I want to welcome everyone out to the Educational Leadership Panel discussion. A pleasure to have you with us. Typically, we would be doing this in person and we would have just enjoyed a nice culinary event. Obviously, COVID-19 has changed that for many of us and we are doing this virtually. I am grateful that the Society of Critical Care Medicine is allowing us to hold this session and I hope that you find it enjoyable. This is sponsored by the Postgraduate Education Committee. I am the chair of that committee. My name is Brian Westman. I'm out of Washington University School of Medicine in St. Louis. The topic that our committee decided to cover today was the topic of implicit bias. We wanted to explore how implicit bias impacts all of us, our own growth in critical care medicine, us as individuals, our programs, and our institutions. We hope you enjoy our panel discussion today. We all carry unrecognized biases that are generated from our environmental and educational backgrounds. These implicit biases impact how we view and how we treat others. Similarly, a collection of biases within a training program can impact opportunities, experiences, and outcomes at our institutions. Biases impact our policies, our programs, and our institutional arrangements. Really making progress on reaching equity will require all of us to be self-reflective and require tools to change the existing structures that are there. These are the learning objectives of our session today. Biases are everywhere and all of us have them. If nothing else, lesson 101 today should be that we all carry biases. Biases are very similar to the fact that all of us sweat. All of us deal with sweating differently. Some of us try to hide our sweat. Some of us cover up our sweat. Some of us try to move into different environments to change our sweat, but all of us still sweat and all of us have biases. Really that should be the takeaway message for everyone here. We can't deny that fact. On top of that, biases cross a spectrum of different topics from race to gender to sexuality to religion, politics, things that can be difficult to talk about at times. I'm not going to say that we're going to be perfect today. In fact, we may make all of us sweat a little bit and that's okay. Part of this topic is for us to feel a little uncomfortable so we learn from each other and grow together. I encourage you to challenge yourself as well when you post questions and bring things to us. It's okay to ask questions about this topic. We want this to be an open, safe environment so we can all learn together. I hope all of you took advantage of the flipped classroom model that we employed for this session. As part of the advertisement for this session, we did share this webpage. We are very grateful for Harvard and their willingness to have this free resource for all of us to access. This is the implicit bias page. It provides tests that you can take to allow you to be self-reflective and learn about your own implicit bias tendencies. I encourage all of you, if you didn't take the opportunity to do this prior to the course, after the course, to reference this webpage and take some of these tests to become more self-reflective. Our panelists and myself have no formal disclosures. Probably the big one that we wanted all of you to hear is that none of us are experts. All of us find this topic fascinating. We all want to improve ourselves in this topic. We want to improve our institutions. We hope to spark a similar interest for all of you, but by no means do we consider ourselves experts in this topic. I am lucky to have an amazing group of panelists with me for this topic, a diverse group from all over the country. I'd like to introduce them to you. Danielle Aplord-Epi is an Associate Professor of Emergency Medicine and Anesthesiology at Washington University School of Medicine. She received her medical school and public health training at the University of Pittsburgh and then completed fellowships in critical care medicine and emergency medicine at Washington University. She is currently the co-director of the Critical Care Ultrasound Program and the Director of Emergency Ultrasound Research with Training and Implementation Science. Her research interests center around understanding the behavioral and systems adaptations required to increase the uptake of evidence into healthcare practices for critical ill patients. Our second panelist is Dr. Corinne Berger. Dr. Corinne Berger is a Neurocritical Care Clinical Pharmacy Manager in New York Presbyterian Hospital, Weill Cornell Medical Center. She received her doctorate of pharmacy from the University of Florida and went on to complete her PGY-1 pharmacy residency at Yale New Haven Hospital and her PGY-2 critical care residency at the University of Illinois Medical Center at Chicago, where she was selected to be a chief resident for them. Dr. Berger is the co-chair of the Student Advisory Committee at NYPH as well as a preceptor to pharmacy students and residents in the Neuroscience Intensive Care Unit. Her research interests include anticoagulation reversal and status epilepticus. And then our final panelist is Marcia Johansson. Marcia Johansson is a nurse practitioner in acute care. She has been practicing as a nurse since 1980 and as a nurse practitioner since 1998. She received her nurse practitioner training at the University of Rochester and completed her doctor of nursing practice degree at the University of South Florida. She is currently the Adult Gerontology Acute Care Nurse Practitioner Program Concentration Director at the University of South Florida and Tampa, Florida. Critical care has always been a passion and she has been active in both the national and local society of critical care medicine chapters. We are lucky to have all three of them with us today, and I'm excited for you to all meet them. Our agenda will be this introduction, followed by Enyo, who will give us our first talk about identifying the bias within. Corinne will then follow on with mitigation of