Hi, I'm Gary Stewart, and welcome to our inaugural AOFAS on the same page book club. We will be reading Just Medicine, A Cure for Racial Inequality in American Healthcare. And next slide. So these are our disclosures. Next slide. Next slide. And so I also just wanted to offer that I'm sure you'll enjoy what we're doing tonight. And go back just a bit. I'm sorry, we weren't ready for that. And on June 29, Wednesday at eight o'clock Central Standard Time, we will be reading another book and having our second book club, which will be Doing Harm, The Truth About How Bad Medicine and Lazy Science Leave Women Dismissed, Misdiagnosed, and Sick by Maya Dusenberry. And watch for updates on AOFAS.org. Next slide. And we'd like to say thank you. This has been really a great opportunity for us. And we want to thank Stryker for funding for the AOFAS Diversity, Equity and Inclusion Initiative. The initiative is provided by the Orthopedic Foot and Ankle Foundation, supported by a grant from Stryker. So as we get started, thank you very much for the slides. As we get started, I'd like to give a few rules. I will acknowledge that we may not all agree on everything or anything. And so this is a safe space. We will not be sharing this publicly. It's for internal uses. And so one of the things that's a hallmark when we're doing this DEI work is that perfection is not required. We are all learning. Let's give each other some grace and room to grow and understand. If you have a question, please, the way this is going to work is our committee will summarize each chapter. Hopefully some discussion will be stimulated by questioning us and having us read them in the chat. So if you have a question as we are going over our book chapters and summarizing them and having a discussion, please add it to the chat room. Dr. Holly Johnson is watching. And she will let us know and we will try to address them and continue to have the wonderful discussion that we expect to have. And we'll do as many questions as we can while trying to move through the book. The goal is to get through the book. And then after that, after about an hour, we are planning to break out into breakout rooms to allow those who are listening to the committee's discussion on the book club to have more of a dialogue. But we really want this to be a back and forth. I really want to make sure that there are great questions. And let's get to it. So I'm going to start with some notes from the author that was in the preface. She wrote this book in 2015. I think we all can say that a whole lot has happened in the last seven years. And a lot of it has highlighted some of the things that involve health, you know, inequity and the diversity, equity and inclusion space. And so the author acknowledged that clinicians at this point in time are committed in general to ensuring that everyone has a fair and just opportunity to be healthy. And that the culture of health not only identifies health care disparities, but implements policies, systems and laws to reduce unequal access to social determinants such as fair pairing jobs, basic education, decent housing, safety and quality health care. Also the understanding of implicit bias is something that especially over the last seven years isn't new to many of us here. We've seen, we've read about it. And for the purposes of this book, she'd like to add that that can be called unconscious racism. Implicit bias, as she states, is the idea that everyone thinks negatively about some people without intending to, and the intent is important. And it could be said it's the nature of things of us, especially as physicians, to assign people to groups and then reacting according to traits associated with those categories. Things most people differ on is the extent to which this implicit bias influences thought, can affect and harm others, and how we can even measure this bias. And this is stuff that's addressed in this book. And so as I go into chapters one through two, and I just read that what the author prefaced, my personal goal in all this is not to be perfect, as I've said, but to understand how racism, bias, and discrimination can affect all social determinants of health. And most importantly, especially for us that are training the next generation, is to see if we could come up with a way to train our future to be non-biased practitioners. So let's start with chapter one. I'll try to time myself. Chapter one, bad law makes bad health. And so the first line is an assumption, basically, that racism is something that happens. It's unjust. And it's an avoidable discrimination based on our race and ethnicity alone, and is a fundamental cause of destruction, even deadly health care disparities in America. And this is what the author Dana Bowen Matthews, the dean at GW Law School, says. But like a lawyer, she fashions herself and begins to make a case as to this. And she doesn't just dive into it, but she starts from the beginning of our country in terms of the colonial period. Now, I personally knew that my own group, slavery is pretty horrible. I think all of us can say it. It led to poor health. There weren't happy slaves, all right? Kind of that kind of mythology that that was something that was happening was not true. I mean, they had a horrible, horrible Middle Passage travel, she states, living quarters with animals, living in sewage, poorly clothed, poorly fed, even by 16, 17 and 1800 standards. This was a horrible health care portion. But what I didn't realize until this book was that how land grants and the property ownership led to Western expansion that resulted in Native American contact with European diseases, their lack of land affected their ability to prosper and basically led to their demise. And there still continues to this day that we then moved on to the Industrial Revolution in her book. In chapter one, she talked about how ghettos were packed with immigrant workers. There were basically vectors for disease among minority populations. Now, I knew as an African-American that many African-American families have that story where someone in their family died because of they couldn't get to a certain hospital or that hospital wasn't meant for people of color. But I also didn't realize until it was brought out in this chapter, as she was laying out her case, that Chinese residents that helped build our country by building the railroad had to take some half-baked serum called a half-keen prophylactic to stop the bubonic plague, which wasn't even really happening, and that Mexican-American workers were seen as basically pathogenic for typhus. I mean, she really laid that out. I didn't realize some of that part of our history. It was interesting to see that the Black and white life expectancy from 1725 to 1853, documented by Du Bois, was so great. And that's something that still exists today. And she's, again, beginning to lay out her case as to how this was something that was happening legally at some point. And so for the longest time, it was legal for Black people and Latinos, Asians and Native Americans to have inferior health care. But then she makes the case that when it became illegal by Title VI of the Civil Rights Act of 1964, which basically said no person in the United States shall on the ground of race, color or national origin be excluded from participating in, being denied the benefits of or subjugated to discrimination under any program or activity receiving federal financial assistance. So that kind of paved the way to really kind of decrease some of this overt racism and maybe even resulting in some improvement. But then as a lawyer, she makes the case that in 2001, the teeth were taken out of Title VI. And that's where we kind of find ourselves in the pickle today because she'll get into it in the next chapter. But explicit and overt racism isn't really something that is accepted now. But she's making the point that there is an unconscious racism that is affected, that Title VI now has the teeth taken out of it, that it's not really able to be as accurate as you'd want. So it's still there, but not as big. And she states that most Americans don't have overt racism, but there's this kind of unconscious racism. And but there's a disconnect. And then I'll end chapter one on this and let there be some form of questions, I hope. But she said that six percent of white Americans say that they don't think about race at all while over, you know, and ninety five percent believe that they are unbiased. Right now, most physicians in the country are white, where thirty five percent of blacks and twenty five percent of Hispanics say that they have been discriminated against or treated unfairly in the past year, not just their whole life, but the past year. And over half blacks and Latino patients believe that health care system treats people unfairly based on their race or ethnicity. So, you know, as she goes through chapter one, she lays how there was a legal case and that there is an historical pathway for there to be health care and inequalities and people who are not white. And then she goes on to state that there is not an overt racism, but there is a kind of unconscious bias. But then many of the physicians who happen to be white don't see that. But then the patients who are suffering the consequences do. And so I was just kind of wondering, as we get on to this in front of my other committee members, you know, how many people knew some of these facts and is there any correlation to kind of foot care? Is this just our society? So when you're in your office turning doorknobs, does anything, you know, kind of come to your mind from this? Does any of this historical stuff come into play? So I spoke for a minute. Anybody on our committee want to give a shot at some of my questions? Well, Gary, I think one of the things that I learned, some of it was quite obvious, but we all know that slave travel to the Americas was horrible and a lot of those details. But I did not know the discrimination against the indigenous people that you described, Chinese immigrants, Mexicans. I mean, it was it was pretty horrific to hear that there was forceful vaccination or medicating of people where there was no risk of disease. And in fact, the the so-called vaccination wasn't even a true medication. And so that really comes back to the back to today where, you know, I really have very little tolerance for for resistance to the COVID vaccine. But then you hear stories like that and it really opens up your mind to, oh, wow, now I understand why there are some populations of people who absolutely have no trust in vaccination. But, you know, you can extrapolate that much wider. I mean, that was