction and group work and maybe having having hit home and settle in. We certainly have not done much of that to this point. I think it would be, I think it's easy to do it with the residents and the medical students because we have them captive. I don't. The hardest part is, again, as you pointed out, I mean we have 20 people on this out of 2200, you know, it's hard to get people to to take the time to do it, and you know most people think that they don't have a problem with unconscious bias I think if you were to pull most people, they would. They would deny that they have unconscious bias, or they don't understand it. Um, so, well, I, I think in theory, it would be awesome. Um, I think realistically, it would be hard to implement it. I would love to. I just think it would be a challenge. Yeah, I agree. I feel like it has to come from the top down, you know, maybe the chairman says, all right, this is what we're going to be doing at our practice meeting. You know, you have to come show up, but until someone's ready to do that, I think it's, it's definitely going to be hard. Again, as Holly said, we, you know, we have the medical students, we have the residents, you know, that we have that captive audience, but for, you know, our partners, it's. The buy in, I think, you know, for all of us who keep showing up to these things, I think it's good because hopefully we're, you know, continuing that change, um, but probably a little lonely for us. Let, let me join in the conversation if that's okay. This is Tom Clanton. And, and so I can give a little perspective on what it was like long ago, because I'm really old. And I think things have definitely changed for the positive. I mean, I remember being in the residency program in San Antonio under Charlie Rockwood, and we had the very first female resident in the program. That was 1973. So definitely a long time ago. And we look at the people that we have in residency positions as instructors nowadays. I mean, we have some incredible female staff members and, and, you know, I just had a group of my last fellows, we had three fellows, two from the United States and one from Norway. All female, and they were great. And they, I think that, you know, we can see McAlgas Hogan now is chairman at the Department of Orthopedic Surgery at Pittsburgh. I mean that's amazing, you know, taking over for Freddy food. And we need more of that, for sure. But I think that the society is moving in that direction. Maybe more so than some of the other societies is is my observation. Thank you for that. Thank you for being on this call. I do believe that we have made some tremendous strides. I do. You know, being involved in diversity, equity and inclusion and belonging work. I do. I'm very proud of a FAS of what we're doing and seeing some of the changes. I definitely would like to see that when we have our symposiums and our WLA symposium at the meeting that we didn't get you know we don't get the bad kind of exodus, just to try to, you know, I don't, and I hate to look at the folks that are on the call right and or preaching to the choir because there are people that are there that are very interested. But I am. And I just kind of sit and ask people like what can we do to just have folks be more interested in something like this because, you know, many of us early on I mean in my training early on I mean the, the person that I was in 2000 when I started my internship and the person I am now from all of the learning and stuff I've done in this field is completely different. And if it weren't for some of the stuff, just being things that I guess lack of better word forced to do, and then having a natural interest just due to my hue per se, you know, it's made me a better doctor in terms of patient care, all patient care. And I think if you are asked our patients where people have complaints about what we do or where you're sued is not because you did a difficult surgery that went poorly or your surgery went poorly. It's because of that personal interaction and getting people to understand how important that is, is something that I haven't cracked a code for, but obviously something has happened and likely due to people like you, Dr. And, you know, those on the call that have gone in and out, and the efforts of everyone in AFS in terms of the board and foundation and stuff but just kind of getting that buy in. You know, if you have a flat foot. Yeah, okay, but this is this is important stuff but I think we all recognize that and there's some great things start small. Yeah, I would recommend that we ask Elaine, who's on the call. Some of the ways that we might be able to keep people in the meeting, when we're discussing this lane. You have any thoughts on that. Yeah, at the annual meeting this coming year and Alina is on the call to. We've already been talking with, you know, Dr. Hunt can hunts program chair where we can put the symposium. And, you know, it's valuable real estate, those of you who've been involved in planning the annual meeting, but we don't want it at the end of the day on Friday we wanted a time when people will be in the room and I think the, the topics that we have this and the speakers, you know, Gary can talk about who they are I think it'll be exciting who's going to be coming to the annual meeting and Louisville. I think that can make a big