Good morning. Welcome to our flipped classroom session on critical care health disparities, beginning conversations for health equity. I'm Marie Carmel Ely-Turen. I'm an associate professor of emergency medicine and critical care medicine, as well as palliative medicine at the University of Florida. Today we are joined by a faculty panel who will discuss the scope of implicit and significant bias, its impact on clinical outcomes, and the implications and opportunities in clinical education and practice. Our faculty will also share some impactful experiences and perspectives relevant to this topic in the academic and clinical settings. By the end of this session, the objectives will include discovering shared experiences of healing after COVID-19 for underrepresented minorities. We'll also discuss methods for teaching a new generation of healthcare professionals about implicit bias and healthcare disparity in critical illness. So before we begin, I would like to invite you all to be engaged in the flipped classroom conversation format. So please go ahead and click on that discussion or Q&A button that's on the bottom of your screen, and that will allow you to send your questions in through the flipped classroom format. Someone will be monitoring the questions, and I will go ahead and read those questions to our panelists throughout the session. So please feel free to go ahead and enter your questions as we speak. If there are specific questions that you'd like to be directed at specific panelists, please indicate that as well in your question when you place them in the chat box. So to begin, I'd like to introduce our esteemed panelists. I'd like to begin by introducing Dr. Varun Shetty. He is an assistant professor and intensivist at the University of Pittsburgh Medical Center Presbyterian in Pittsburgh, Pennsylvania. We'll then be joined by Naomi George. She is an assistant professor at the University of New Mexico, also an intensivist in Albuquerque, New Mexico. And then finally, Dr. Natalia Arizmendez, assistant professor at the University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania. So to begin, I'd like to start by introducing Dr. Varun Shetty, talking to us about communicating with caring. Hi, everyone. Let me begin by sharing my screen. All right. So I'm going to be talking about implicit bias. It's something that I believe is not talked about enough, which is why I thought I should talk about it. I don't have any disclosures, but like everybody else, I have my own biases. So we're going to talk about, 15 minutes is not a lot of time to talk about implicit bias, especially with me losing some time with my computer quitting on me. But we're going to be talking about the why, the how, and the what. Why does implicit bias matter? How does it matter? And what can we do to change or to manage implicit bias? So implicit bias is really what the name says. It's implicit. It is not explicit. This is different from explicit racism, explicit sexism, or what have you. It is what everybody has. We grew up with it. It is impossible to get rid of implicit bias. It is both inherent and it is learned, learned from cues that we grew up with from society. And there are several inherent aspects to it as well. And in today's age, with more and more people, with most of the population, if not all of them, being actively anti-racist or trying to be not racist or not sexist, contemporary bias today is largely unconscious. So why do we have implicit bias and how does it matter? So implicit bias is an evolutionary trait. According to dual process theory, there are two forms of thinking. One is the slow analytical form, and the other one is the quick pattern recognition type of thinking. The pattern recognition type of thinking is what we do most commonly. It helps us get through the day. We cannot function without bias. Implicit biases also protect us from dangerous situations. Imagine the cave person in the jungle that hears the rustling in the bushes. They know from previous experiences that it could probably be a predator. So implicit bias protects us in certain situations, helps us get through the day. So it is unrealistic to think that we would be able to get rid of implicit bias. And it is not incorrect to think that it is all bad. But what we need to identify is where implicit bias doesn't work and where in our society and where it could be hurting us. So that brings me to how implicit bias is affecting individuals and society negatively. And I'm just going to be talking about health disparities and career implications. So there are several studies done on implicit bias and healthcare outcomes. Very few have actually tied together actual implicit bias assessments with healthcare outcomes. It's difficult to do. One, because it's difficult to measure implicit bias. We don't have perfect measures. And two, it just has not received the kind of attention that it's meant to receive. So there was this one study published in the New England Journal of Medicine. It was a survey done at ACP and family medicine conferences. They had standardized videos of black patients and white patients presenting with symptoms of chest pain. And three cardiologists, three different cardiologists had vetted and were in agreement with what the video showed. The physicians were more likely to recommend cardiac catheterization appropriately to whites rather than women and black men. In another study, which was retrospective, physicians were more likely to recommend knee replacement to men rather than women. In another large retrospective study, which was where they balanced out the covariates of other severity of illness, they found that Hispanics were twice as likely to not receive opioid medications when compared with white patients for long bone fractures. This study was elegant in that it connected pro-white implicit bias that was tested on physicians through the implicit association test. The implicit association test is a test that was created by folks at Harvard University. And it really is not a perfect test, but it's a really good test to find where people have implicit bias. And they compared that to how likely were physicians to give opioids to black children as opposed to white children. Black children inappropriately got less opioids when compared to white children. And this was associated with a higher pro-white implicit bias. This also has career implications. There was a large scale study of 300 odd letters of recommendations. This was a qualitative study. They found that most of the letters in urology, this was in urology residency, most of the letters in the urology residency letters of recommendation were written by men. And they talked about more leadership qualities, efficiency, these words that had these strong implications for men. For women, the words were more on the lines of being compassionate and empathic, all good qualities, but there was this stark difference. And it kind of contributes to cementing certain stereotypes that people may have. In another study, all members of, this was 140 members of the Ohio State University College of Medicine admissions committee had a strong pro-white implicit bias. This again was the implicit association test that you can find on the Harvard website. This is, there was an elegant study, shout out to my co-fellow from Pittsburgh, to Andrea Elliott. They did a simulated study where they took 33 physicians and they had standardized patients with different races. And they looked at verbal and non-verbal communication. And they found that though the verbal communication was the same for black patients or white patients, but the non-verbal communication was significantly worse for physicians when it came to black patients. And this was in terms of how much distance they had, whether they leaned in, whether they sat close to the patient or not. And I think that's telling on what we experience clinically in real life as well. And another troubling study was this large scale retrospective study that looked at patients who were septic and critically ill. And they found that critically ill black and Hispanic patients were less likely to receive inter-hospital transfers compared to whites. And these studies should make us uncomfortable. This whole talk should make us uncomfortable because we are grappling with some uncomfortable topics here. So what can we do about bias? And I'm not saying that I have the solution to implicit bias, to taking away implicit bias and managing it within one talk. But there are some tried and tested strategies that may help. So one is to know yourself. We all have bias. Take the implicit association test, go to this website, take the test. It's a little involved. It takes about 10 minutes or so. And I am embarrassed to say that I took the test and I had a moderate bias that stereotyped that was in favor of men at working place and women at home. Now I consider myself a feminist. I consider myself an anti-racist. It's very embarrassing for me to share this, but I think it's important. It's important that we talk about our biases so that we can bring it out from the unconscious to the conscious and actually begin to have a conversation about it. And then we will begin to address it. Empathy. Always, when you have a patient, if you are actively trying to be empathic, that will help mitigate bias. And get to know the individual. I had an elderly Black lady who was diagnosed with post-cardiac arrest. And I sat down with her family and I asked them, what gave your mother joy? And they said, she loved walking in the park during the fall. She loved to see the colors of the leaves change. She loved to dance in the kitchen when she was cooking. And suddenly, she wasn't just another patient. None of my patients are just another patient, but this gave me that individual connection. None of those barriers were broken. Suddenly I saw this person for who she was. And that's a great way to mitigate bias. Equal status contact. It is well known that finding role models or having people in your own profession at your own level from different walks of life, it mitigates bias to a great extent. So this would mean getting out of our insular world, trying to reach out and meet more people and try and see more people from different walks of life. Consider the opposite. This is a little vague and was a little difficult for me to understand, but try and stick with me here. So there was an elegant study done in the 1980s where they showed a bunch of Harvard Stanford students, four studies, two of them were saying that death penalty deterred murders and two other studies said death penalty did not deter murders. And when they just showed these studies to these