something, too, that I've always kind of known about the things like the Tuskegee experiment, but, you know, I just sometimes you just kind of get caught up in your own kind of, you know, background of where your folks have been discriminated against. And just to see that it was so kind of ubiquitous was something that was quite disturbing and just just concerning to us all. So. And I think it's it's also, you know, enlightening that it was policy, too, right? It wasn't just how folks were feeling. It was it was overt and intentional policy, which, you know, I think we think about today a lot. You know, we're talking about voting or what have you, you know, pick your 2022 item. But this specifically for health care goes back, you know, centuries, if you will. You know, I don't I don't think that's something that most of us know. Yeah, something that stood out to me, too, was the I mean, the fact that most Americans, I think you quoted, 95 percent don't believe that they have biases, whereas I've certainly seen I'm sure we all have seen colleagues or attendings acting with, you know, with definitely biases. And so to me, that just really shows there's a pretty big disconnect, our level of awareness and what in our in our own biases. I love that. I mean, the way you put that was completely perfect and almost a perfect subway into Chapter two, where she talks about implicit bias in health care disparities. She discusses colorblindness. And for some of those of you who may be, you know, not familiar with colorblindness, some of those of you who maybe came to age in the 80s, I mean, that was like, you know, that's what was kind of hammered into us that, you know, you need to be colorblind. You didn't see race and you didn't want to judge any of that. And many of us would frankly love for that to be true. But she also makes the case as a lawyer that there's loads of literature telling us that that isn't true, that we are not colorblind. And that fact, all the data points that we're not colorblind. And in fact, we all have bias. And that was something for me that kind of kind of took the weight off. Right. Because the truth of the matter is we do have bias and realize that I'm not a bad person because I have these biases was was something that's important. And for those that don't know bias, what a bias is, it's a negative attitude in many cases about one group of people relative to another group. Implicit bias is that negative association and it's unintentional, which is important and unconscious. And research has shown, and this is from the book, that implicit bias directly influences behavior more than the explicit. So you could have someone that says some crazy ethnic or racial slur, but in effect, it's the kind of the person that's not saying that slur, but kind of has an unconscious belief that happens in about 500 milliseconds. And the other part of it that makes me feel not such a bad person is that this happens quickly. And so, you know, she goes into what's great for me and most of us, I'm sure, as clinical scientists at the very minimum, that is there's neuroscience to it. Right. There's three three regions of the brain. And I did want to be a neurosurgeon at one point. And so I did kind of look into the brain and you've got the amygdala, the dorsolateral prefrontal cortex and anterior cingulate. I can't say I remembered that, but I did look at it in this book and stayed at a holiday in last night. And basically the amygdala generates automatic responses to racial stimuli. Why this dorsolateral prefrontal cortex and the anterior cingulate cortex work to maintain those responses at an unconscious level. So you've got a part of your brain working to keep things unconscious where you have your amygdala generating these things. And then she even gives more neuroscience where she discusses four processes of automatic thought and how stereotyping and prejudices can occur due to implicit bias, automatically again, unintentionally again, and unconscious conscious level. And then she goes into this implicit association test of which I found out about four years ago. And I took the implicit association test. It was developed by, I believe, Harvard and a couple of other schools and has really been been kind of rigorously evaluated. And it states and it's kind of some questions that pop up on the screen. And based on a reaction, a couple of seconds, they're able to determine it's validated where your biases are. And so I would actually encourage everyone, if they haven't while reading this book, to Google and take that test and you'll understand more about implicit bias. And so it even said that pro minority physicians can have a pro white bias. And so one of the things she starts kind of talking about, which probably makes all doctors nervous and she alludes to this, is that maybe there should be a law based on your implicit bias to kind of help us control that. And so she gives also some great examples of physician bias and behavior. And no one really has to say it, but, you know, I kind of offer this up as my ending of chapter two, trying to stay on schedule, saying, you know, is everyone with implicit bias a racist? She says no. But she does say that implicit bias is racism to a degree. And so I think that is something if you look at the figure on two point figure two point two on page fifty three, you talk about not only that physicians have implicit bias, but also patients have implicit bias and how there's a big cycle to it. And the thing that I really liked in chapter two was figure two on page 40, where she goes into how you store these, you know, you kind of store memories and then you identify in a group. And then when you meet someone, you retrieve these things and then you're activated in terms of implicit bias and then you get biased perceptions. And this could influence your decisions in the way you conduct your business. And she gives it, you know, it's a book and it's based on neuroscience, a lot of social science. And she gives some data behind that. I definitely know my own personal thing is that I think and she goes into a great documentation of implicit bias. And I don't know, what does everyone kind of feel about that? Because I think about in my office when I see my at least 40 patients a day and how you have to kind of go really quickly, my amygdala might just be kind of worn and wild. And I just offering that out there. Well, Gary, this is Dave. It's funny, we were talking about this at lunch today. So it was me, one of the fellows who's an African-American male, another fellow who's a Caucasian female, and one of the residents who is an Indian male, and we're talking about this, and we were saying like at a basic level, like as physicians, probably our greatest asset is being good recognitions, being able to recognize patterns, right? We recognize patterns to, you know, diagnose diseases and like to sort of just feel people out, and that is like 100% like vocalizing and like that is the imagery of bias, right? Like we're making judgments on people regularly. Will they be compliant? Will they not be compliant? Can they afford the treatment that we want them to have? Do they have access to the treatment? And we sort of just make all the decisions based on what we think is in their best interest, and is that, I don't know, is that a good use of our bias? Like I feel like what we do as physicians is inherently, you know, manifesting our inherent biases, and I'm not sure it's a bad thing. Maybe just talking about it is what helps to decrease the adverse effects it can have on different populations, but I'm not sure. We didn't really come to any conclusions. I just thought it was a point that we were struggling with this afternoon. David, that's a great point. I am, you know, it just made me think about when I was in medical school, and we had a class about, you know, cultural differences in expression of pain and discomfort, and it almost seems that in an effort to improve patient care, we were almost reinforcing certain biases. And yeah, I would like to kind of like echo what Joan was mentioning. I think these go back to our roots, like how we express or kind of how implicit bias come into our interaction with patients come from like what we have seen and how we grow up, and that actually makes the starting point with interactions, and that sometimes that's why we're not aware, because that's how the environment that we grow up many times, whether it is at the house and college or high school, and we try to bring that up, and sometimes we're not even aware. So it's difficult to control what we're not aware of, and it comes like it's not only the moment that we're with the patient, but actually how we think about people outside of the clinic or outside of the operating room. That is just the way that we interact. So I think that's how like this is the root of the problem or the root of how we carry implicit bias without knowing, and how that can affect the patient interaction. Yeah, I think some of those two are protective in nature, and they're helpful, and some are really hurtful to kind of have some of those biases, but you're having those biases, the patient is having those biases, and you guys are trying to meet somewhere in the middle to come up with a decision, and if you're not aware of what's happening potentially, then those biases can they can snowball, and you can have that one interaction where it said, I just didn't get through to that patient today. I don't know what happened. We just we were both kind of somewhere different, and then you have those times where it works great, and you end up everybody's happy, but those things just to be aware of those that they are happening, I think it's kind of one of the main pieces that I took away from with these biases is understanding you have these biases, they have these biases, and being aware of them. Yeah, if I may say something, you know, I think it's very important, number one, that we're talking about it, and that we realize that we have these biases, you know, because, you know, during the years that I was growing up, I don't remember the term implicit bias even coming up, right, so the fact that we recognize that we've got these, you know, sort of issues is very important, particularly as we move towards, you know, automation and AI, and how we are inputting a lot of our biases into computer generated models, so that way that we can predict how a patient may behave with a certain type of treatment, or pharmacological, you know, whatever, some sort of medication, or anything that we're going to do to try to cure a disease, or to fix an anatomic problem, we have to realize that our biases