difference. Overall working. Well we're getting towards you know long in the teeth of the night. But we've got someone batting cleanups to knock it out of the park. Lorena. Without further ado, if you want to go through your article. Absolutely. Okay, so the last article of the night. This was an article published in 2020 in the media portal of the American, I think in the American Society of Medical College Journal of Teaching and Learning Resources, and the title of these article is I didn't know what to say, and is basically a workshop that they developed that in Indiana University on a specific approach on how to participate and respond to racism, discrimination and microaggressions, and the approach is, is an observation of like the tactics that they want to develop during this workshop that is basically observe why think, feel and desire. So this was a foolish for by for authors, the first authors are the creators of the workshop, which is silk so to Santiago and Jacqueline Mac, both at Indiana University, and the educational objectives of the workshop, as they develop was mainly increasing about conversations how whoever experiences that with conversations, feel comfortable, whether it's communicating or not communicating in the situation regarding microaggression discrimination racism, and how they can acknowledge and start practicing this algorithm that for them, it will be a good communication tool to respond. And when we talk about microaggression racism and discrimination, the first thing as we were talking through the past articles is mainly, what is the definition and the use of definition that was published by Victor Smith that a mainly was microaggressions are defined as subtle verbal and nonverbal insults directed at people in love color, often automatically or unconsciously. And the other definition was that layer insults based on whether it's race, gender, class, sexuality or language immigration status. And finally, the cumulative insults, which cause unnecessary stress and people of color. So once we have those definitions clear, they look at how we can address the cut between like actually when we're looking at an institution, and we want to actually create in terms of work environment relationships, but also with patients. So they the goal of these was to develop these workshop to decrease or to address the gap that is necessary to create more equity and diversity environments. And the methods of the paper were basically about the workshop, it was a development of the program. This program, as I mentioned before, it was developed in 2018. And it was part of a sequential workshops that the university was developing in terms of what the goal of the explore topics as minorization, stereotype threat, emotional labor, code switching, racial battle fatigue. So it was part of like a big group of workshops that they were developing around those years. And one of the key points of these workshop, it was including how microaggressions can be very important in how we can address racism, discrimination and bias. The prerequisite of the being part of this workshop, it was that the of whether the facilitators or the presenters or who were involved in the workshop should have to have some knowledge about equity, and they had to have knowledge about equity, inclusion, and these in terms of how they have experienced that, but also if they have been involved in different activities where they learn how to address these things. And the implementation of the of the workshop, it was ideally, they established the group should be between six to 18 person or people for per session, and usually the optimal length of this workshop, it was about two hours. And how the developed agenda was initially, everybody gathered together, they have like any like a food or drink, and they talk about for about 15 minutes about what would be the goals, and also to get familiar with the definitions of this discriminatory behavior, diversity related topics, and then they introduce in the workshop and scenario, and how they try to manage this, it was And I like create how we can dramatize a specific situation and they are very specific about this when they are talking about these how you can implement these in different institutions, they advise that you should try to take a situation that is very local or has been related to the area or location where you are and I think that's important because I think things changes if you are in the northeast, the south. At the end of the day, all are my progressions, but I think if you develop a workshop that is with a situation that is familiar to the participants, it will be easier and more productive in terms where you can get from the workshop. So what they did, they create two facilitators who present the idea in about the following 30 minutes after the initial discussion, and they invite like a third person that it was going to play the role of the patient, and they kind of like create the whole drama about how the situation presented. They were introducing their ideas, the facilitators and how they were thinking, they asked all the participants to think about it for about, I think it was initially for 30 seconds in silence to reflect about what they were looking at, and then the whole episode And after that, the two guests or the two main facilitators were sharing