students without any priming, it just increased polarization. People who already believed in the death penalty became more strongly in favor of it and people who were against it became more strongly in favor of that. But when they asked the students to consider the opposite, that if you see the data leading you in one direction, stop for a moment and think of this from the other side. Think of yourself as a lawyer opposing, thinking about the other side. And that's when the difference is reduced and they came more close to the center. So this, I think, is important when we are considering people, when you're recruiting people for jobs or when we are considering people for certain decisions. Think, just stop for a moment and think, look at the data that you have from a different direction because the data is not objective because we are subjective. So we need to make sure that we we need to make sure we know and remember that we have bias when we are interpreting data in front of us and think about considering the opposite. Know that implicit bias increases during times of stress. When we are stressful, we are leaning more on our more on the type one type of thinking that is the intuitive thinking and less so the analytical thinking. When we are in the ICU, we are constantly faced with moments of stress where we are looking at pattern recognition and making multiple decisions at a time. So know that implicit bias increases during these times of stress. So what can we do about it? When we practice certain analytical thinking, for example, when we are studying to be physicians, in the beginning, it would take a lot of time for us to come to a certain decision about a certain management. After a point of time, after multiple repetitions, it becomes second nature. That's what we need to try and do when when it comes to bias and know that implicit bias is always a part of our thinking and stop and think when we think that we might be we might be going in one direction. Think about, you know, try and use some other solutions in your armament to mitigate bias. This was an interesting study that I came across where they treated implicit bias like mortality and morbidity. This was basically a black patient that did not get medications, pain medications when he appropriately needed them after an ankle fracture. And he had no history of drug use, but there was concern for drug use mentioned in his chart. So things like that can be should be dissected and discussed in the medical community. So we can incorporate implicit bias rounds within our teaching sessions. Checklists, intensivists, nurses, we all love checklists. So and doing more of this helps mitigate bias. The camera technique is interesting, and I'll try to do this quickly. It's basically dissociating observations from inferences. For example, if you see someone with torn shoes and disheveled clothes coming in, just make the observation for what it is rather than coming to a quick inference of maybe, you know, we might think that the person's homeless. No, divorce that thinking and see the patient's qualities or the other person's qualities for what they are without making any inferences. Now, now we've talked about this, let's just do this exercise and it's going to be a little difficult doing it online, but I think I think we can make it happen. So what I want you to do is I'm going to show you a bunch of pictures and and I want you to think about the first thing that comes to mind. Think about whether you're attracted to this person, whether this is a person you want to talk to, whether this is a person you want to hire and and see what's the first thing that comes to mind. And I'm going to give a couple of seconds for every photo. Do you think you're attracted to this person? Do you want to hire this person? Want to talk to him? You're attracted to this person. Would you like to talk to this person? Talk to this person. What's your reaction to her? What kind of work do you think she does? Okay, now for the big reveal. So this is actually a general practitioner in New York, and he's founded this nonprofit that looks at, you know, helps people get their tattoos removed so that they can start a new life. This is what he looks like when he goes to work. And this is a member of parliament who participated in a photographic campaign that showed black men in hoodies from different walks of life. This is Ted Bundy, the infamous serial killer and rapist, who looks charming in this picture. And this is Katherine Johnson. She is a mathematician for NASA, and she actually played a crucial role in the success of the Apollo mission. This is Rory Cooper, and he's a famed inventor and founded the Human Engineering Research Laboratories at Pittsburgh. And this is a CIA officer who was outed by Chinese aid in 2003. This is Bernie Madoff, who ran one of the largest Ponzi scheme in history, and he defrauded countless people. Thank you, and I'm open for questions. Thank you so much, Dr. Shetty. So as a first question, I noticed you had brought up some strategies potentially that we can use at the bedside in order to align with our patients. Question is, is there any evidence supporting that understanding one's implicit bias actually impacts outcomes? I did not come across any, but that's what we need desperately. I mean, we barely have enough evidence. We're just scratching the surface on how implicit bias is affecting outcomes, and we need to explore that more, but these are some, these individual strategies have been shown to mitigate bias, but they've not been tied to patient outcomes yet, and I think that's our next step. That's what we need to work on. Fantastic. Next question is, are there effective strategies to use when at the bedside or when preparing to meet families to be more self-aware or to check oneself? And I would recommend, rather than just being aware of implicit bias and thinking that, oh, I might be biased towards this family or to this individual, that can sometimes enhance implicit bias if we are not actually using these techniques. So I would recommend diving into the strategies that we talked about and trying to make that part of your routine. And a lot of intensivists, a lot of nurses already do it. We try to learn more about the patients. We try to learn them, understand them as individuals. So what I would recommend is focus on the strategies that we are not using enough and consolidate strategies that we are already doing. Thanks, Dr. Shetty. One last question for you. So we talked about checking in with ourselves and we have lots of checklists, right? So there's a checklist manifesto. Should this be part of our checklist in intensive care when taking care of patients who we've never met before? I think that's a great idea. I think doing it at the bedside might be a little harder and onerous, especially in busy ICUs, but we could incorporate it into the social work rounds that we do in the afternoon or during teaching sessions. So I think there might be some innovative ways to do that. And I would be happy to hear ideas that people might have. I think we absolutely should incorporate some form of bias mitigation in our day-to-day practice. Thank you, Dr. Shetty. I know that Drs. George and Dr. Arizmendiz are also on the line. And if either of them wanted to respond to those questions, we definitely want to open up the floor and allow them to respond as well. Okay. So thank you so much, Dr. Shetty. Okay, so to follow up, I'm going to introduce Dr. Naomi George. And her segment will be on conversations about COVID-19, healing in the long haul. Dr. Naomi George. Good morning. Thank you, everyone, for joining. Give me one moment. I'm gonna start sharing my screen. So, today I'm going to talk about perspectives from indigenous New Mexico and its relation to the COVID-19 pandemic. I have no disclosures to share with the group today. This is an important topic, I think, to bring to the fore. We've seen a lot of reporting in the lay media and lay press around how COVID-19 pandemic has affected Native American people across the country. But I want to just add some context before I introduce a video and some speakers who are going to share with us about this topic, really from the front lines. The first thing I want our audience to be aware of is that reporting on COVID-19 for Native American and indigenous communities across the country is a complex task and one that leaves a lot of imprecision, so our knowledge around this topic is incomplete. Part of the reason for that is that reporting around test positivity, hospitalization rates, mortality, et cetera, that's all under the control of the various tribal governments and they may or may not elect to share different data with CDC or the Indian Health Service. The second reason, and I think this is a really important thing to acknowledge, is that many Native Americans in the country live on tribal lands. Many tribal members do not live on tribal lands. They may live in urban or non-urban areas, and so that changes the way that we may see reporting because hospitals are unlikely to collect accurate race and ethnicity data on their patients when they come in. According to the Indian Health Service most recent data, which I've tried to highlight in this map on your slide, there is a tremendous amount of variability around how COVID-19 has affected Native American communities with Midwestern and Southwestern Native American communities being those that have been hit hardest. For this discussion I thought, and in collaboration with the Native American Health Office at University of New Mexico, that the best thing would probably be not to hear from me on the topic but to hear some voices from the community. So in a moment I'm going to introduce a video, hopefully I'll be able to share with you all, featuring two community members in New Mexico that are going to speak around topics related to COVID-19 and their communities. The first one is Governor Brian Vajo, which I'm very excited to have been able to record an interview with. Governor Vajo is the governor of Acoma Pueblo, which is about 60 miles west of Albuquerque, New Mexico. And Acoma Pueblo is a federally recognized tribe on the historic land of Acoma. It's roughly 5,000 acres, so it's a small area compared to some of the other Native American homes in New Mexico and the Southwest. But it has been continuously inhabited for over 2,000 years, making the Acoma Pueblo tribe one of the oldest continuously inhabited communities in the United States. And Governor Vajo has been on the front lines of managing this pandemic for his community, and I think has a lot of valuable insight to share from the community perspective. The second speaker is slightly