are then going to be input into the computer algorithm that's also then going to generate a result that could in itself be biased, right, so the fact that we recognize that we have these is, it's a great step, and the fact that we're talking about it is a great step, and then we could seek to find ways to protect and to prevent these biases from continuing on into the future. No, I definitely agree, and when I'm reading this, I was thinking, gosh, what are all the things that trigger me with bias? I mean, and it comes with just opening the chart. I mean, I don't know what EMR you guys use, but we use Epic, and number one, you see up in the left-hand corner is the patient's picture, or no picture, and you generate biases based off of that. You generate biases off of how many allergies does the patient have? I mean, so just by going into the medical record, you're already triggered of, oh my gosh, what am I going into, before you even walk, you know, open the door, so, you know, these are all things that I'm glad we're having the discussion, so that we can be cognizant and aware of these biases, so that we can, you know, kind of have them aware, so that we would go into the patient's room, we're not affected by them. That's so funny that you say that. When we were talking this afternoon, we were all agreeing, like, when we see someone that has fibromyalgia on their chart, like, everyone has, like, a million different thoughts of, like, that patient, and it's, like, totally not fair, but we all have that reaction. Yeah. I think the greatest challenge for me, Tony, in reading this, as Gary was mentioning, is that, you know, when you look at the science she presents, it seems like we really, all of us really do have some level of bias, whether we realize it or not, and for me, the hardest part is that you feel, I'm sure I speak for most, if not all of us, you feel like you're going to work and doing the best job you can to take care of everybody equally and equally well, and after you read the book, you're asking yourself, you know, you come home today from the office, I'm like, now, where did, did I, no, in other words, so you've become aware that you have these biases, but what the book hasn't helped me with yet is, when am I, when am I exercising that bias and when am I not, and I'm trying to wrap my head around that as I think about all the patients I saw today, did I do the best job for every single one of them, and if I didn't, then what is it that made that not happen, so that I still haven't figured out. I agree, and I'm sure a lot of us are in that same boat, but given the interest of time, I have chapter three, and it's the physician's unconscious racism, and just to summarize briefly, it's, you know, she reported that in 2003, the Institute of Medicine reported unequal treatment provided to first comprehensive proof that health disparities and associated minorities receive unequal health care from medical providers, and she goes on to individually tell us that, you know, treatment for cardiovascular disease, you know, minority patients are not the first to receive angiography or bypass surgery. With regards to renal disease, you know, minorities are not the first to, you know, be offered transplant services. With HIV-AIDS, they might not be given the most new and expensive treatments because they presume they can't afford it. With asthma treatments, you know, minorities are not receiving, you know, the most adequate preventative care. However, they're going to the hospital and spending the most dollars on their exacerbation of the disease. You know, the same goes on for diabetes, for cancer, you know, when she gave specifics of, you know, lung cancer, breast cancer, how, you know, minorities are not offered progesterone therapy or radiation therapy after their treatment, and then she also mentions, which I was like, huh, reverse disparities in that African Americans receive more bipolar medication than Caucasian counterparts despite danger of long-term damage from these drugs, and this one really hit home because we're all foot and ankle surgeons, but minority patients more likely recipients of an amputation even after you control for prior hospitalization, geography, and their comorbidity disease such as diabetes. So, unfortunately, minorities are receiving more amputations, and it made me think, huh, when I look back, yeah, I think most of the patients that I can recall are definitely minorities over Caucasians. Like, how can we change that, especially within our specialty? And then lastly, it just, she reported that since the IOM report, there has been definitely progress towards understanding the bias, but no progress in addressing the role the physician unconscious bias plays in causing desperate treatment and health outcomes that racial and ethnic minorities suffer. So, how can we as a society, you know, change our minority patients from getting more amputations? I mean, I think that's one that we can definitely try and help. It's funny you say that, Tanya, because not only just reading this book, but kind of doing this stuff for a little bit now, I have slowly started to notice that in notice that in myself. And I think that, especially as we get to the later chapters, you know, part of it is that identifying that you are biased. And even as an African American, you know, being biased against African Americans, and it's just, you know, it makes you, it kind of really triggers something deeper. But, you know, you can't, if you don't identify, like if I find that sometimes people don't even want to delve into it, then you can't, you can't get better. And I think it's just about getting better. Just like if someone, if you're having a lot of complications during surgery, if you're not, if you're not trying to get better at it, or no one tells you, or you just deny that you're having a whole bunch of bunions that are getting infected, then you're not going to be better. And no one's perfect. I think it was one of the interesting parts of this, I think it was this chapter two talked about how physicians if they knew they were being studied, would, would would do better in recognizing and or offering care that would be more on par with non minorities, even if they're, if their known extrinsic biases were high on their IAT scores. And I think this was also where the medical students or, and younger physicians had evidence where they could, despite whatever their measured biases might be, had less differences and discrepancies in the type of treatment that they were being, that they were offering to patients. So the idea that you know, physicians are all type A and we're all competitive, we all want to get the best score on the test. So there's, there's probably something to that in terms of how do we, you know, how do we, how do we change it? Well, you know, I think that the other thing that at least she drives home, which I appreciated, I thought this, I thought it was, it was a hard book to read. It was hard. I mean, it was good to read, but it was hard. And I think the one thing she drives home is the unconscious part of it. And that we're all really trying to do our best, just as Chris said, you know, we really, I think each and every one of us is trying to do their best and, but we're failing is the bottom line. And it's funny, since I finished the book in the last week, I have, I'm already trying to make a difference, you know, and making sure that every time I walk in the room, I try to treat or offer every patient the, you know, you sort of go overboard a little bit. But thinking about it, I think is 99% of it. And then, and then you act on it. Because again, we're all, I certainly know most of the people on this webinar and everyone's a great person and everybody really wants to do the best they can. So hopefully it's like recognizing is the biggest part of the battle. And acknowledgement, self-acknowledgement. Yeah, just to follow up on that. If this is a safe space, then I'll be honest. This is Dave Thorderson. I'm on our DEI committee for our department. And I've read about these IATs about probably a year and a half, two years ago now. So, you know, I got the link, took the test, and I was shocked and embarrassed to find out that I have a very mild white bias. And I'm thinking I hate racism. I'm extremely liberal politically. I mean, for instance, the last president, I hope he gets hit by a bus. And that just to put it in perspective, and I'm not asking for anybody else's political opinions, but I just, because I considered him racist, and it just boiled my blood. And I take this implicit bias thing, I'm trying to figure out, okay, how, how is that if I'm so strong against it? And she mentioned, I think statistics uses 70% of people, white folk in America are heavily some bias, and I've been doing my best. So I probably upwards of, you know, I have a summer representative sample made 10% of my patients are black, and I do my best. And I've been way more cognizant of it, I don't even actually know what I was doing wrong. And one of the problems of the book, I think for all of us is it's all about cardiac studies, and you know, transplant studies, and people on transplant lists and asthma care, and all that, which are life threatening things. The amputation part, yeah, we got that. But I don't really do any amputation, my practice, I got elective practice. So none of it really translated directly to me. I know it's there. I'm looking for it. But I tell you, for those of you that have not taken it, there's a very simple thing and take a link to follow that link and take it. And I was shocked and embarrassed. And I'm saying this just because the book's accurate. I try to be anti racist, and yet I scored slightly pro white on that damn thing. And I will share that I was extremely sexist. As a woman, I was appalled that I was sexist when I took that IAT. So it is enlightening. So I encourage everyone, if they haven't to do it, because it does, you know, open your eyes to your biases. I haven't taken it yet, but I plan to. But I on that note, I think, I think the way she said it was that everyone in the US has biases, and physicians are humans too, we're people too. And so we also have biases. And so I think, you know, sometimes the view is that as doctors, we were held to different standards, or somehow we act differently than just the general population, but, but really, we're, we have the same biases. So. So I'll move on to just a quick review of chapter four, we've already talked about some of these things. But at this point in the book, she starts to introduce the bias care model, which is a conceptual framework that the author devised to