their reflections. And after that, each individual have a 10 minute reflection, where they can take notes and see how they were be going to address these and how they will, what would they will do, and why they will do a specific situation or not. And the way that they assess the goals of the workshop, it was to see if the learner increased confidence and comfort, and they did a pre-workshop, post-work survey to see how they feel comfortable looking at these situations and talking about it. And the reflection exercise had two main questions in the survey. So one, it was what motivates you to respond or not respond? Because a lot of people just stay silent. So what motivates you to not respond when you are experiencing a microaggression situation? And the second question was, what extent do you believe your role as an educator in these types of situations, whether it's your staff or you're a trainee influences the broader learning environment, where you have more trainees around you? In terms of who are the facilitators, were two individuals that have expertise in equity and inclusion topics, critical situations, and try to put the learners in that environment where they feel comfortable talking about it. In terms of the learner characteristics, there were a total of 30 people, including faculty, but not only trainees. They include everybody at the university, faculty, professional staff, residents, fellows, medical students, everybody who wanted to participate. The only requirement was that they have to have some sort of knowledge or relation to equity diversity interaction. And that, of course, include a lot of people from minorities. A total of responses of the survey was about 24. And the learners have the opportunity to discuss like four main topics about diversity. One was race or ethnicity, gender or gender identity, or gender expression, sexual orientation, and finally, spirituality and faith. And they were looking at the percentage of how they react. So when they look at the response from the trainee, based on race or ethnicity, before the survey, they argued that only 67% feel comfortable talking about it. But after doing the workshop, 92% of trainees that respond to the survey feel confident talking about it. So the change and the impact that the workshop have in this group of population was significant. Same way when they were talking about gender or sexual orientation, their confidence increased from 58% to 83% and 79% respectively. Now, when we talk about different staff, people that is not a trainee that they designated as colleagues, before, of course, their confidence was way higher compared to the trainees. It was 83% for race and ethnicity or gender or gender expression. But after the workshop, this one increased to 96% and 88%. So overall, all the participants show that the confidence after doing the workshop increased. Of course, it was more notorious in the trainee population, but everybody got some sort of benefit after doing the workshop. So when they look at the reflection exercises and the responses at why it motivates you to respond or not, the most common responses to these was why people felt that they needed to respond and one of the reasons why for others. So usually it was because they were advocating for another person that was involved in this situation. For them, it was another common response or moral values. And also when they look at why they didn't respond, it was very interesting to see that the main reasons was power dynamics. So it seems like sometimes we're afraid of what the situation can cause in our work or in the moment that we are in our location, relationship and the lack of knowledge on how to tackle issues. And I think that this is why it's so important to talk about it and makes ourselves feel comfortable with the topic. So when we are facing these situations, actually, we know how to respond. When they were discussing the results, the authors said that definitely implementing these type of programs can create some awareness and this makes people to have better tools on how to learn how to be vulnerable and feel comfortable with it. So I think, well, what is important here is how, once we are aware of the situation and we feel comfortable that we're not the only ones experiencing these, definitely will push us to be more motivated to just respond in a positive way and try to advocate not only for others but also for ourselves. So I have a question for the group. So I have a question for the group. And is, have you ever heard about the imposter syndrome and how do you feel kind of like communicating with your group when you see these type of situations? Do you talk to them that you relate to the situation or is this something that we just try to advocate for them but we don't talk deeper of the situations that we have embraced before that make us feel comfortable or just make us push to advocate for others? I would just say whoever came up with imposter syndrome is a saint. I got, you know, until they, somebody said this, I just thought I was only one. I didn't realize that this was something that professional people who are very highly qualified even experience. And so I, you know, for the longest time, you know, I've just kind of just in silence about it. And then when this kind of came out, you know, I would talk to other colleagues, kind