more clinical in nature. This is Verita Smiley, and she is one of our two fabulous Navajo interpreters at the University of New Mexico. We've had Navajo interpretation available 24 hours a day since about March, between two interpreters. So she has been doing a tremendous amount of work since March, and I'm very thankful that she was able to participate in this interview for you all to see. Many folks are familiar with Navajo. It is a large area, the Navajo Reservation occupies a large area of Utah, Arizona, New Mexico. It's over 27,000 square miles. There are over 300,000 enrolled tribal members, about half of whom live on reservation land. And as you may have seen in the news, the Navajo tribe has been deeply and disproportionately by the COVID-19 pandemic, with over, it's estimated over 180 deaths per 100,000 people, which makes the Navajo Nation harder hit than pretty much any other community in the United States. And I will let Ms. Smiley share with us some of her experiences. I want to let you know, these were two very lengthy interviews that I have bridged into a 20-minute segment that I'm going to share with you now, but I do have the complete transcript for people who want to see more of these interviews. And I'm happy to share in my contact information is available to see that. So without further ado, I'm going to begin sharing. Give me one moment to reshare my screen. Our community has, I think, our community has, I think, has done a great job at responding to the pandemic as best as we can and could have. We did very well for a very long time, keeping our under 10 tribal members for several months. We did experience a death in April, and that was just devastating for the entire community. And then we saw the spike, we experienced a spike and did all that we could to be responsive to what was happening here at the Pueblo. There are some things I think that we have identified as significant issues of concern when some of our tribal members have had to be transported into a hospital in Albuquerque or in Grants, which is the city of Grants, which is 16 miles west of us. And in these situations, we, in the very early phase of the pandemic, had very little information accessible to us. And when we were working with the State Department of Health and the hospital and the patient, we did what we could from almost 70 miles away from Albuquerque to support the individual in the hospital, but also to support the family who they left behind here on the reservation. One of the things that we recognized very early on was that because family members could not be with their loved ones while they were in the hospital, that there was a severe lack of coordination for providing some level of communication between families and their loved one in the hospital with COVID. I have to give credit to a couple of hospitals in Albuquerque who, through their Native American liaison or their Native American health services programs, did reach out to not only our Pueblo but other tribes to help us then develop those communication. It was very difficult at the very onset when we had our first tribal members have to be transported to a hospital, and of course for some, where elders were concerned, there was a language barrier. For some families, there was just the reality that because we don't have the best access to the internet here on the reservation, that virtual communication using a virtual meeting platform or even texting in some situations just wasn't an option. And so what was really sad for us was to see that we had tribal members in the hospital who couldn't have communication. One of the things that a lot of the community members and families were expressing was they didn't know what was happening to their family member while they were in the hospital. They didn't understand fully the implications of, you know, a hookup to a ventilator would be. They didn't anticipate, I don't think many of them did not anticipate that there might be some things that a lot of the community members and families were expressing was they didn't know what was happening to their family member while they were in the hospital. They didn't understand fully the implications of, you know, a hookup to a ventilator would be. They didn't anticipate, and I think many of them did not anticipate, that there might be some rehabilitation following hospitalization. When we're seeing some of the hospitals reaching capacity at Albuquerque and when there aren't any other options other than to send our tribal members further away, this causes grave concern for families, especially those families that are intergenerational households. And, you know, all of a sudden a family member is is away and there's an unknown about whether when that family member might come home. The emotional toll that it's taken on these families is tremendous. Families here at Acoma have already, are making great sacrifices as a result of our executive orders and mandates around closure, access on and off the reservation, stay-at-home orders, curfews, lockdowns, all of those things. Really the big one is the fact that because of COVID, we have not been able to observe any of our cultural calendar. And so this takes a great toll on the mindset of the community. And then when you have a family member who becomes infected or a family becomes a cluster, these family clusters, it is just devastating for families. My name is Veda Smiley and I'm a Navajo interpreter here at University of New Mexico Hospital. And I've introduced myself as a Navajo woman. I'm born for the Meadow people, born to the Water Flows Together people. My paternal grandparents are Bitterwater people and my paternal grandparents are to Elrin House people. And I'm originally from Coyote Canyon, New Mexico. I believe COVID-19 has affected our people tremendously, not only here but out in their home areas too. First of all, it affected our people with limited resources, meaning the people that have limited resources with lack of electricity, water, and transportation. And then also when they go through their culture shock by coming here to the hospital. I mean, they come here from having no electricity to coming here with big lights and everything else. So our people have really gone through a lot of culture shock by going through this COVID, by going through being treated by medication that they don't understand, that they've never been treated by before, by a language they don't understand, English, which is something totally new to them. By coming way out here with a transportation they never rode on, which is a helicopter or maybe a plane, that's traumatic. One, first of all traumatic for them. And then when they come to the hospital, a face they don't know, a language they don't know. When they come to, they're getting undressed and they don't do that. And also being put on a gown, which is, their gown is open to the back, which the way they don't dress. We don't dress like that traditionally. Everything has to be to the front. So there's a lot of traumatic things that they go through. We have tried tremendously hard to be there for them. So when they arrive here at the hospital, that we're right there by their side to let them know that there is a Navajo interpreter here. And it makes, it brings comfort to them, for them to understand that, okay, there's someone here that understands me. There's someone that I can talk to here. Everything is not so strange anymore. I can actually say what I need to say and this person can talk to me the way I understand. So just like everybody else, when we get scared of something, we tend to fight. So sometimes our patients are fighting, but once we get there, they calm down and we tell them everything that's going on. The first thing we do, or the first thing that happens is that we introduce each other by our clan, which is very comforting. And then thereafter, it's a clan system where we say, hello, grandmother, hello, grandpa, whatever clan we are related, that's how we start identifying each other. And that brings the calmness into the patient. And the patient will start listening to whatever the doctor is saying. This public health crisis is expanding beyond, you know, the effects of the disease, the virus itself. But now we have these issues around mental health that are just as dangerous and I think calls for a whole other crisis. And as I mentioned earlier, you know, you compound these with the fact that as Native Americans and as Acoma people, who are rooted in a culture that has sustained us for millennia, and we share a strong belief in this way of life. And when we can't practice that way of life actively, it takes a severe toll on the community. I have actually interpreted for people where that if they receive the care, or they've been in the hospital for a certain amount of days, that they didn't, the Navajo interpreter was not called. And they don't respond to the providers. They don't respond to nurses. They just, they just diagnose them as unresponsive. They diagnose them as dementia, or they just give them a different diagnosis. But as soon as somebody finds out, oh, they're Navajo speaking, they right away call us and they respond to us. So it's just the lack of communication. The ACL, known as the ACL Hospital, or the Yakima Canyon-Seto Haluna Hospital, which is located on our reservation, has been here for almost 50 years, and is the healthcare facility that our community has used since its establishment, along with the Pueblo Laguna, which is our next door neighbor and the Navajo Band of Canyon-Seto, which is located in between Yakima and Albuquerque. That community is now known as Tohajo. But the three users of this facility recently were faced with the situation of the closure of this hospital, the closure of emergency room services, of urgent care services, 24-hour urgent care services, the loss of medical staff, many of whom, many of these medical providers were longtime healthcare providers to a large population of our Yakima people who have had underlying health conditions or dealing with managing their health conditions. And so when we saw the disappearance of these resources from ACL Hospital, we became very, very concerned and very frustrated, and as have our tribal members, by the fact that having survived COVID-19, having maybe experienced some time in the hospital, maybe some rehabilitation, and then coming back to the community, no longer having a primary care physician at the local hospital, and or even the services at the hospital is an issue we are dealing with even today. Even the patients that are tracked, they have a track, or even though they're intubated, they still do need interpreting because their first language