bias within your program. And finally, Marcia will talk about a culture of promoting healthy interactions. I would request that we save all of our questions and discussions to that point. We will have an open session there at the end of about 15 minutes. Questions can be submitted in the chat box during the session, and we will do our best to address all of them at the end. I'm excited for us to have this session today. You'll see my email here on the screen. I'm more than happy to answer questions after the session and continue the conversation after we finish up today. Thank you very much, and I hand the time over now to Enyo. Hi, my name is Enyo Ablodepe. I'm coming to you from Washington University. It's a pleasure to talk to you today about a topic that's a little hard to hear but so important for us as educators in our spaces. I'm talking about implicit bias. I have no disclosures. So what is implicit bias? And more importantly, how does it affect the training paradigm for which we all operate? So let's break down the words. So first, implicit. The key here, and this is a quick summary slide if you are unable to hear the rest of the talk, is that it is an automatic response. So it's not your fault. So there's no need to say, oh, I don't have it. No, you do. We all have it. It's meant to be a shortcut in our brain to get us to be able to interact with the world as fast as possible. It's an evolutionary process that's built in, but it has positive consequences and it has negative consequences. And today, it's important that we talk about the negative consequences. So bias, what does that mean? Well, a bias is just a preference, a predisposition towards something. We all have it towards regular objects, but in this case, people, and it affects our training, it affects our ability to help manage our patients, and it's informed by our lived experience. So if you are human, you are biased, and that's okay. So again, we all have it. It's implicit, meaning that it's automated and unconscious. There is an explicit bias that we do need to talk about, not so much in this forum, but it's important to consider because without mitigation, it can lead to more explicit biases, which we all don't want. Again, it's unconscious and automated, and in this forum, it's really important to think about so that we can make sure that recruitment, retention, satisfaction, and equity within our members, within our trainees is as optimized as possible. So again, it's like a fog, implicit bias. It's like a thing. And you may not have heard that word frequently, but you should be hearing it more. We should be talking about it more because it's what we breathe. It's what we experience, see, feel, and hear. It is normal, and it is normal for us to have implicit biases that are maybe a little embarrassing, but you have to first acknowledge it in order to be able to identify what you can do about it. What are some characteristics of implicit biases? Well, it's pervasive, as I mentioned. It's completely ubiquitous everywhere. It is different than implicit biases, and while related, they're very distinct mental constructs, and I would favor that one can lead to the other. And at this point in our process, we are all trying to figure out how to make sure that we don't get to an explicit bias portion, especially because we have levels of influence and can affect trainees and our medical training environment. These implicit associations, and I'll use the word associations because that has more of a positive connotation than the word bias, they don't necessarily align with our declared beliefs. So again, this is not punitive. This is not saying that we're bad people. You have these biases because of the world that you live in, including myself, and it may not necessarily fit with what one believes about a thing or a character or an object. But again, being aware that those unconscious biases exist will allow us to be able to mitigate that in the conscious space. These biases or associations tend to hold up when we're within our own group, and so you'll hear later opportunities and options to mitigate it or through getting out of our own group so that we can have different experiences. But these biases still exist even within our own inner groups. It is malleable, implicit biases. Our brains are completely complex, incredibly complex, and these associations were created to help protect us. Through time and experience and other methods that we'll hear about, there are ways to unlearn or to de-bias what we have already have in our subconsciousness. Associations and biases, what are some examples? I mean, this starts in kindergarten. This is a picture I took from something online. This is talking about an assignment for children where they have to look at an object and then match it to something, so making an association. We can do this in our sleep. It takes two seconds. We all know that milk goes in a fridge, a hammer goes with nails, and that a key goes with locks, and that's what this environment in the US, let's say. But if you talk to children that are in another country, in another area, these associations may not make sense. Associations are also specific to the area or the context one works in. And while we're talking about milk and fridge and things that are inanimate, the issue is that we have these associations with people as well. When we look at a person, when we look at an object, when we think about different aspects of humanism, we have these same associations, and we need to be honest about that. So here it is, right? So not just a fridge or a nail, but people. Look at each of these people. You're immediately thinking something about them, right? Good, bad, whatever. And as you go through looking at the different people, there are different assumptions and associations that your mind are making in the unconscious space and then in the conscious space. These are implicit biases. They have done studies showing that with MRI capability and with vital signs, heart rate and blood pressure, that