of very trusted colleagues, and find out that this wasn't something that is rare. And so now I just state it, you know, I have trainees and medical students and children and just say, look, everybody experiences this thing, or a lot of people do, maybe not everyone, and that is really real. And I think just even saying it and admitting to it is one of those things. Different thing that the author also mentioned is that when we see these situations, it's important to whoever was exposed to these have a deeper conversation with that person. Sometimes we just do something very superficial and at the end of the day that doesn't generate an impactful change. So the more deeper that we get into the situation and make everybody aware, even whoever maybe did it, it was an implicit bias or microaggression that they were not aware. Just make them aware might make a change that just live it a little bit subtly. By the silence is it that everyone's ready to be done. Other people have to have at least a couple of comments on or not. So, well, I guess, I guess the one thing, and the keeps occurring to me is not so much I feel like in the workplace, where I, and maybe this is coming from a white male privilege standpoint quite frankly because I'm not subject to some of And that's where I'm probably my most confident and, and I'm a semi senior physician where I am and so I'm, you know, I'm in control the room and I don't have a problem telling residents or student on a problem correcting anybody if I feel like they're not doing what they should do on any level. And I think the harder parts for me when I'm is is out in areas where I'm where I'm less confident where I'm more susceptible to peer pressure, you know, the gym, the, the golf club, the, the, you know, wherever it is, where I'm probably more likely to hear, you know, macro aggression, if you know beyond micro aggression off, you know, jokes of poor taste and that type of thing and how to, you know, have the courage to speak up in those situations where I'm not the one kind of run in the room. And I think those are the places where I struggle the most and probably have the least amount of courage. Sometimes I have to work on and wrestle with. Yeah, I think that is definitely a tough scenario when you're in that that environment. You know, but even with like my family, you know, I feel like I've had the courage to call them out on some stuff that they've said I'm like, oh my gosh, you know, you know, that's, that's not appropriate, and, you know, give them a, an analogy as to, you know, what it is equal to, you know, and I think when you put it in that perspective, you know, making a teaching moment, I think it's definitely helps and I think we're circling our theme is, you know, call them out, but make it a teaching moment. And, you know, maybe say hey that's inappropriate we'll discuss it later and you know talk about it that way they're not embarrassed and because I know I would be mortified if, if I said something and, you know, I was called out on it I would be thankful because, you know, I would want to change that behavior of myself but I'd also, you know, be embarrassed and I'm sure, you know, we're not in the, the realm of trying to embarrass people but just make it educational, educational moment. Oh, I was just gonna say, sorry Gary, one, one more thing. Just that Tanya made me think of that and also, Robert. It's a good reminder that microaggressions, you know, there are certain groups of people that microaggressions happened to them in the workplace, but also happened to them in the grocery store, and at the golf club, and in the gym. And those people need us to be upstanders maybe more than anyone else. A lot of us can walk through this world and, you know, experience microaggressions in one small facet of our life or work is a big facet so I shouldn't say small but, but maybe not feel it elsewhere, but there are people who get that everywhere. And that it's like Gary said the beginning. These do chip away at someone. And, you know, the microaggression at work that really hurts them. It's not because that one instance was maybe that bad. Because it's piled on top of so many others. Thank you all for your time. You know, although the, the, you know, we had, you know, you can say only 22 people but we had 22 people but I felt that this was really a great discussion. And thank you all for your time it was it was definitely worthwhile. And we will can be continuing this in 2023. Good to see everyone, please enjoy your busiest time of the year. And thank you for giving us some time. But anyone else like to offer anything. No, I echo what you said Gary thanks for spending, you know, an hour and a half of our precious time during a busy time of year. But I am excited that we continue to do these and I think it's important to continue to do things because with each one of these I'm learning, and so therefore, I'm hoping I'm changing and facilitating the change that we're trying to embody with these, these programs. Well said time. All right. I think you all did a great job. Way to go. Thanks everybody. Have a great holiday. Happy holidays. Thank you.

implicit bias

microaggressions

discrimination

racism

medical field

unconscious biases

patient care

workshops

programs

abusive behaviors

inclusive culture

diversity and inclusion