is Navajo, and they can still hear, so they still need interpreting. Just because they're tracked or just because they're intubated, that doesn't mean that they don't need an interpreter. They need an interpreter because their head can still move, they still can say yes and no, because we just had that incident recently where I kept calling and checking on this patient and the nurse was telling me, this patient is not verbal. I understand that the patient is not verbal, but I kept insisting. I said, well, I need to, finally, one of the nurses called me on the patient and I asked the patient, I said, would you like to hear the Navajo language? And of course, obviously he said yes. And I said, would you like for me to change your preferred language on the computer from English to Navajo? And he was saying yes, so that's what I did. And he was saying yes, so the nurse was interpreting for me by nodding his head yes and no. And that was very emotional for me because we actually kept that away from him for how many days? So I just talked to him. I said, well, the sun is shining outside and the clouds are coming up and now I'm getting emotional. And this is what, there's a lot of people out there, Christmas is coming around and these are things that our patient like to hear because remember, they're just there in bed. They need to know these things. A lot of times, providers use family members to interpret. Family members tend to hold back important information from those that do not understand English because we've gone through this so many times. I mean, I can tell you a story where we had a grandpa that had tested positive for cancer and the family member was interpreting for him the whole time. And by the time he was getting ready to sign a consent for surgery, that's when we were called. And we had to tell him everything. And he said, I have what? They never told me I had cancer. I could have gone home. I could have gone home to my hogan. I could have had some traditional singing done. I could have spent some time with my sheep, my cows, my livestock. I could have walked around my hogan again one more time and look what happened. I'm here, I'm having my surgery. Nobody ever told me this at all. So I asked, who's been interpreting for you? And he pointed to the young lady that was standing there. And I said, well, what have you been telling him? I just told him he had something. So cancer was never mentioned. Grandpa didn't make it. That's another emotional, there's so many emotional stories when they use their family members to interpret. They hold back important information thinking that their family member is not gonna be comfortable hearing the truth. But a lot of times it's comfortable for them to know what is going on. Either go home, sing and go walk their hogans or go see, visit their animals because that's the ones that they feel comfortable around is their animals. As Native Americans and as Acoma people who are rooted in a culture that has sustained us for millennia and we share a strong belief in this way of life. And when we can't practice that way of life actively, it takes a severe toll on the community. And so I don't know that we have the answers at this point. I don't know that we have any assurances from the Indian Health Service that there will be any real support and resources that get made available through the Indian Health Services to our community. I think if we can do more in state to really take a much more aggressive approach in terms of providing even just some basic information about Native American culture, about the diversity of tribes within our state. Navajo beliefs are very, very different from those of Pueblo people and the Apache tribes. Hispanic communities, and the various denominations of Christianity and other religions. And so where Native American beliefs are concerned and just Native American lifestyle, I think is a concern that we need to provide and come together to develop those materials and our training, some mechanism to inform medical providers and administrators of hospitals throughout the state that when they receive a Native American patient, COVID patient, that they have some general understanding or they know how to, they know who to contact or they know how to, they know who to reach out to to find out more information about the culture and the community from which these individuals originate. I would like to share that just everybody, please just stay home and be safe as much as possible. Even though we miss our loved ones, even though we miss our homes, even though we miss family members, this is a time that we have to think of something else to do in our time. Like right now, I've learned, I actually just look back in my archives, my archives meaning what my parents taught me. My parents taught me, sit still. When I was small, sit still, learn this, learn this. And my mom was always working on jewelry. She made necklaces and stuff like that. And she said, sit still and learn this. One day you're gonna have to sit still and you're gonna have to teach yourself something. So I was going through my archives one day and I said, you know what, mama, this is what you taught me. This is when you told me to sit still and I'm gonna sit still now and I'm gonna start making your jewelry. So that's what I've been doing during this pandemic is been making jewelry. And I thank my mama for that, for teaching me how to sit still and mentally be strong because my mama is here with me. And my dad told me, no matter what you go through, you go to work, you take care of your kids and you take care of your loved one. So that's what I'm doing. Thank you, Dr. George for that very powerful video. I wanted to pivot to the Q&A session if that's okay with you. Absolutely, thanks. Okay. All right, great. So the first question was actually around communication. So a question often posed is, I don't know what to say to the patients when they are Navajo. How do I communicate and speak to these families? That's a really wonderful question. It's one that we get a lot. And I think the advice that we've been hearing, our team probably can be extended to a lot of different situations where the cultural background that you bring to a conversation, you may not share with your patients or their family members. We're fortunate at the University of New Mexico to have an Office of Native American Health and to have communication experts who have dedicated their career to understanding best communication practice. That being said, one of the foundations, sort of touchstone principles that we've learned is around cultural humility, asking the question. So when we approach a family, we may say, I don't share your cultural background. Tell me what I need to know to best communicate with you. Tell me what I need to know about how your family makes decisions. To ask questions such as, how do you like to receive information? Do you prefer information directly? Or in many instances, people prefer information to be shared in the hypothetical. When I've had patients with similar conditions to your loved one, what I've seen is X, Y, or Z. And that using that hypothetical or third person may be a preferred way to share information. But asking the family is almost never wrong. Saying, this is a terribly hard situation for you and your loved one. I don't wanna make it worse. How can I communicate with you best? How can I help support decision-making? And if I do something wrong, please help me, let me know. And with those sort of open-ended entreaties when you begin, I think you can avoid a lot of either missteps or potential conflicts with families or patients at the bedside. Absolutely. Thank you so much, Dr. George. To dovetail on the communication around families, one of the questions that were asked is, how often do we think it makes it easier to have family there to interpret for us? And I suppose to dovetail on your presentation, can it be a hindrance and how much of a barrier can it be versus a tool, a resource in communication? That's also a wonderful question. And I think something we may have learned a lot about inadvertently during the COVID pandemic when many of us are not allowing visitors in the hospital. And there's a fair amount of literature and I can refer listeners to references in the chat later on that suggests that professional medical interpretation is critical, is crucial for your family and relying on family interpreters, I think is something we've learned since medical school is probably not a best practice. And I think that was highlighted really well by Ms. Smiley in the video. That being said, disambiguating interpretation from family support, I think is important. So while you may not want to use a family member to interpret medical information, having a family member present, like Ms. Smiley was mentioning in the video, for potentially an elder or someone who is very unfamiliar or potentially confused or discombobulated by their circumstance, having a family member present as support is crucial, though you may not want to use them for interpretation and avoid using them for interpretation in lieu of a professional medical interpreter, I think is key. Thank you, Dr. George. And I just wanted to share a comment that was placed in the chat box, thanking you as well as the session planners for highlighting our relationship with the Native community, the Native American community in this session on disparities. Yeah, that's a super important point. One thing that I don't think we got to highlight here is how much underrepresentation there is in the medical community for Native American groups, indigenous groups. So having these voices available, I think will be critical for us as a society to providing better care and to dovetail on something that Dr. Shetty shared, changing the composition of the healthcare workforce to be more representative through things like understanding implicit bias, ultimately I think is what's needed here. Thank you. Dr. Shetty and Dr. Arizmendiz, if you're able to unmute your microphones, we would love to hear from you in terms of response to these questions as well, if you have anything else to add. I just want to say thank you so much, Dr. George, for sharing that video and your insight to the Navajo population. Thank you. And as I mentioned in the beginning, I do want to thank everyone for bearing with me for my very poorly exercised videography skills. So I do have uncut version of the video for people who are watching this. So I'm going to go ahead and share that. I'm interested to hear more conversation from Governor Valle or Ms. Smiley. All right. So for our next segment, I would like to introduce Dr. Natalia Arizmendiz. And I