there are some vital changes, small changes that occur when each of us sees one of these people. Because there are different moods and different reflections that we're getting based on what we see, what we hear, the environment, the social constructs that we're in that are reflected to these people who we don't know and know nothing about. And so again, being aware of that, because we may be in places of power affecting trainees and in the training environment, it's absolutely pivotal to being able to make a change. Again, to just bring it back again, that it is okay to have implicit biases. We all have them. Think about stand-up comedy or talk shows or things like that. These things are funny and they're good because they take advantage of implicit biases. Could you imagine if a stand-up comic had to go up there and use all of the politically correct statements and things like that? It wouldn't work. They take advantage of these implicit biases in order to make the joke funny, because there's something you're assuming when they describe X or when they describe Y. Even more pivotal with more people thinking about these implicit biases and how they affect our every day, this was a study in 2000, and they looked and saw that these big five orchestras, so people who are really good at music, were predominantly men. And why is that? Women play instruments as well. And so they started having these blind auditions, and they had high expectations for their numbers to increase more than the current standard, which was 12%, and it did increase until they realized that even though they were doing blind auditions, the women were walking into the audition, even though blinded, with heels on. And the sound of the heels versus the sound of shoes that men wear was enough to unblind what they had intended to blind. So when they had people take off their shoes and then walk into the auditions, then it was much more equitable in terms of representation of men and women when it came to success being recruited for these big five orchestras. Implicit biases occur everywhere, even when we intend for it to not affect what we do. This study, I'm sure a lot of you guys have seen, this was in 2017, and looked at pictures of people all 50 years old complaining of chest pain from cardiologists to see how they would offer therapies for them and found that even with good intent, with the same troponins and the same labs, same vital signs, that the skin color of these participants affected the clinician's suggestion of what kind of therapy they needed, either invasive or non. And this was one of the first studies that really talked about implicit biases in medical trainees because we believe, obviously, do no harm. We want to do the best thing for our patients, and we try, but implicit biases are present and keep us from being able to do that very well or can keep us from doing that very well and certainly can also affect and keep us from being able to have good representation of our trainees and their experiences. Associations, that's a better word, but it's really a bias. This slide here is really to depict that if these associations and biases aren't really nipped in the bud, both identified and mitigated, which will be talked about later, then it can lead down to two, three, four, and five, which are then to stereotypes, which are kind of reinforced biases, prejudices that are sort of self-identified associations, discrimination that then becomes more systemic, and then those isms that none of us want to have about us. At some point, I think of these sort of like cancers that you may have, sort of biases or kind of early cellular changes, and then as you get to stereotypes and prejudices, you may have like just an isolated tumor, and then by the time you're getting to discriminations and isms, it's metastatic and it's everywhere, and it's much harder to treat when it's at that level. It's much easier to fix something when it's at a cellular level as a very local level. We all have these implicit biases, and again, it's not just race and gender, which are the two most common, but there's also age, education, size, ethnicity, language, income. I mean, there's so many biases that we all have, and to be really honest, reflective about the fact that these associations exist in our brain to help protect us but can be negative and making sure that it doesn't affect how we select our trainees, how we retain our trainees, how we train our trainees, and how then they go on to help manage patients and making sure that their biases don't affect the patient care as well. So if what I've said kind of resonates with you and you already knew that, then that's wonderful. Keep preaching the message that these biases exist. If you haven't heard this before, I encourage you to go and take this exam. It's exam, but it's really a test. It's a test for you to see unconsciously what some of those biases or associations that you may have in your own space or in your own context, and I think it's very useful to be able to, again, put a name to it so that one can figure out the best ways to unbias or to mitigate that issue. There's research, again, in this area that is becoming more prevalent because it's a very important concept. I think people thought, again, previously that bias was a bad word, that it was intentional and conscious, and now we know that it's not intentional. It's unconscious. It's part of what the DNA of being human and the DNA of being human in the context that you currently exist, but it is very normative and largely unintentional. The problem here, and I think a place where this kind of talk is so useful is that we know that based on the social cognition theory that these perceptions, biases, associations can become hardwired into our cognitive functioning, and that's where it becomes a problem. Again, as people who have influence and power, having these biases or associations hardwired where it affects how we recruit and how we select becomes an issue that then treats this problem to become more