help explain how implicit bias can lead to healthcare disparities among minority patients. And it's a complex model. So we won't go into the details of it. But she describes six different mechanisms as to how this can happen. And, and that the biases, the implicit biases can occur both on the patient side and on the physician side, she focuses more on the physician side, but it does go both ways. And that it can happen before, during and after the clinical encounter. So I'll focus on how it can happen before the clinical encounter. So the first mechanism that she describes is the physician's biased perceptions about the minority group of the patient can influence expectations or assumptions of the patient before the encounter. We spoke about it already, basically just looking at the patient's chart, or even just looking at their name, seeing a Chinese name or a black name, just triggers assumptions and previous experiences that we already have without us often really knowing, knowing that or being aware of it. And so she states that stereotypes about minority patients can override physician's knowledge of medical facts and also their good intentions or their clinical training. And she gives some examples of that. One example of how it can override medical facts is that transplant surgeons stated that they did not offer transplant surgery as an option to minority patients because of previous, basically negative experiences with minority patients who didn't have enough resources, even though there was no evidence that the patient currently being treated lacked resources. And the second way that this can happen is the stereotypes of the physician basically overriding their good intentions. And this is where I guess, again, where we come back to the disconnect between the explicit and implicit bias in each individual. And so a doctor could report a weak preference for whites over blacks, but then the IAT score could show a strong pro-white preference or implicit preference. And so, and we know that the implicit bias is much stronger than the explicit bias in terms of how the treatment is afforded to minority patients. And then another point she makes is that, I thought this was interesting, about how medical students and residents kind of progress and just form stronger implicit biases as we go along in our medical training. When I think back, I certainly remember a lot of instances in this. And basically, we all have cultural competency training in medical school, but that really addresses the explicit bias. The things that we learn on our rotations and from senior residents and attendings enter our brains in the implicit bias. And those are going to be a lot stronger and have a much more powerful effect than any cultural competency training. So, and then the second mechanism that she introduces is the physician's implicit biases can lead to interpreting statistics in a discriminatory way. And this happens when a doctor misuses accurate statistical information to come to an inaccurate conclusion for a specific patient. And one of the examples that she gives is when, or if a patient comes in complaining of feeling down and sad for two weeks, which is, you know, could be diagnosed as a major depression. And if a physician knows that the incidence for depression in whites is 10% versus 6% in blacks, then the doctor may, if it's a black patient, may not ask as many follow-up questions, which could ultimately lead to a diagnosis of major depression. So, and this, she also said, this is more likely to occur under time pressure and large patient loads, which we pretty much all experience now. So my questions for the group are, well, we'll start with, how do you feel your implicit biases were influenced during your training and by senior residents and attendings? I mean, I think that it is, I think it is rampant, you know, I don't think there's any way other to say it. It's just, I think the nature of how, you know, I mean, we were trained, I mean, you start talking about even the fact if you have a differential diagnosis, I mean, you're coming in and you're sorting, you're trying to get to diagnoses. And now we have to kind of figure in what, you know, racial or ethnicities may be playing into that, that we didn't even realize. And so until we put this into some form of educational context when we're teaching from med school, even I think in high school, I know that won't happen, but I just mean that that is to be aware that you have those types of biases. And I even remember thinking, you know, if someone has lupus, you know, I remember being taught that that kind of was an African-American disease when it's not. I mean, I see it all the time. I mean, there may be a certain percentage, but, you know, maybe I haven't ordered enough arthritis panel on my patients because I maybe had biased in a certain way. So I think it's rampant. I think that there, I can think of one very specific thing. It's like uncomfortable for me to even say, so I'm not gonna be too specific about it, but that there are certain populations who have a lower pain tolerance and that females in this population have a low pain tolerance. And, you know, this is what they sound like when they yell. And it's like repulsive now to think about it, but that was something that as a resident, I was taught, I was taught that by my senior residents. Yeah, I think we, I can remember, we had a clinic, a free care clinic where we'd bring a lot of prisoners in. And certainly I think all of us as residents going through that started to develop biases by virtue of the experience. And so certainly I can imagine that as we went through, there were a number of other unintended, unconscious biases that we develop in patients. And I would say it goes beyond patients. I would say we start to also develop biases against even our own colleagues. For example, if you had residents that were lazy, so you had to pick up their slack with work. If you had an attending, for example, that you would observe and maybe didn't respect for one reason or another because of how they interacted or handled patients. I think there are a number of different biases that we probably unconsciously absorb as we go through patients and beyond. I know when I was in resident, it made me think back to, some of the senior residents would tell the juniors how to present the patient to the attending so that they would treat them non-operatively because it was a patient that was not gonna do well with surgical intervention. So you would say, this is a IV drug user who was X, Y, Z. And then the patient or the attending would make it to where they would treat them the way we wanted them to be treated rather than giving them the unbiased presentation of the patient. So we do it ourselves. I definitely agree with that as well. I mean, it's just, she really highlights the bias piece that I think has been alluded to, or maybe even more directly stated over the last three to four years. But I think it's a lot that's out there. Do people notice that language barriers come into play too? When you're running your busy 40 patient clinic and now you've added that speed bump of a language barrier, do you find that you change the type of conversation? Do you find that you jump to the physical exam quicker and to the x-rays quicker? Do you find that your explanations are shortened? I'm curious how people, because I think that is something that we may all struggle with and maybe a type of bias that we develop that we don't talk about much. I think that's a really good point. In reading this book, I definitely realized that I've certainly done that. And I think the biggest part just comes from the time constraint. Because when I know that I have to use the translator machine, that that business is going to take twice as long as you have to wait for the translator to say everything. And I realized that I can get impatient and I'll then, I think, ask fewer questions. So I've certainly done that. And I realized, gosh, if I'm feeling frustrated, the patient certainly can tell that I'm frustrated or getting impatient. So I think the language thing is a big one. I mean, I've hardly ever heard it talked about before. Yeah, another, Daniel, that's such a great point. And another aspect of that, that now that I'm, of course, now I'm thinking about it, I'm like, yes, I do that all the time. You start to find maybe somebody else who could translate faster. So at least in my training at both MGH and HSS, they're very specific about who should be translating because they're an unbiased translator. But if you're in there with a patient who, you know, say is a Polish speaking elderly woman and she's there with her grandson, you readily may let that grandson translate for you, but you know that you're not supposed to be doing that. But in the interest of time and everything else, you sort of allow certain things to slip by. I'm certainly guilty of that. One of the other thing I found out was that when you're taking a consent, for example, at the end of the clinic, as Daniel was saying, and there are 20 things you have to explain to the patient about consent. And if it's a language line, I think you might end up not getting all the 20 points through. And I noticed that as well. So that's a good point. Daniel, I think one of the interesting things about that example is that to me, that's an example where it may not be so much a personal slash physician bias, even though it manifests through the physician, but more of a systemic problem where there might be a systemic solution. In other words, as Jacqueline said to me, if you could eliminate the time factor for that so that there was a process in place that it was just as easy with a translator, et cetera, to be readily available so that that exchange could take the same amount of time as all the other exchanges, I bet all of us would be much more excited about that interaction. Yeah, I love it. We could have more time with that. You know, if you had say, hey, you know, you have seven minutes per patient, but this patient, you know, you need like a 20 minute or 15 minute time slot to do the back and forth and make sure that you're accurately getting information. You know, we get put on that time constraint so much. I mean, one of those things that I can see it like, because I have lived that with patients is sometimes it comes from the patient side as well. So the patient sometimes wants to be short because they just don't know how to express themselves. So I think this is some bias that it's there, but it comes in both ways. And I think this is like, it was a great kind of introduction for move to chapter five, which we talk about the