want to apologize. Her title is currently the Critical Care Fellow at the University of Pittsburgh Medical Center in Pittsburgh, Pennsylvania. Dr. Arizmendiz is going to present a talk on cultural conversations, the next generation of leadership. I just wanted to also invite the audience and remind the audience to click on that discussion and Q&A button on the bottom of your screen, send in your questions through the flipped classroom. And Dr. Arizmendiz is going to be providing questions to the audience and allowing for polling. So please go ahead and use that button to respond to those polling questions during her segment of the talk. Dr. Arizmendiz. Okay. Just going to share my screen here. Okay. Thank you for that introduction. I have no financial disclosures, but as a brown woman, I do have an invested interest in this topic. Of course, there will be some subjectivity given that I have my own inherent biases. I do not pretend to represent every underrepresented woman or man of color. That being said, I have interviewed several colleagues from across the country and will provide multiple resources for those of you interested in learning more. Furthermore, I hope this presentation will give insight to the problems at bay and that you may reflect on your own biases and create change within your institution. There are some limitations with this Congress being virtual. This is a brief overview of what we'll touch on. We'll start by reviewing current statistics. We'll have a polling session attempt to make this more interactive. Then we'll discuss diversity and inclusion ideas, as has been done in some academic centers, as well as endless and closing remarks. I was asked to speak on cultural conversations. I'm sure this picture is an accurate representation of your standard table discussions during morning rounds. In 2021, many may be still wondering why are people of color still underrepresented in medicine? Diversity and inclusion committees were created well before the BLM movement, after the death of George Floyd. Most institutions have expanded their recruitment efforts, have some sort of presentations on microaggression trainings and inherent biases, yet our representation still remains low. The tables here were collected from the AMA Master File of Practice Specialties in 2018. You can see that amongst critical care medicine in women and men, representation in Black, Indigenous, and Latinx physicians are vastly low. Dr. Lanefall published an article analyzing the demographic trends of the emerging critical care workforce from 2004 to 2014. Although the proportion of female critical care fellows increased, there was no significant increase in underrepresented minorities. The yellow dotted line represents the U.S. Census, and the black dotted lines are the critical care fellows in each of the demographic groups. From left to right, we have white, Hispanic, Black, and on the bottom, Asian, and American Indian. Moreover, reviewing manuscripts by Dr. Santhosh and Babik, we see that despite the influx of applications from diverse demographic groups, there's quite a discrepancy in those selected for critical care fellowship. The orange highlighted here, the orange dotted line represents the applicants, and the blue dotted line are the fellows. Let's dive a little bit deeper into what's going on at the level of medical schools. This chart here represents the percentage of U.S. medical school graduates by race and ethnicity for the academic year 2018 to 2019. 6.2% were Black, 5.3% Hispanic or Latino, and 0.2% Native American or Indigenous. This slide and the following slide were gathered from the AMA. This slide in particular represents undergraduate institutions supplying 40 or more Black or African American applicants to U.S. medical schools in 2018 to 2019. Highlighted here, you can see that overall applications in general are low, and even then, the vast majority come from historically Black colleges, and only represents 2.3% of all Black or African American applicants to U.S. medical schools. This table here, undergraduate institutions supplying 30 or more Hispanic or Latino applicants to U.S. medical schools from 2018 to 2019. And similarly, you can see that all of the percentages are in the single digits for these marginalized groups. So, in summary, representation across the board from undergraduate school to medical school to residency and fellowship are low, and cannot just be attributed to a lack of interest. We'll go ahead and move on to our polling session. Again, all submissions are anonymous. We're just going to allow our staff to assist with the polling feature. So I cannot see the polling responses yet, but this will be shared with what all of our participants have selected, and then I'll review the answer once I'm cued. So go ahead and make your choices and we'll move on. So, I'm just being asked to remind everyone that the instructions on how to enter or answer are at the top of the slide. They are on live stream, so go ahead and respond as the instructions direct you to do on the top of the slide. Okay, so it looks like for our first question, 25% selected A, 13% selected option B, and 63% selected option C, and 0% selected option D. So this is actually a group of residents discussing what they want to order for lunch. So we'll move on to our next question, which our IT techs will help with this. So again, I'd like you to select the best option for where you think this interaction is occurring. Maybe you're just A. We're a smart group, I don't think you need me to say the last word. We'll give you some time to make your selections. Just reminding the audience once again that the instructions on how to answer are at the top of the slide. Please go ahead and place your responses based on the instructions there. Okay So here are some of the answers. Sorry, we had to cut that a little short um, so 46 selected a 15 uh answer choice b 27 c and 6 d So this was actually an academic center support psychologist to a resident And So for the the sake of time I'm going to go ahead and let me share my screen. I'll go through the next examples that were shared with one of my colleagues Okay So this is an inpatient setting A resident is caring for a white child. The mother says to the child She is dirty brown in front of the attending in front of the nursing staff Two residents chatting after the death of george floyd if you and I were speeding to save someone's life I can always say that i'm a doctor and you can't get away with that. They'd probably shoot you I'm afraid of retaliation even as an attending And My personal favorite so you're going to upmc who was the person who called So if this is how we communicate with each other let's examine language and communication on evaluations and letters of recommendation Because even then there are stark differences As dr. Shetty touched on earlier during this session Women and minorities are often described as lovely Energetic depending caring and empathetic whereas white men were described as knowledgeable exceptional best outstanding bright and organized So racial and gender bias permeates the process and ultimately affects passing exams such as the osce clinical skills Residency and fellowship positions and even career opportunities. There are a few Sources here listed on this page that are also cited at the end of this presentation Moreover this board depicts how even the interview process can be a painful reminder that underrepresented minorities are unwelcome in medicine I have uh circled an example here that i'm sure we all are guilty of Where black and underrepresented minority faculty members are only featured on the diversity and inclusion page This makes the applicant now less comfortable discussing other interests. They recognize their stereotypes portrayed reliance on affirmative action and interest in diversity and inclusion And ultimately causes the applicant to perform less well during the interview day So racism and discrimination exists it exists in our health policies It exists in our workplace from learner to learner from faculty to learner Inpatient patient families to staff and most certainly exists in our selection process in undergraduate schools medical schools residency and fellowship So, what are the the harms of having these unaddressed biases Well, one example was the incident in new york in which amy cooper called the police on christian cooper no relation i'm going to Play a brief clip of the video Will you please stop sorry i'm asking you to stop please don't come close to me, sir I'm asking you to stop recording me. Please don't come close to me. Please pick your phone up. Please don't come close to me And i'm taking a picture calling the cops, please. Please call the cops Please call the cops i'm going to tell them there's an african-american man threatening my life. Please tell them whatever you like So christian cooper politely asked amy to leash her dog And enraged amy called the police stating that an african-american man was threatening her life And we don't have time to dive into Why she felt entitled nor why she couldn't handle a black man asking the police to let her go Why she felt entitled nor why she couldn't handle a black man asking that she just obeyed law But when we look into uh her previous employer you can see similarities in many of the um, Opportunities that our institution and companies across the country have she had exposure to implicit bias training Her company also had a diversity and inclusion statement and also hosts bias workshops Thus In order to change culture, we're going to have to get a little uncomfortable before we begin to feel comfortable So remember how goals of care discussions were rarely discussed so much that we created and designed a whole program Dedicating to teaching us how to even talk to patients and their families near the end of life And this wasn't until 2006 so Not all people with racist ideas are bad people and some can be an expression of unconscious unconscious biases created from past experiences Yet, it's not a matter of rationalizing or dismissing these biases It's just a way that we were raised rather We must recognize and address these biases in order to make forward progress towards our our goals Additionally, we must understand that this will take time and we may not have an immediate tangible measure But we must continue to do this and we must do this for the sake of our patients our colleagues and for the sake of humanity So when we talk about action We need to create a safe respectful environment for learners and faculty to thrive in the workplace in order to provide better patient care So the following are ideas that have been implemented in some