systemic. Then, of course, it's now this stage four metastatic disease that is very hard, essentially, to treat. Going back again to normalize it, back in our brains, parts of our brains are set up to be able to continue these associations, again, intentionally, evolutionarily for fight or flight, but as we move to the subconscious or the conscious portions in the frontal cortex, we can now use reasoning, empathy, and impressions, experiences to mitigate or fight against what our natural base associations that are set up in our automatic portions of our brain here. Again, what we'll talk about in terms of the ability to mitigate are really to help one and two, which is our biases, associations, and stereotypes. Once you get into the three, fours, and fives, I think we'll need another session for that, but all of this can be unlearned, and that's the good news for us today. These biases are most likely activated once you know what they are, are most likely activated when there's stress, when there are time constraints, if you're multitasking, because, again, your brain has done this intentionally to get a shortcut. When you're multitasking in the critical care space, trying to do a lot of things, you're going to likely activate those biases. When there's a need for closure, making a decision, that's another place where it'll be likely activated, so be aware of that. If you get past the bias and are now into the stereotype land, things that encourage those stereotypes, and it's pivotal, I think, as we think about trainees that are selected and that are represented, is that when the target is solo or near solo status, specifically here, let's say you have a person of color among all white colleagues or a woman among all male colleagues or vice versa, these are situations where these stereotypes can be certainly activated. In the employment context, if they're members of a group that were previously admitted, now resumes a job in a nontraditional role, or if there's a perceived lack of fit between the target category, female, a person of color, and their occupation, let's say an orthopedic female resident or attending, those sorts of things also set one up for ongoing stereotypes. For selection of trainees, for selection of employment, when criteria are used in terms of evaluation that are ambiguous, these also allow our biases to take effect as opposed to more traditional and objective criteria for advancement, selection, retention, etc. So, final points about implicit bias. I hope I was able to help bring that out, which is that it's what it is, and it's there. It is what it is, right? So, it is pervasive. People are often unaware of it. It's not intentional, but it exists. We must address it. We must be aware of it personally and then address it as we are influenced to our trainees and with our patients. It can predict behavior. It doesn't always, but it absolutely can be influential in that when those context sees that predisposed activation of those biases, so we should be aware of that so that it doesn't predict behavior that then leads to stereotyping that then leads to discrimination. People of power or influence have to especially be aware of their biases. Think about judges, right? Trying to be impartial and knowing that you have a bias towards X. It is an everyday act to try to stay neutral and not to be given into those unconscious base biases or associations. I like to think of it like farting. I have a young child, and we're going through the potty training phase, and so everybody farts. We all do it. It's functionally necessary, okay? If you try to hold it in, bad things will happen, but there is a right time and a place for that release of gas to occur. And like potty training, as we become more cultured, as we become more aware, we can learn ways to mitigate or contain our biases or stereotypes, but first, it begins with identification, understanding, and thinking about it within ourselves, and that's okay. Thank you so much for your time. Welcome to the Educational Leadership Panel Discussion on Implicit Bias. My name is Corinne Berger, and this session will focus on mitigation of bias within your program, and I have nothing to disclose relevant to this talk, but I will disclose a few things about myself. You can see that I am white. I'm female, and I identify as female. I'm Jewish, and I'm a pharmacist, so I'd like to start with sharing some of my own experiences and examples, and then we can move into some techniques that we can all practice to help reduce implicit bias. A few years ago, I was moving into my role as president of the New York City Society of Health System Pharmacy, and we had our traditional pass the gavel meeting with the board of directors. One of my board members, who chairs a major event, came up to me and tells me, I made sure to put so-and-so and so-and-so, who are two women, as chairs because women are good party planners. And what was more unbelievable than him saying this so casually was that he didn't even realize how it had come off, especially to me as the incoming president and with what I hopefully consider to be more qualities and positive attributes than party planning. And during my presidency, I would see how this individual treated other male leaders as compared to how he treated me, and it was very subtle. I think from a bird's eye view, it would be really hard to notice, but if you're on the receiving end of the little slights or minor comments, you can really feel their impact. And I realize now that sometimes these subtle comments or microaggressions can have a lasting impact and really change our behaviors, and I know that I felt more self-conscious about myself as a leader when I was around him due to some of these actions. More recently, I was participating in a Twitter journal club, and this tweet came up as a response to the question, what do you perceive to be the top barriers for women assuming leadership positions? And the tweeter wrote a riddle that reads as follows, a father and son are in a horrible car