implicit bias during the clinical encounter. And when she talks about this, she mentions how there are some factors that affect that clinical encounter and how physician bias influences verbal and nonverbal communications and the behavior of the patients as well. So she kind of talks about a few points that she feels kind of like direct that interaction between the patient and the physician. She mentions how the communication, how the physician address that initially can be toxic and can just lead to clinical disparities. She put a few examples in the book when she said like the length of, and there are multiple studies when they talk about the length of time that white physicians spend with minority patients and is significantly less when they have a look at like a video recording, they have see how they engage less and even their body language changes. And the patients, they're able to notice those things. And even they said there are many different styles of communication, the way that the physician address the patient kind of determines what the patient is going to interact, how much is going to express and how much confident is going to have in the physician and how these actually affect directly the outcome of the patient. And there are studies about these as well. They talk about assumption or preconceived ideas and it comes from both ways. And there are in minority patients, sometimes they don't look for care or they just avoid to look for medical attention because they are just have the preconceived idea based usually a previous experience how the physician just didn't engage or just cut them short or they just think the patient because of their background in terms of education, they're not gonna be compliant with the treatment. So they just, instead of like seeking care, they just avoid to go. And then when they just look for care, it's too late, but it's because they are always thinking that physicians are not gonna pay attention or just don't gonna even believe what they're complaining about. And a way to kind of like, to keep that in mind that the clinical encounter goes both ways and should be based on reciprocity, which is the way that the patient and the physician act between each other. And there are a few examples that I actually have, I have experienced this personally, how it happens the opposite way when it's a minority, a physician for a minority group and a white patient and how the patient judges the physician and how that can change totally the environment and the interaction between the two of them. So the best way that you said that we should try to address these is to be aware of our verbal and nonverbal communications that can actually break into miscommunication. As long as we are aware of these and try to be always impartial with our patients, probably we can minimize those things. And I feel like I have seen myself sometimes having some bias with patients. For example, when I see them like if I'm late and they start complaining or they just speak really loud to the medical assistant, I feel like when I go into that encounter, I am like a little bit apprehensive with my interaction with the patient or when they ask where I'm from or when I have patients ask me where I train, not even where I'm from like originally, but they only care where I do my training. And I feel like I try to overpass that, but those are things that we, because we should be aware of those, can I minimize those things? So I have a few questions for all the group. What type of attitudes have you seen or have you been aware even after reading this book that you feel has affected your clinical encounters with patients, whether for minorities or different attitudes that can break that perfect communication between patients? And if you have seen any communications coming from the patient that can change your interaction with them? Sure, so I'm in Northern Florida, so I'm at the University of Florida now, and I can tell you Northern Florida is pretty much the deep South. It might as well be Georgia, Mississippi, Alabama. And every time somebody comes in with a MAGA hat, I get a little tense, right? But to your point, I just try to recognize the fact that I am being a little tense and I do have some nonverbal cues that could lean the patient encounter in one direction or another. And so I try to put that behind me, right? I try to sort of avoid the sort of negative feelings I may have towards that, and I proceed with the patient encounter. And just like you, I have been asked, just based on my last name, where I'm from, what language I speak or whatever, and I just, and sometimes you don't wanna necessarily engage to that degree with your patients. And so I do try to move beyond those things, so that way I can get the job done. But to your point, I mean, this is something that I deal with, or many of us deal with every day, for sure. Go ahead. I think sometimes it happens to me, I'm like, oh, are you the PA? Or like, and then that's in some ways, sometimes I try to not get affected by those things and just like clarify what my role is and understand the patient doesn't have to know. But yeah, I think the more that we are aware of these things, the easier that we can try to minimize those. I agree with that. The other thing, the other thing that, so I'm in Idaho, a pretty conservative state, and we had a really low COVID vaccination rate, and that was, it's been frustrating for us as physicians, you know, trying to operate where, I mean, I have cases canceled constantly because patients are COVID positive. And, you know, that's one of the things that I think I've gotten caught in where I just assume everybody, I think Holly already touched on this. I'm sorry, I was operating, so I was kind of in and out, but I think Holly touched on this. I kind of got caught up with being frustrated with everybody who wasn't vaccinated and assuming it was just a choice, a personal choice. But having read this book, I think that, you know, there are probably a fair number of those patients who it was a choice, and especially for the minority populations and what's happened in our history, you know, who can blame those patients for not trusting our health system and trusting vaccinations, but also just access. Especially in Idaho, we didn't have like really bold vaccine campaigns. I don't, you know, we weren't rolling out clinics all over the place to the extent that some other states were to get those vaccines to minorities and people in areas that have less access to care. And so I just think that that was another example and something that I've sort of taken a step back on and gone, all right, I got to start thinking about this differently because I do think that was one of the many, you know, plays into that implicit bias where you don't really think through all of the reasoning and you make those assumptions and you do that without even meaning to. I think that trust and whether or not people are going to, if you will, take the advice or trust the advice is a good segue into chapter six where we talk about bias going beyond the clinical encounter. She gets into her mechanism five and six of the bias care model. And she sort of highlights the idea that particularly as we're going through a differential and trying to figure out what's going on, there's some uncertainty, maybe it's a complex case and maybe the, you know, the decision-making tree is difficult and the more challenging that gets, the more likely that physicians are to revert back to their implicit biases in terms of how they're gonna prescribe a treatment moving forward. She highlights in that chapter some examples that minorities are more likely to get restrained than whites, highlighting primary care physicians often having trouble or making less referrals or having trouble referring to subspecialists. So people may not get the subspecialty follow-up care. I think that touches on us particularly in our subspecialty world. And, you know, a lot of it gets into what Dr. Petto got into earlier, which is that when physicians may decide to alter treatment or not prescribe treatment due to cost, assumed ability to comply or not comply, may make assessments on intelligence and ability to follow instructions and that type of thing. And then in the mechanism six is more on the, how it affects patient satisfaction and their experience from the encounter. And I think this, again, trust keeps coming back to being the main theme of these. She notes in a lot of studies, minorities and blacks in particular are more likely to not seek care, not follow-up care, to change providers, change health care systems, when they've had the impression that they've been victims of bias. And she talks about it interestingly from a social science standpoint that perhaps this makes this subject even more difficult to study because if these folks are essentially getting lost to follow-up even in these types of studies because you can't follow along their treatment and how they're actually, what their outcomes are because they move away from the providers and the health care groups that might even be looking at them. She talked about in that chapter and it was mentioned earlier about pain and how when particularly when it's vague pain, it's abdominal pain, it's pain that doesn't have an easy solution like an x-ray showing an ankle fracture or that type of thing that routinely Blacks are undertreated for their pain. I think that was one shining light is that when she mentioned ankle fractures as an example, when there's something a little bit more objective, physicians tend to be better at limiting those difference in treatment. So in our world, maybe that's helpful. I think I want to quote the book, but I think there was one of her interviews, this may be when Dr. Thorderson was speaking, it made me think as someone who did medical school in Detroit and trained in Detroit and where I am politically and where I send my kids to school and all this type of thing, thinking that I should be in a pretty good place relative to understanding my biases, but I think this probably is going to apply to a lot of us and a lot of our colleagues. This physician said when they asked about their own bias experience, said I can truthfully answer that question, I can say no. I was exposed to Asian people, to African-American people. I come from a missionary background. I grew up with African-American kids and folks from an early age and I had that interaction. I had my parents teaching and so I was blessed to exposure to all kinds of people, ethnicities, genders, and so I didn't have that bias and so it doesn't apply to me and everything's good. I think that part of the