institutions and some new innovative ideas that are waiting to be employed But now addressing culture Let's normalize feedback. Let's be honest. Some of these are honest mistakes many of which can be remedied by a simple apology So let's use this more as a educational opportunity to allow for personal growth If your hospital doesn't already have one you can create an anonymous reporting system for violations of professionalism Have implicit bias training grand rounds presentations and even have workshops that develop the skills to give and receive feedback You don't already have one creating a diversity and inclusion committee To serve as an open forum for mentorship support and to provide feedback regarding your hospital's efforts And let's listen more Gender and racial biases are demonstrated in the interruption patterns throughout the corporate world Women and minorities are interrupted more often than white people So don't interrupt us give us the same respect that you demand Now when we talk about procedures Such as violations and Professionalism repercussions don't have to be extreme such as losing one's job, but could potentially consist of a certain number of modules required or some Presentations to be given to faculty and learners on something that that you learned as well as community involvement You should also create Faculty and fellow resources to provide for anonymous psychosocial support And consider having presentations to faculty and staff on language to be used during evaluations and letters of recommendation So creating a better system can be done by first analyzing your hospital environment with annual surveys should also diversify your hiring Editorial and other administrative panels and require the completion of the harvard implicit association test for all recruitment faculty So as mentioned previously by dr. Shetty, ohio state university college of medicine Assessed the implicit bias of their admission committee and found a preference towards white men Following the iat results ohio state university matriculated the most diverse medical class Which one can conclude by acknowledging your own bias may lead to more objective review of applicants You could also consider blinding the recruitment process, which is photos and names and of course connecting with the community There are multiple high school undergraduate study programs pre-medical and medical associations that you can get involved with I think you'll be amazed by the countless opportunities that you Your hospital and your community can take to start narrowing the racial inequities I will refer you to the deboy kerner commission and heckler report Information has been out there. We just haven't been listening So it may be helpful to create Different work groups to tackle these tasks. We at upmc have training and workshops data driven decision making Engagement policy review and revision and structure and organization So the next steps Let's re-evaluate language Women and underrepresented minorities are constantly identified as female physicians female intensivists a first generation physician throughout my career I've heard faculties address me and other underrepresented minorities as having a higher likelihood of being selected for a position Because I am female and because i'm underrepresented I'll never forget my first icu rotation. It was a surgical icu in milwaukee, wisconsin And after a week my attending at the time Mentor and dear friend eric siegel gave me feedback. He told me I belong And he told me I am one of them Not once did he mention my gender nor my race So this is the type of respect Support and encouragement we need from our colleagues our faculty and hospital administration The ama has a beautiful outline of where you can begin to start on your journey So in conclusion This is not a moment Racial justice does not equal diversity Statements without policy change does not equal equity This is a movement This is a movement in which we want to better represent the population we serve and have our perspectives and our thoughts challenged by others of different backgrounds I hope you'll reflect on today's session and work with your team members to create a safer inclusive environment There will also be a roundtable discussion february 8th, I believe from 5 p.m to 6 p.m And i'd like to acknowledge mikaela stocks dr. Amber tucker colleagues from across the country secm and dr Emlett as well as my mentor and friend eric siegel These are my references Thank you, Dr. Aras-Mendez, for that great talk. One of the questions that we've just received that we have on the Q&A is, how do we promote culturally competent equity in our teaching environment with the existing disparities that exist within our hospitals? That's a great question. I think we first have to recognize and acknowledge that these inequities exist. A lot of these have been there for years. Black and brown voices have shed blood, sweat, and tears trying to get us to listen. I think we need to first recognize their existence, and we need to be able to speak up. We can't be silent anymore. By speaking up, we'll then begin to rebuild trust. I think that was a question earlier, is how do we rebuild trust? The very foundation of that question acknowledges the fact that there's distrust. Where does this distrust come from? From who? By where? It's everything that we've done to these marginalized groups. From the early unethical gynecologic procedures on enslaved black women, from withholding medical treatment in the Tuskegee experiment, and then also the very sad truth that knowing that the black maternal mortality rate is three times as high than that of white women. We need to recognize these disparities exist, and then start to work with society in narrowing these inequities and disparities. Thank you so much. Doctors Shetty and George, if you'd like to unmute your microphones, we'd also like to hear from you if you have any perspectives on that specific question, creating a culturally competent environment, teaching environment, with existing disparities that are in our facilities, in our hospitals. Thank you for that wonderful presentation. So much good stuff in there. And I liked how you pointed out that implicit bias trainings, some of these corporate undertakings to try to reduce bias or improve diversity and equity in the workplace are present at the very institutions that are highlighted in some of the more recent controversies, let's say, that we've seen in the lay press. How do we as fellows, as residents, as junior faculty, people who may not be in positions of leadership on this issue, push leadership to acknowledge that their current measures in place to improve equity in the workplace may be falling short? That's a great question. I think what I have learned throughout my training is just continuing to speak up, especially if you have a diversity inclusion committee, you do have that support, and we know that there is power in numbers. Also, I think connecting with our community is very, very important, because ultimately, we're trying to make things better for our patients. So having that support, bringing things to your hospital administration, and then also diversifying your panels, right, because we need everything to be challenged, we need different ideas to be brought into these discussions. If we have a racially exclusive group of panels making decisions on what we're doing with our patients, what we're doing with our hospitals and medical education, it's going to be very hard for us to get our message across. Dr. Arias-Mendez, we have a question that was placed in the chat. First, it starts with a thanks for your presentation, and it follows with a question on recruitment. How does blinding the recruitment process help? That seems like it would help with equality, but not with equity. Should we be more intentional in choices we make to build a team that better represents the population we serve? Yeah, I definitely think, and that was just an idea, I don't know if there are any institutions that have done that, but I have noticed that, again, recognizing that there are women and men and different names that may be difficult to pronounce, we have our own implicit bias, right? And so that's just an idea that came to mind to see, would this make any difference? I don't have the answer to that, I'm not sure, to be honest. That was my personal idea, just to see what we could do. And so, Dr. Arias-Mendez, I also have a question, and this has to do with recruitment. So frequently, I hear, well, they're just not out there. The women, the underrepresented minorities, the people from inferenced groups, they just aren't available, they're not interested, they're not applying. In many ways, we understand that the onus is upon the industry, the system, in order to identify these individuals, but do you have a sense of what would be, of how we can create avenues that can improve the representation over time for underrepresented groups, including minorities? Yeah, and I think that there is an interest. So in one of the articles that I shared, there are more applicants, they're just not being selected for the positions. So I would counter that with that article there. And additionally, just reaching out to more associations, there's the Latin Medical Association, there's undergraduate study programs, and getting out into the community. I think we have to give the same educational opportunities to people in underserved areas, right? Because it starts with the children. If we're not giving our children the same education, we're already putting them at a disadvantage, even before they get to high school, before they get to undergraduate school. So I put a lot of emphasis on the community. And then we can reach out to the other medical associations with students interested. I think that's probably the key. And then throughout residency, I think the diversity and inclusion committees should serve to connect people. Fellowship is a little too busy, I think. I've tried to do that right now within my first year, and it has been challenging. But I think in residency and connecting potentially with second year fellows, critical care fellows would be important. So I'll follow this up with a comment and then a question. The comment is, I feel one of the first steps is to educate the leadership of departments and divisions. The behaviors have to start from the top to evoke change. And speaking up is good, but the message has to get to the highest level. And so the question that follows is, do you think that all critical care fellowship programs should include formal education on leadership for better equity? Oh, most certainly. I couldn't agree more with