crash that kills the dad. The son is rushed to the hospital. Just as he's about to go under the knife, the surgeon says, I can't operate. That boy is my son. And as I struggled to answer the riddle, and of course later realized that the surgeon was his mom, I asked myself, do I have implicit gender bias? And incredibly, it is possible to have implicit biases against members of your own associated group. And as we start to learn more about implicit biases, it brings up the question, how do we address this? This article takes it one step further and even suggests we should treat female and male residents differently, and I can tell you the letters to the editor in response were very polarized with a lot of different opinions on both sides of the argument, but I think what the authors here were trying to bring up is that at a minimum, we should recognize that these biases exist and identify ways to mitigate them, and certainly we can argue and debate what the best way to do so is. Well, these are anecdotal examples, but I know that we tend to respond better to real data, so this study looked at speaker introductions during Medicine Grand Rounds, and what we see here is that when men introduced women, they used their professional titles, such as Dr. So-and-so, less than 50% of the time, as opposed to when they introduced men, which was more than 70% of the time. And so even in a formal setting, we have data to demonstrate some real outcomes of gender implicit bias. Okay, so my next example, I actually borrowed from my fiance. He was an associate director of pharmacy and, you know, moving on up within his health system and starting to demonstrate himself as a key player in the department, so he got invited to a director's brunch, and this was a small gathering of site directors within the health system that was organized by the vice president of the department. The only problem is that the brunch was scheduled for Yom Kippur, which is one of the most religious holidays in the Jewish religion, and one that requires fasting. So he had two options. He can miss this amazing networking opportunity, or he could go and watch everybody else eat around him. And of course, being the go-getter that he is, he chose to do the latter. But putting him in that position really made things difficult for him. And as I think about it, I can recall numerous times where I had an exam or a deadline on Yom Kippur, and some of the challenges that that posed for me. So you can see here that implicit religious bias may not necessarily be blatant anti-Semitism. That would be more of an explicit bias. It can just be comments of confusion about a religion, like, oh, you have to fast the whole day, that's so weird. Or, you know, a meeting or exam or something important scheduled on a major holiday. And so I think some easy ways to try to mitigate this is, you know, you can't always keep track of every major holiday or every religion, but if you're reviewing the holiday schedule or even sending a doodle poll for availability, that may alert you to some red flags of days not to schedule. Well, aside from being Jewish and a female, I am also a pharmacist, and I did complete two years of residency training. A few months ago, there was a lot of controversy regarding this tweet describing who gets to be called a resident. And the person who tweeted it said, words matter. In the medical setting, resident, residency, fellow, and fellowship belong to physicians only, and only is in all capital letters to make it very clear. And this was in response to the position statement on postgraduate training of nurse practitioners and PAs. So even though this doesn't explicitly mention pharmacists, pharmacist colleagues of mine all over the country were pretty angry at the thought that our own residency training was being questioned. And it's interesting because the person who posted it starts by saying, words matter, and I wonder if she really understood the depth of that statement and how people might react. Well, what about my PharmD? Does that warrant me being called doctor or being introduced as doctor? This was a Wall Street Journal opinion article questioning whether our soon-to-be first lady, Jill Biden, should be addressed as doctor for her PhD in education. And the author says, Jill Biden should think about dropping the honorific, which feels fraudulent, even comic. So whether you agree or disagree, these implicit biases between members of various professions can actually affect our interactions with each other. Instead of, you know, having to prove why maybe I do deserve the doctor title, I wonder if we'd all be a little bit better at our jobs if we just learned more about each other and with more perspective we could worry less about owning, you know, a specific title or a training program and just have a deeper respect for each other. And as we think about implicit professional bias, which admittedly is not the first type of bias that comes to mind, it often does help to take a multidisciplinary approach and increase our opportunities for contact, meaning we should seek out opportunities to positively interact with other group members. For example, a physician can shadow a nurse to see his or her bedside care. Many institutions and many services have moved towards multidisciplinary rounds with representation from various disciplines. We can all learn together and from each other if we have interdisciplinary educational sessions like this current session. And one great example is the COVID vaccine rollout. In my institution, we were and currently are all hands on deck. So we have pharmacists, PAs, NPs, nurses all helping to vaccinate. And as we are sharing our experiences and helping each other and working together all to accomplish the same task, it's very insightful and it helps really build perspective. So sometimes having a shared task or being part of a code team together can really help give you perspective about others' roles. And so, you know, some of these examples were just my own personal