challenge, or I guess I would open up to my question is how do we, I think a lot of people probably feel that way, and how do we make this approachable and get people to at least admit that bias exists and further admit that it affects how we practice without stimulating a defensive posture and I think people feel threatened and no one wants to be called a racist and so how do we get through that? I think that as I've been going through this, just trying to acknowledge that there is this bias. I think the science that she goes through with the neuroscience and when you delve into it, it makes complete sense. You take that IAT, no test is perfect, but then we all see we have bias and to acknowledge that, I think that is the first thing and it takes people like us that are taking the time on their Wednesday night to learn and to read a book that is actually, although it was well written, very difficult to get through because you have to do this introspection and then you learn all these horrible facts and just it makes you really sad, but I think that for us as physicians, when we sign up to do what our job is, you just kind of have to turn that humble meter up and kind of spread the word. I think it's only going to be, I can remember four years ago trying to talk about some of this stuff and everyone's just like, I'm colorblind and I'm like, ah, no. I know what you're trying to say, but you're actually kind of making yourself sound worse. It's almost like saying, I've got plenty of Latino friends. I've got plenty of Black friends. You're like, ah, that sounds so bad. You just don't know and I think just kind of spreading the word is important. I just wanted to add that we have a third of the book to go. I hope everybody that has stayed on will stay on. The CME portion, I have to say that the CME portion has ended, but we are having such a wonderful discussion that I hope that everyone stays on to continue the discussion on the next three chapters, but thank you. Just to follow up on that, I agree with Dr. Stewart. I think awareness is key. Being able to talk about it, being able to admit that we all have, whether the type or the form, but we have some sort of implicit bias. I think talking about it, having insight and introspection into that is important. Then moving on to chapter seven, I really enjoyed this chapter because I think this is where the book really starts to focus on strategies to reduce implicit bias in order really to transform bias care into equitable care across all races. I think this chapter really challenges the assumption that discrimination leading to implicit bias is unavoidable and beyond conscious control and provides evidence that these prejudicial beliefs are malleable, even though they may be ingrained and acquired over a lifetime. Throughout this chapter, she introduces three types of interventions that can be used to alter implicit bias based on evidence provided by social science studies throughout the years. Number one, she talks about stereotype negation training, which is founded on replacing automatic activated beliefs with non-prejudiced ideas. She likened it to breaking a bad habit, which in this case would be implicit bias, and through repeated prolonged exposure to new structural models, a new cognitive structure develops. I think the second solution she, or I guess mechanism she discusses, focuses on automatic negative stereotypes through counter stereotypes, and that being positive, having positive associations. I found this at the beginning a little difficult to conceptualize, but I think the example she gave really helped me to understand it a little bit better. She gave an example of a study where participants were shown pictures of minorities in leadership positions, like Martin Luther King, and then they were shown photos of disliking Caucasians, like Charles Manson. Interestingly enough, this led to significant reductions in automatic preferences that we sort of have underlying. The third and last one is social and self-motivation, and I think this sort of shifts the onus to the individual and society and relies on the response to social demands or relationships. She gives another pretty good example on how research demonstrates that participants show less negativity and give more favorable racial responses about African-Americans in the presence of African-American experimenters, so I think it's sort of like it's kind of like the Hawthorne effect. You sort of adjust based on, you know, the society or the structure or the environment that you're in, and so I think these strategies that she discusses are really lacking in cultural competency programs, at least the ones that I've been involved in, and so I guess one question I have for the audience is what are people's experience with cultural competency programs at their institutions? I don't think they address these issues. I think the cultural competency programs that I've been involved with at Jefferson or in residency, I didn't think that they addressed these issues in a tangible fashion, like specifically like the chapter that we're talking about did. They didn't have real strategies of how to combat them, right? I like this idea of the breaking a bad habit, right? I don't know if you're trying to lose weight and eating chocolate at the end of the day is contributing to it, then you have to understand that that's the trigger. You have to like recognize it, and then you have to find a way of reprocessing your thought so that next time you encounter it, it comes up differently in your mind. I don't think that I've learned that before. I thought that this was interesting. I like this chapter because this was the first point in the book where the rubber hit the road, like this is how you can try and change what you thought was unchanged. Maybe you didn't even recognize it in the beginning. Well, it exists. Actually, you can change it. Here are some ways based on some evidence that you can actually change it. I haven't experienced cultural competency education in my health system in a way that embraces a solution to it. I like the way that she did that here. Yeah, and I agree. I think programs, at least at my institution and the ones I've been associated in the past, have really focused on explicit bias and have just glossed over implicit bias. Right, like not using offensive language, like yes, of course, we all understand that, right? Right, yeah. It's the implicit bias where the underlying problem is. It's a tough task to really find a solution to, so it's easy to just sweep it under the rug, but I think that's at the crux of the problem. I think the other problem with our cultural competency trainings is they're like, I don't know, for me and my institution, it's just a PowerPoint presentation that you have to go through every year, so you're just like next, next, next, next, and you're not really taking it in and making a change. It's just I got to get through this so that I can keep on practicing, and that, I think, needs to change too. Yeah, I think it's really interesting, and she goes into a lot of, I guess, more broad ways to make changes, but I think just all of us, even on this call, just on a very individual level, can make a big difference. I was running late to the call. We had it on in the operating room, and it stimulated conversation with our anesthesiologist, my first assist, our nurse circulator, the scrub tech, and all of us from the first 15 minutes of the book club were listening and then talking about it, and I think just that, I just had a moment where I was like, this is how we, this is how, I mean, there's a lot of other ways to make change, but this is probably the most effective when you can really keep things intimate and personal and have those one-on-one conversations, and it was really interesting. Everybody kind of started listing all the ways that they may have unconscious racism, and we all were talking about how we all were out doing Black Lives Matter marches, and we're like, we can't be racist, but it's really, I think, calling attention to it, and even with your close circle of friends, getting people to sort of admit to themselves that this is real, I think, is the start, because then you can start building, you got to have that foundation, then you can start building programs and have people that want to participate from there, but I think we should all really, really strive to at least bring those up among our closest peers and the people we trust. So how do we, I'm sorry, so how do we get across this message to the people who were reluctant to be on this call, right? So I feel like we've got this self-selected pool of people who are open, and they're open to their own biases, they're open to hearing more, learning more, and figuring out this problem, but what about the ones who were reluctant to be on this call? How do we get this message across to them, right? So how do we get them to not be defensive and to open up and understand that they do have their own implicit bias, you know, because that's one of the things that I've, one of the issues that I've run into is for, and I'll be honest, I mean, I've got some friends who, and they are friends, but they're very, you know, sort of stuck in their ways, right? And so how do we, how do we break that barrier and get them to understand what we're talking about on this Zoom call? Anyone have any thoughts? Well, you know, I think it's such a great question, honestly, and I think that the biggest barrier is getting people to admit that they have unconscious bias. So people will say, well, you know, I don't have it, so I don't need to be on the call. I'm not racist, you know, or I'm not biased or sexist or whatever it is. So I think it's trying to allow people to acknowledge it without a lot of like blame or putting a lot of guilt on people. You know, I think in the book, the author basically calls unconscious bias racism, and that's really, and again, you know, nobody wants to hear that they're racist and nobody, most people, most, you know, say white doctors, again, we're all trying to do our best. We're all trying to do our thing. And we think we're doing the right thing. It hurts to be called that. And so, you know, reading the book, I get it and I'm all in, but I think for people who haven't read the book, it's sort of letting them understand that being, having unconscious bias doesn't mean necessarily that you're an outward racist, and so it's okay to acknowledge it. And then now you have to figure out how to treat it. So I think for me, it's just the, just getting someone to acknowledge it and being okay with acknowledging it, that, hey, it's okay to acknowledge it. Kind