your comment as well as your recommendation. Absolutely. To your point regarding reaching out and the volume of people, perhaps applicants that can apply to programs in critical care fellowships and other undergraduate programs, the volume clearly as you had presented is out there. There are applicants there. They're just not necessarily being selected. And a really great example of a pipeline that was created in order to increase representation was published at Emory University, where they partnered with a HBCU in order to identify undergraduates that are interested in medicine in order to ultimately over the long term, over 12 years, create a pipeline for increased representation in graduate medical education programs. So to your point, partnering with groups where we understand those cohorts, professional cohorts exist, may very well be one of those strategies to use in the future as well. And I'll be honest. I'll just share my own personal experience because I am the only physician in my family. And I didn't even really come to be interested in medicine until I found some old mortuary books. And then one of my friends in middle school was applying to a health careers high school, which was a school dedicated to people interested in medicine and science. And the only way I learned about that was through her. So there was nothing within my school, there was nobody going around handing out pamphlets. Of course, the internet wasn't that big back then. But again, giving the same opportunities to people across the board, I think will also increase the workforce and underrepresented minorities. Excellent. So what I'll do at this point is just pivot to the panel discussion. And I will present questions that are coming from the audience to the entire panel. So I'll go ahead and start with our first question regarding cognitive bias. And this question will be for Dr. Shetty. Cognitive bias is rarely taught in medical education. For example, thinking fast and slow. Our medical school has a course, but it isn't covered well in residency. Are there ways that we can incorporate bias training throughout the curriculum? That's a great question. I think the best way to do this would have to be policy change. It has to come from organizations like the AMA, SCCM, ACGME. It has to become a part of training at every level so that it becomes second nature. And I think that's the way to incorporate it into medical education from the beginning to the end of our training. Thank you. Any other comments from other panelists regarding cognitive bias? So our next question is actually for the entire panel. Thank you for this educational, helpful representation. Curious, do we think that we add to the problem of division and separateness by referring to each other as black and brown people? My point is that not all non-white people are subject to bias and racism. When these color metrics get added, it serves as a divide. Further, I have yet to see a true black person or white person for that matter. Is it okay if I go first? Absolutely, Dr. Shai. Well, I think that's a loaded question in a Pandora's box, right? I think historically, you know, these divisions were created and these divisions have been amplified over a period of years. And I think the solution is not to be colorblind. The solution is not to forget that these differences exist because there are historical implications. There is systemic racism, systemic sexism that has happened over generations. So ignoring these divisions would mean ignoring the problems that come inherently with these artificial divisions that were created in the first place. So we have to acknowledge them and we have to work together to get past them. I agree more with you, Dr. Shai. Sorry, I'm just scrolling through the questions as they come through. Many of them are not questions, but rather comments about thanking you for this presentation. And there are several of those comments that have come through. So another question that was brought up was how to deal with the concern regarding the reverse, where patients and families may have bias against medical staff. And what strategies do you think might be helpful in those situations? Well, that's a great question. I think sometimes what often happens is, of course, they're going to have their own biases. And when you reflect on this, we'll think, oh, well, is it something that they did wrong? Are they just misinterpreting my actions or what I'm saying? And I think what we should do, especially when it's a negative interaction, is we should reflect on that, right? We all decompress after a hectic week in the unit. Whether it's yoga, whatever it is that you do, I think you should do the same with these interactions because it might be something that you're doing wrong. And I know it sucks. Nobody wants to admit that they're the ones who are at fault. I know because I'm a fellow, I'm constantly doing the wrong things and apologizing. But just maybe taking a step back and seeing how did I approach this family? And then, of course, just treating them like people instead of just a diagnosis. So I can speak to this point very specifically because I've seen examples of this. And from my perspective, every relationship, unfortunately, especially in medicine, starts off with a power dynamic. And sometimes that power dynamic may be expressed through the relationships that we perceive that we have when we meet each other. And I think that from the standpoint of physicians, we do want to make sure that we can level that playing field. And so if there is a power dynamic such that the patient perhaps feels very vulnerable and is expressing a bias perhaps that comes from a place of fear or their personal perspective, I think the onus is on the provider to figure out how to level that playing field. And without leveling that playing field, unfortunately, it undermines the relationship that we have with our patients. It undermines our rapport, the communication, the trust. And so we can't detect all biases that people carry or bring into the room. But if it's clear that those might exist, exploring that so that you can level the playing field, identifying where the fears exist in order to navigate and perhaps correct for that may help as a first step. I had something similar written down, but you said it so well. It was great. Thank you. Yeah. I think sometimes just a little bit of honesty is also helpful. A good example of systemic bias that perhaps exists is what's happening right now in the setting of COVID-19, where we recognize that a fraction of the underrepresented groups in our communities are getting vaccinated compared to their white cohort. And these are populations that are highly vulnerable for comorbidities, for complications, for mortality. And so a lot of their biases actually are carried or expressed systemically because they're afraid. So they're not getting the vaccine. And so I think part of the approach there in, again, leveraging that playing field is just honesty, asking them what they're so afraid of, basically presenting what Dr. Arizmendez presented earlier regarding the history of bias in research and how some of our groups were treated and being honest about that up front, being transparent about it, and then being transparent about what has or has not been done to ensure that they will get a fair shake in getting therapies and having their complications treated. I think until we are willing to be transparent and open about those discussions, we're not in a position to level that playing field and really offer these treatments to all people that really are candidates. Exactly. Well said. So I'm just looking to see if we have any more questions that have come up. So this question is for Dr. Arizmendez. Can you also speak to how to address overheard comments from residents regarding other residents or from a fellow regarding a fellow, from a nurse regarding an APP, et cetera? As a senior person on the team, how should these situations be addressed in real time? I think they definitely need to be addressed, depending on what it is. I have had several instances where I have needed to call out systemic racism, inappropriate comments from patients to my resident, especially being, I remember there was like a condition and one of the residents was there. We call it CODES conditions, not UPMC. And one of the patients who was supposed to be coding uncomfortable, probably being transferred to the ICU, was insulting my black resident in front of the nursing staff as the nurse is standing there smiling at his comments, which is inappropriate. And so you need to address it, especially in that instance, you need to do it right then and there in front of the patient. So I cut him off. I said, sir, this is your brain doctor. This is your brain specialist. Because he told him, you look like a rapper. What's with your hair? And he started making all these other comments. So I think in that instance, it needs to be addressed right then and there. Another incident I had was an incarcerated patient coming in where we had some sort of discordance between the prison guards and not allowing us to contact family. And, of course, during COVID times, there's limited visitor restrictions. And it seemed as if, you know, the guards were just okay with the fact that this poor brain dead man was staying, was laying here for two days and we were unable to contact family. And, you know, I went back and I debriefed with my team in private that this is systemic racism. This is unacceptable. We need to contact our hospital system to figure out what we can do. So I think there's different ways of how to approach this. But I would not delay it and, you know, try to revisit the discussion a week after. It should be done in the moment. If it's definitely degrading one of your team members, I would do it right then and there. Dr. Georgia, I'm going to offer a comment on this important question. As was mentioned earlier, it's so important to speak up if you're witnessing something that's happening right in front of you. And so often we know also that we're not present for conversations, disparaging remarks, really inappropriate discussions that may be happening between other people. And we know it's present. We've overheard it. We know it's commonplace. People may refer even, you know, I hear this commonly on the words to the entire population. Well, they're all overweight. They come from this background. They're this or that type of person. And, you know, these conversations are happening. And I find one way that can be helpful, and I think Dr. Shetty brought this up very beautifully in his presentation, is to orient or redirect the conversation towards the