examples. Obviously, there are so many more groups and examples that are missing here because we can have implicit bias against almost any group. But luckily, as we've started to show, they can be mitigated. And we can mitigate them when there's a conscious effort or even a mandate to mitigate implicit bias. And this would be, for example, a residency selection committee charged with increasing the number of women. We can also implement implicit bias training programs. One college of medicine did implement a training implicit bias reduction techniques. And after that, they actually had their most diverse class. In addition to training programs, we really need to assess biases within our own programs and then our own individual biases. And there are some sort of basic steps we can walk through in order to do this systematically. The first one is just building awareness. So, awareness of bias, gender, racial, etc., but also of the consequences. And certainly, implicit bias can lead to differences in evaluations, burnout, lower productivity, smaller applicant pool by potentially turning off some groups of interested applicants. Building awareness can also help people recognize that they have some unconscious decision making, and maybe they're not fully in control of some of the decisions they're making. And so, once we have that awareness, we can engage in some practice exercises, which we'll talk about. And then on a bigger level, we want to implement institutional and organizational change, changing the culture, changing committee structures, researching this, and then repeating these steps. So, doing this one time through is really great. It brings attention to the issue, but we can't, you know, reduce or eliminate implicit bias, which sometimes take decades to build and go uncheck with just one sort of interactive session. So, we want to make sure that we are preventing decision making that is based on biases. And some of that stems from doubting even your own ability to be objective. So, when we teach people that unconscious thought process, about unconscious thought processes, it may actually lead you to be more skeptical of your own ability to be objective. Sometimes we need to change the conditions of decision making. So, think slow. This really means just engage in mindful, deliberate processing in order to prevent implicit biases from sort of kicking in reflexively. Whenever you can, try to use clear, objective, unbiased criteria for decision making rather than subjective criteria. And then hold those decision makers accountable. They are more likely to implement specific practices that prevent the behavior from occurring if they are held accountable. And something that is helpful is using metrics. So, aggregate data is much more impactful than anecdotal examples. Here are some additional mitigation strategies. So, we have counter stereotyping. This is where you identify individuals who are admired or respected and in the same demographic as the individual. So, a lot of people were very excited when President Obama was elected and soon to be Vice President Kamala Harris because they represented demographics that were not traditionally or ever in these positions. Here's an example of the first nurse getting the COVID vaccine within New York State. So, this is a person of color hoping that posting this picture will motivate other people of color to also maybe be motivated to get the vaccine. We try to teach perspective training. So, just taking the perspective of the other individual, sort of building that empathy to help actively oppose implicit bias. Consider the opposite is really just saying instead of telling yourself why this candidate is a good fit for the position, ask yourself why shouldn't they come in for an interview or why are they not qualified for the position and see if that then changes your decision about the candidate. In group peers, this would be referring to if possible hiring in clusters or cohorts. If that's not possible, trying to make teams of non-dominant groups. For example, if you have a work project, put a team of women together and see if maybe somebody who wouldn't have normally emerged as a leader maybe would have that opportunity. And finally, we can implement objective standards. So, this can be something as easy as within an organization having a template for moderator introductions whereby we ask the speaker their preference and their own introduction so that way they can be introduced as doctor if they prefer or otherwise if that's appropriate. We definitely want to find commonalities whenever we can. I can tell you when I interview candidates and they come in and they say go Gators, that just triggers such a happy thought for me and there's certainly a bonding that I immediately feel. So, finding common identities between you and the individual and seeing them as an individual with those shared characteristics rather than being part of a group. On the left, I have pictures of my family and I traveling to Paris. In the middle, I have Billy Joel. On the right, running a marathon. Runners tend to have a bond, but it could be a hometown, language proficiency, art, music, travel, any sort of commonality that you can develop with the candidate. When we are talking about recruitment and hiring, we want to make sure that the job descriptions that are posted are not biased towards a particular group and that includes using language that's maybe not associated with a particular gender. For screening, whenever possible, we want to blind committee members both towards to photos of the candidate or to even their names. So, we've seen that resumes that have African American sounding names can have lower callback than white sounding names. So, if we can blind committee members as much as possible to keep that objectivity, we may see less implicit bias kicking in. People who are doing the interview, we would absolutely love for them to have implicit bias training. That way, they're aware of what to look out for and again, just identifying biases