of like how Gary started out the conversation, is this a safe place? Like, it's okay. Again, we're all good people, but trying to get to that next step of accepting it. But I don't know how you do it. How would you guys feel if, I mean, as an idea, what if the ABOS made this an integral part of like the WLA, for those of you who are partaking in that? And, you know, because I think what Holly was just talking about is, and I think it's been expressed by multiple people tonight is, you know, we made the leap, if you will. We, you know, took time out to do this. And one of the recurring themes is, man, this was uncomfortable. Gary said it too. You know, this was an uncomfortable book to get through. And I think that that's the first step is sort of, it's almost like, you know, we're very competitive as orthopedics, orthopedists, and, you know, we don't want to have a chink in our armor. And once we recognize that chink is there, we want to correct it. You know, I think most of us do. I hope most of us do. And I wonder if having some sort of mandate for those people who might be a little hesitant, you know, would pick up a good, not everybody, but a good group of people and say, man, geez, didn't realize that. And have some, you know, internal competition that would drive them towards change. I think that's a good point. I think that perhaps take it even further, you could even do it at a state level for licensure. It should be a part of a wider discussion. I know in part of the book, and we'll probably get to it, you know, she talks a little bit about how this is now being embedded in the MCAT. And, but she also points out that even though it's going to hopefully increase awareness, she's not clear that that is going to translate once these students get into the later years of medical school in what we're hoping it will end up changing. So, you know, and that's, and that's, it's interesting, you know, bringing it to chapter eight, I think Dr. Endu was having some issues being able to dial in. So I'll just fill in for him. And, you know, thank you, Chris. Definitely that's what she talks about. She talks about that in chapter eight, what are some of the structural solutions that we could offer to this? And a lot of people discuss their cultural competencies that occur at work and different things. And in the chapters, she kind of breaks down that some of those don't work at all. And in fact, some of those cultural competencies end up being worse because, you know, not only are you having to take some time out now to, to do something like this, but, you know, you kind of feel like it's force fed on you and it may build some resentment, you know, why aren't they talking about, you know, my issue? And now I have to take extra time to click through these slides. So, or take a test or what have you. I've, she talks about this and she gives the prayer that I always kind of associated with Alcoholics Anonymous and she does too, the Reinhold Niebuhr kind of a prayer about, you know, give us, you know, the grace to accept with serenity, the serenity prayer. I think a lot of us have heard it before. And she just talks about how there's no way to do this lightly. And that if you're going to do this, it's going to be as uncomfortable as reading this book was. If there was a criticism that I would have of the structural solution change was that, you know, I am a person that, you know, kind of is just resistant to any type of legislation. You know, it's just, and she talks about it at the beginning of the book and, you know, I'm fairly liberal minded, but I think she talks about how physicians just in general kind of have bore the brunt of some of this stuff without some of our structural of support systems, like our hospitals. And then it could be even some of your staff, you know, how are you going to get, there's many times that sometimes I'll hear my staff member talk to an older Black woman as hun, and I'll have to correct that, but that's not going to the other, you know, thousand employees we have. That's just me correcting them. And I know how offensive that is to that older Black woman to have someone young like them call them hun. And so I would think that unless we as the leading bodies, whether it be our society, whether it be ABOS, are willing to kind of take the jump and have people be angry at us and then become used to it. We're gonna have to definitely do things like we are now where it's structurally embedded, whether it be in our exams, whether we're talking about it to our trainees and having even honest sessions like Dr. Neary did today in her OR. I mean, I would have loved to have had this in everyone's OR while they're operating. And so I think that that is something she talks about, you know, the AMA even, their Council on Ethical and Judicial Affairs, the ACGME has a lot of information out there now, but there's so much information that it has to be a structural change. And I, you know, I don't see how, I kind of find it hard to see how that could be legislated. I mean, we can't get anything passed, so I can't see how that would happen. So it's kind of up to us to do it and to just kind of slowly slog through. Yeah, and I agree. I think even in, I know they're doing it for the MCATs and stuff, but in residency programs, I don't know if it's an ACGME requirement to have some sort of competency training and diversity and equity, but, you know, at least at my program now, you know, we have monthly journal clubs and no matter the topic that we're discussing, one of the journals is always something about diversity, gender, physician burnout. And I think, you know, if there's a way that we can sort of get like, you know, training programs for it to be mandated, it sort of just kind of puts out that awareness and you may not capture, you know, everybody in the audience at a residency program, but if you capture two, three, that's going to continue to grow and that's feeding into the newer generation of physicians. So I think, yeah, starting, you know, starting there is not unreasonable. I also think that if we try to be like practical with how we want to approach, kind of like give them key points of like the same way that I feel like, so I connected with Ms. Briggs in many different levels because I have seen this in the past. So I like kind of like reinforce the idea that I have, but also like the last chapters, how she kind of tried to address those things. So I think making people aware, but in a kind of like easy way, like not judging, but also being direct to the point, I think people would appreciate that and make them think about their situations and how their interactions are, and maybe how they apply to a particular situation in their lives. And so I also want to point out that, you know, just it's not just us here, it's the AOFAS, the Quebec city meeting will have, you know, a full symposium dedicated to the DEI. And I think that's an important step for our society. And so for those that aren't able to make this call, there are certainly other avenues in the AOFAS. And I think, you know, you always run one of two risks, right at one end, you're on the risk of someone saying, you know, being very, becoming defensive, but you also have at the other end of the spectrum, the risk of, oh great, I was on this call. So I'm not racist and I'm set. I've checked the box. And so at both ends, the answer is to meet in the middle. I know what we've tried to do is, and I would urge you to do the same, and I would love to do collaborations, is we started looking at our own data. We looked at, you know, 1,500 patients that had operative ankle fractures and found that if you were Spanish speaking, you were twice as likely to end up in the ER again after, and this is research that we're going to publish as if there weren't a language barrier. And so what may be a racist bias of, well, they're of a certain race or ethnicity, excuse me, and therefore they're non-compliant, they're not following up. It may just be a difficult navigation of language barrier. We looked at over 500 people that presented with ankle arthritis to see if we differentially treated people operatively or non-operatively based on race. And what we found was that we actually did not, you're likely to have getting surgery was not, but if you were non-white, you were likely to have a longer hospital stay after a surgery. And if you were a Hispanic, there was likely to be a longer lag time between your initial visit and your time to surgery. And it's unclear why, is that a bias? Is that a language barrier? Is that, but just exploring it in your own practice, and then maybe through the AOFAS, collaborating across multiple sites. I would love to do that project. I invite all of y'alls across multiple sites and see if it's regional. And this is the power of the AOFAS. And so I think what we have here is a condensation nucleus at the AOFAS that I would love to see expanded to the thousands of members. And that's what we're doing. Yeah, I think that's a great point. And that's a great segue to this, the kind of the final chapter, which is the new normal, which is, I think this one was a bit hard to kind of think about because of the implications to us and implications to what that would do, both of us as institutions, but personally. And the author bring forth the legislative strategies to improve these levels of healthcare inequalities. First, she kind of brings in these main strategies to align delivery of care with these social science facts. One, she talks about, as was in the introduction, the Title VI of the Civil Rights Act and revisions to that to allow for the implicit discrimination clause. Then she recommended restore these private action for disparate impact claims, and then also adding in negligent care, standard of care to this. These were all in effect trying to bolster up this Title VI statute in order to make these changes from a legislative side. Now, she goes into various examples and she talks more about Title VII because that has a lot more examples that can be used. But in terms of Title VI and what are the ultimate objectives are, one is if you structure the new anti-discrimination laws, they can accurately account for the scientific evidence that we have on this unconscious bias and how it harms what we do. Second, proposed legal hope to incentivize the structural changes in healthcare. And the last one really was that if we use law, then we can meaningfully shift the social norm that presently tolerates these unconscious biases. Now, she's a lawyer. She, of course, has got to go to the law at the end and got to kind of bring forth that. And she says that changing the law is