personal, towards the actual patient, the actual family member who's in front of you. So during presentations, we may not start with, this is a 69-year-old male with, you know, hypertension and this and that and the other medical illness, and limit your so-called your so-called one-liner to very bare-bones demographic descriptions and comorbidities, but to expand that to say, this is a 69-year-old retired carpenter, a grandpa of, you know, three, or whatever it is about that person that humanizes them, and to interject that humanization to all of our interactions on the team so that slowly we begin to break down this concept among trainees or nurses or ourselves, faculty members, leadership, that this is just a group of people who are, you know, have S, I, or Z traits that are sort of fixed or assumed that, you know, frankly, we all know is untrue. They're all individuals. And to try to reorient during even rounds is a sometimes powerful tool that can help when you're not actually present for the disparaging comments. You just are trying to reorient the team to each person's humanity and individualism. Thank you for those comments. We have another question in the chat box. Thoughts on how to manage up when, as a trainee or a junior faculty, you've had biased training. Perhaps you may have the language to talk about the issues and see a situation involving someone, but perhaps your senior does not have the awareness nor the language. So thoughts about how to manage up. So I would maybe ask your senior, would it be okay if I share, you know, this information? I don't know if this would be surrounding an incident or what, but I would just ask for permission to share your knowledge and then tell them what experience you have, your expertise. So just have an honest conversation with them first. I think I agree. I agree with that. I think what's important is at that time, try to keep the conversation focused on how you felt, you know, say this is how I felt, you know, and often I've had these experiences or try to get those experiences so that we can talk about it without trying to pass judgment and let no one can ever deny your feeling. So I think keeping the conversation focused on you and your feelings would be a good way to bring that up with your seniors. So, Dr. Shetty, I do have one for you. How do we get beyond the checkbox phenomenon espoused by medical schools and healthcare organizations where implicit bias training and similar courses are taught, yet we know unfair treatment, injustice, racism, and inequities pervade in our ICUs, hospitals, and society? I think that this has been touched quite a bit by several of our panelists, but perhaps you can help us perhaps help us just talk through this once more. I know that you had a few ideas about this earlier that you had addressed. Yeah, I think it's important to not just have some implicit bias training in organizations and trainings. I think it's important to examine the content of what's being taught and how it's being taught, whether it's workshops, whether it's just modules that people click through and say it's done, and it needs to be periodically examined and re-examined and updated. And I think it's important to keep studying that and study the effects of that and keep improving on it as we go along. It's going to be a process and not an end in itself. So we have another question regarding a trainee. So this question is for Dr. Arizmendiz. As a trainee who is used to being the only person of color in a room, especially as a learner, how do you express these concerns or express your frustrations about issues that may be racially motivated without earning the label of being the angry black woman or too sensitive? I'm used to being uncomfortable and biting my tongue for the sake of professionalism for fear that I'll be labeled as problematic. How do you get the necessary parties to buy in if they can't even fully, I apologize, to buy in if they do not fully comprehend the problem? Yeah, so that's a great question. And I've personally dealt with that throughout medical school as well as residency, and it wasn't until the end of residency where I began speaking up. So I would say, you can't keep biting your tongue. If you need to meet with your chiefs, with your program director, I would start bringing up these issues now. Additionally, I've noticed I would introduce myself in patients as just, hi, I'm Natalia. I'm the critical care fellow when I was a resident. I'm the resident doctor. And as soon as they hear that, especially being a woman, whether you're wearing your white coat or not, a woman and a minority, is they will ultimately stop hearing everything else after you say your first name. You're not a doctor. Maybe you're a nurse. Maybe you're there to clean their tray. So now I introduce myself as Dr. Eddies Mendez, and of course, they're going to have something to say about my last name because it's quite long and it's difficult to say up here in the Midwest. But yeah, I would definitely start reaching out to your superiors, your chiefs, your program director, and always hold your head high and introduce yourself as doctor. I think that's a great question. And I have actually been in similar positions and I have bit my tongue many a time, and especially when people make fun of my accent. And it's tricky because you want to interrupt that, but you also don't want to change the mood in the room because often this happens when people are laughing and when everybody's in a light mood. So one way around it is now I try to exercise interrupting it right away, maybe just saying it with a smile and say, hey, that's not what I sound like, and then move on. And then just move the conversation on. So we've interrupted it, that stops the conversation at that moment, and people move on to something else. I'm not perfect at it. I'm still working at it. And it's just something that I think has worked every time. Yeah, and I think one of the things just tagging off of that, because often I'll go in and the patients will start asking, oh, can you bring my tray over here? Can I get a cup of ice? And of course, I know where the ice in the water is, but I'm like, oh, I don't know where that is. I'm the doctor, but I'll let the nurse know. Or, you know, when I say my last name, patients have been like, where are you from? And I'm originally from Texas. So I tell them I'm from Texas, and they're like, they asked me, no, where are you really from? And then to try to make this a little humorous, I'll tell them, what do you mean? You can't tell? I don't have a twang. And I'll start doing a little Texas accent, just so that way I personally don't get offended that they're actually trying to find out where my origins are. You know, I think at times like this, it's, I think it becomes really evident that people of color and people from underrepresented minority groups that are practicing in this environment are also faced with a bit of a tax, right, for sort of representing their entire community when in front of patients, having to bite their tongue, being extra careful about what they say. And I think it's important for the audience to know that, you know, we're all leaders in our own environments in some way, and that we all should be playing a role, not just the people of color, not just the folks from these minority groups. All of us should be playing a role to help to leverage what, leverage this community so that everyone has a stake in this, in this environment. Specifically, doing things like, someone had mentioned managing up, giving our peers a tool to help to support us when in that moment that's embarrassing or uncomfortable. Perhaps letting your peers know, you know, when I'm in the room with this family, it'll be very important that you identify me as doctor and not call me by my first name. That I think it's very important that as my attending, when I walk in the room, that you let the family know that I, as a female, as is the doctor, and I will be taking care of them and asking them to manage you up so that you are not undermined when they walk out of the room is really important. And you know, I think that our peers, our mentors, our attendings, our faculty are all, they're all engaged in this process. And so regardless of what groups you're from, it's really important that we all are all managing up as much, as much as we can so that the burden is not just on the individual to do these things. So I believe that those are, that's the extent of the questions that have been posed to the panel thus far. And we are moving towards the end of our session. Any final comments from our panelists? I'll just start off with you, Dr. Shetty. I think systemic change begins with the individual and I think it's really important for us to look inwards every day as often as we can and try to grow. And that's what is going to bring systemic change over time. Dr. George. Just want to thank the co-panelists for putting together such wonderful talks and for the opportunity to share some of the experience from our community. And I'll take a lot of the lessons we've heard today on the panel back to my work and my job. So thank you to our panelists. Dr. Aras-Mendez. I would also say thank you as well. This was fun. A lot of information shared here. I think it's important for everyone still listening to realize that this is not just a moment. If you've learned anything from 2020, this is a movement. We have to keep this up. I couldn't agree with all of you more. I've learned so much from this session. And though I've met many of you before, there's so much that I'll be taking away from this talk as well. I want to thank all the members of the audience for participating in this flipped classroom session and for sending in your questions and your comments that have really helped us all really work through some very, very challenging scenarios. And as Dr. Aras-Mendez said, please take what you've learned today back to your communities. We're hoping that you learned at least one thing today that you can take back to the bedside and take back into your academic environment. Again, I'd like to thank our esteemed panelists for their insight, their perspectives, and for their expertise. And I wish everyone a great day and continued sessions at the SCCM. All right. Thank you all. Thank you, Dr. Alley. All right. Take care. All right. Thank you.

implicit bias

healthcare outcomes

unconscious bias

societal cues

negative impact

strategies to manage implicit bias

self-awareness

checklists

indigenous communities

COVID-19 pandemic

data reporting challenges

cultural understanding

Native American communities

support and resources

underrepresentation of people of color