that they may not have known and some places even make it a committee responsibility of the people who are interviewing. As far as evaluations, how are we even evaluating our trainees? We have data to suggest that there are differences between male and female gender and the evaluation that they're receiving. The article on the right talks about emergency medicine residents who, when they started the program, were actually evaluated very similarly suggesting that they had, you know, the same knowledge base, etc. But by the time they graduated, the men were actually attaining more milestones than women. So, something to think about, especially if we are involved in evaluating residents. And so, we really should be serving our programs and thinking about some of these questions. Are we acknowledging bias? Have we even talked about it within our programs? And if we have started those discussions, have we formalized them? Do we have a specific implicit bias training program? And if we do have a training program, is that program sufficient? And this was a study done of a survey of pediatric residency program directors. Most of them did say it was important to have implicit bias training as part of the residency program. Less than half who had a training program actually thought the training curriculum was valuable. And then when they really drilled down and said, well, what was effective? It is important to note that, you know, maybe just having a didactic lecture, it appears is not as effective as really investing the time to have some of these group discussions. And a majority of them did say that there was a positive impact on patient care. So, it is nice to see some of those outcomes after implementing these programs. So, I will just end with, you know, reminding everybody not to lose the momentum. And I think everyone who's watching this has done a key first step in learning about implicit biases. We know that we may not have explicit biases, like the isms, you know, racism, sexism, but it's likely that many of us do have implicit biases that maybe we weren't even aware of. And it's important to identify those, also try to identify them within your own programs, and then think about what are the next steps and how you're going to follow up. And that follow up should, you know, be something that's concrete and periodic and involves not just yourself, but members of your program, your trainees, and your leadership. And so, if we can keep that momentum going, we'll not only be aware that implicit biases exist, but we'll really start taking the steps to mitigate implicit bias. So, thank you for tuning in. Please feel free to tweet me with any thoughts or suggestions. And I'll see you all during the Q&A. Hello, my name is Marcia Johansson. I'm a critical care nurse practitioner and an educator. My presentation today is about a culture of promoting healthy interactions. I have no financial disclosures. However, I do want to disclose that I have made a colleague or two cry, which does not promote a healthy work or training interaction. I'm not proud of it, but in this presentation, it is important. Thank you to Dr. Berger and Dr. Ablodepi for their presentations on implicit bias and potential ways to mitigate the impact. I will share practical resources to avoid microaggression and improve professional interactions. I want to start by reflecting on implicit biases. They are the unconscious prejudices and negative attitudes towards certain groups of people that can compromise relationships, training, and good health care. I have listed a few from the literature that can affect health care, but there are many more that can have an effect. Microaggression can be a symptom of an implicit bias and includes everyday snubs, humiliations, criticisms, or insults towards marginalized groups or any person in their day-to-day interactions. Microaggressors are often unaware that they have engaged in offensive or belittling behaviors. Making fun of a person or trainee for the way they speak, such as if they had a southern accent or they spoke in broken English, can seem insignificant, but when done in a group can make the person self-conscious and they may withdraw. How do we create a healthy work environment? First, we must recognize that our unspoken or spoken biases and microaggressive behaviors that involve patients, coworkers, or trainees can make the clinical workplace more difficult. Second, when a microaggressive or biased situation occurs, recognize it and explore the message that you are sending. If necessary, apologize. As program directors, we must address these situations as they arise. If you are the aggressor, apologize to the group and move on. It is important that we develop this culture in our everyday work, such as on daily rounds, during meetings, or at morbidity or mortality reviews. Think about opportunities where you can create a healthy work environment. Remember that you are the captain of the ship and a role model for those that you interact with. In order to create a healthy work environment, I want to review eight approaches that you can use. Introspection, Mindfulness, Perspective Taking, Slowdown, Individuation, Messaging, and Institutionalized Fairness and Restart. I'll review each of these concepts. Introspection. Identify and understand your own preconception. There are different implicit association tests and methods of self analysis that you can use. In preparing for this talk, we were all encouraged to take the Harvard Implicit Association Test, which allowed us to discover hidden biases that we may have that may affect day-to-day decision making. If a microaggression occurs, recognize that it occurred and understand the message that was sent. Is this what you intended? Mindfulness. Mindfulness can be affected by many factors, so be aware if you exhibit bias or microaggressive behaviors. They occur most often when an individual is under pressure or feeling increased stress. Some ways to combat stress can be through daily exercise, listening to or playing