the first step. And then this next step is inspiring providers to fundamentally and structurally change the norms overall to impact healthcare delivery. This is kind of the summation of it, but we talked about AOFAS and being the ability to kind of bridge some of these gaps and also state legislative and federal legislative. This is looking at the Civil Rights Act. What do you guys think about the argument for legal change? How does that, how do you feel? It affected me in a certain way, but just understanding how you feel about that can be a very interesting and tangible experience. Experience. I think I alluded to it when I kind of went over chapter eight, just a little bit, just to keep the discussion on that is that, although I just, whenever some law is passed, it just seems like it has some unintended consequence. I mean, when I was in medical school, that HIPAA law passed and my understanding was that HIPAA wasn't even meant for what we use it for now, it had some other meaning, but then like kind of the whole slippery slope of legislation have led to where it's very punitive. And it seems like the people that end up paying, maybe it is keeping the secrets, but of patience, and we all know what we're supposed to be doing. But now we have these large EHRs that don't communicate. And that was something, again, that came out what I thought was a relatively good law in PPACA, but then now we have these EHRs that don't communicate. And so my nervousness would be, if you had something that was talking about implicit bias, then what you may have is this whole, almost like reverse racism thing, where you as an African-American physician are now like, someone says, the meaning was to try to help healthcare inequities, but in a sense, it now ends up being punitive for doctors in a way that it wasn't intended. And so I would like Title VI to have its teeth back because it looked like when they were doing their legally speaking, that it was a small part of, I think, a Sandoval case that ended up stripping that from what it was that's true intention. So maybe something that would allow that to be more, to be where it was, but I don't wanna be the one to stop progress. I just would hope that if it were something legal, it would really have to be vetted, I guess. That's bold and it definitely makes, people are gonna have strong opinions on it. And maybe that's one of the points of writing it. And then my first thought was we're, on the surface, we're talking about maybe prosecuting people for essentially a thought crime of an, I thought minority report is where I went in my sci-fi nerdness, but she did. I don't think you can lead with that. We're talking about how do we get people into the fold and get to analyze this. I don't think we lead with, you may get prosecuted if you don't do this. That probably won't open a lot of doors, but she does talk about viable defenses. And I think it's kind of like anything else. If you follow your policy in your hospital regarding, records and harassment and I mean, pick, we had a consultant a few years ago. I remember he kept saying, our policy is we follow our policy. And so if we have a policy about bias and healthcare and equities, and here's the training that we put everybody through, and here's the awareness we're trying to put out with, that you protect yourself. So she does talk about how the defenses might come, but that's a hard one to jump into for sure. Yeah, I'm gonna jump from, we've been talking about implicit bias. I'm gonna jump right to explicit bias and admit that. So to me, I have trouble with supporting a legal solution because to me, this person's talking about essentially penalizing individuals who she herself also in the same book admits are trying to do the right thing. And so now you're talking about penalizing people who are trying to do right. And there are other parts of the book where she talks about malleability and the fact that there is data to support that people like us who have these implicit biases can actually be retrained to do the right thing. And maybe that to me would be a better approach than throwing a bunch of legislation and penalties at people who are just going to work trying to do the right thing and do well by people. I think carrying forward from there, I think to conclude, when I heard about this book back in 2015, I was really intrigued. And when I went through it, obviously I've learned a lot myself. I think I also agree, it's a very difficult book to go through and understand. And I think the implications and the changes that we want to make are not going to be easy. Obviously trying to make legislation and get everybody on board will be an easy way out, but it will be difficult to implement. I think to conclude, I mean, I like those five M's that you mentioned about that it's currently morally untenable, critically untenable. It's basically monetarily untable where the minorities do not have enough health budget as part of the total health budget. And in addition, it should be a problem which we should manage. And finally, this last M was it is maximally or massively urgent. So I think these five M's kind of gives me the conclusion about what are the problems we are facing. And I think it is definitely an urgent problem that we need to solve, as otherwise the healthcare budget that we look after, and also just look after the minority patients. I think what I learned from this was that all of us have implicit bias, unconscious racism. And I think it starts from schools and goes up all the way to being the provider. I think what I would like to say in regards to this would be I would like to improve myself, but also get my healthcare provider, my medical assistant, because sometime I'll get a medical assistant who will tell me, you know, this is the patient who is this, this, this, and your mind is already set up for their diagnosis and treatment. So I think best thing would be to talk about it, as Caitlin Neary said, and try to expose more people to this book. And that's what I would like to do in my practice. Can I ask a question that I struggle with is, when you move, let's say away from bias, but you move away to medical rationalization, where your decision-making is based on criteria that disproportionately affect a specific group. For example, if you're an arthroplasty surgeon and you say, because of complication rates, I will not perform knee hypnoplastics in someone with a BMI over 40. But we know that certain groups may be predisposed to obesity, diabetes, for a remarkable number of historic reasons, right? Because certain things aren't proportionally distributed, diabetes, poverty, everything. Is that a form of racism when you look at the numbers and it disproportionately affects a group of people and how are you going to internalize that in your practice? It's something I struggle with and I'd love to benefit from the group. And by the way, to that point, even the things like the vaccination rates, there was, I remember, that's what I thought, right? I'm open-minded. And then there was an ethicist column on the New York Times. It's like an intellectual dear Abby by a professor of philosophy from NYU. And someone asked the question that, and he said that when you look at the data, minority populations don't have much lower vaccination rate has everything to do with level of education. It's a malattribution. And if you go to some places of the South, actually, black Americans have higher vaccination rates than the whites locally, because of politics and things like that. And so sometimes I worry that how do we deal with that? How do we deal with medical rationalization that disproportionately affects a group of people? I think she argues that it is unconscious racism in a way. And then, cause there's several examples actually in that chapter six where she talks about you, even if you try and make a socioeconomic argument, as you're saying, there's gonna be a disproportionate effect of minority groups because of how things are laid out at least in current society. So, but how you, I think it's very hard to draw a line between race, ethnicity, class, wealth status. I mean, it just sort of so intertwined. I think for the purposes of our discussion, it's good to be intentional about separating them because I think it's easy to gloss over the racism part of it, if we talk about resources and socioeconomic factors. I agree, doc. I think that that is what she really was coming down to and it kind of went into her biased care model. It was a relatively busy thing where, but I just, her point was that so many things were related and interact. And I do believe that her, she would argue that this still comes down to implicit bias or unconscious racism. And that sometimes we put some of those rational, rationalized numbers in when in actuality, if you kind of normalize for some of these things and that's what she was putting in terms of her data, that it still comes down to racism. I think at the end of the day, like having these discussions is important. And I think as a country, the United States, is in a unique position where like we're a hodgepodge of like people from different backgrounds, ethnicity, race, compared to other countries in the world, with my experience. So I think we're in a unique position to really sort of set the tone for the next generation and society as a whole, if we can figure out this problem. It's really at its infancy. And so like, do we have the answers? No. Are we gonna have the answers in the next 10 years, hopefully? But I think continuing to make people aware of all these issues is important. And I think we need to capitalize on this opportunity. Well, I'd like to take the opportunity to say thank you to everyone for your time. I loved the discussion and I just, it really, really, I think was great. And so we'll go ahead and let everyone get their time back. I loved it. And thank you for joining tonight and please look forward to June 29th on our new book club. And I hope this becomes a thing where we continue to try to discuss and solve the problems. And so if there's nothing more, be sure to claim your CME and hopefully we'll see y'all soon. If there's not anything else, good night.

AOFAS On the Same Page Book Club

Just Medicine: A Cure for Racial Inequality in American Healthcare

Stryker

AOFAS Diversity, Equity, and Inclusion Initiative

healthcare disparities

racial and ethnic minority populations

implicit bias in healthcare

unequal treatment

physicians' unconscious racism

bias in medical education

implicit bias in clinical encounters

communication disparities in healthcare

reducing bias in healthcare

cultural competency programs