music, meditation, focused breathing, or through the use of purposeful pause. STOP is an acronym for a practice that is primarily used to inject a little mindfulness into your experiences throughout the day during times when you need it most. It is easy to get caught up in all of the stressors and activities of daily life. Sick patients, time management, meetings, added responsibilities for education, and that is just during the work day. What about the stressors waiting for us at home, especially with the quarantine restrictions? It can be overwhelming. By applying mindfulness to experiences or times during the day, your mind will be on autopilot less and you will be able to check to see how you are feeling, what you are thinking, and most importantly what behavior you are engaging in. S stands for stop. What are you doing? Pause momentarily and give yourself a little bit of a reset. T stands for take a deep breath. Reconnect with your breath. The breath is the anchor in the present moment. When I take a deep breath, I realize that I often I realize how often I take it for granted, which is not the case for many of our patients. O is observe. Notice what is happening both inside and outside of your of your sphere. What are you thinking about? What were you doing? Are you thinking more about yourself or the group you're engaged with? And P is proceed. Continue what you are doing or don't. Use the information gained during the pause to change your course if necessary. Whatever you do, do it mindfully. P is for perspective. Perspective is considering experiences that are occurring from other from other persons, from another person's point of view. Ask yourself, how would I feel if what I said to a patient, trainee, or co-worker was said to me? You may need to read or watch content on YouTube or TED Talks to gain insight from different groups to improve your perceptions of others. Slow down. Just like with mindfulness, you may need to pause and reflect to reduce impulsive reactions or behaviors. When you pause, you may want to ask for clarification. You may want to separate intent from impact or share your own experiences with the group. Slowing down gives you the opportunity to acknowledge the potential for bias and can help the aggressor change behavior. This can be done in your mind or if it's someone else, it can be done, it can be a learning opportunity that is presented in a constructive way. You may want to identify positive examples of people in that stereotype group that may be public figures or friends. Individuation. Evaluate people on their personal characteristics and not on their affiliated group characteristics as to avoid group bias stereotyping inferences. Connect with others over shared experiences, common interests, or mutual purpose. You can ask about family, hobbies, sports interests, or past experiences. Through identifying personal characteristics, it will help you to inform clinical decisions and will help you to connect on a personal level with both patients and trainees. We also have advanced directives such as living wills but at times they are not enough and knowing what a person's hobbies might be may be more important to bring out than the fact that they have a living will. How can we change bias behavior and microaggressive behavior? One of the keys is to create a strong culture of change. We are currently seeing a patient safety culture change but what if we use the same process for implicit bias? We need to develop a systematic approach by incorporating a continuous improvement process, practice unbiased behaviors, and then reflect back on what works and what didn't work for your group and organization. I had a student that used role playing with standardized patients to implement behavior changes. It was highly effective. The next three topics are addressed in further slides. So messaging. Check your messaging and make sure that you are saying what you mean. How many times have you heard the phrase, it's not what you said but what the other person heard that makes a difference. Practice your messaging to make sure it creates a more inclusive environment and helps to mitigate implicit bias and microaggressive behaviors. Your statements that welcome and embrace differences in your group are highly important. I was once teaching a conference on, I was once at a teaching conference on patient safety where the speaker who was talking to a group of nurse practitioners, medical students, and pharmacists stated that she's not really sure what pharmacists and nurse practitioners do as she works mainly with medical students and that totally shut down the whole group because she only then addressed the medical students and not the rest of the group which needless to say was not a really good messaging technique. Institutionalized fairness addresses your organization. Have you developed a diversity committee or group that looks at policies to make sure that they are inclusive? In education we are looking at how we can incorporate diversity and inclusion into our curricula. There is an equity bias tool that can help identify blind spots in your organization or even in your office. What message are you sending by the artwork or the information displayed in your office? And last, setting the reset or restart button. As society changes we also have need to change how we address implicit bias and microaggression. We need to look at ways to improve and not rest on our past achievements. One company that never changed their products or market to keep up with the technology was Kodak. It is now no longer a thriving company and that was because the leadership did not recognize that the rest of the world was changing and that they needed to change with it. As health care expands and becomes inclusive so must we as providers. So when we look at the effects of creating a culture to promote healthy work interaction we see improved job satisfaction, decreased staff turnover, reduced role ambiguity and workload. A group marked by trust, mutual regard and active engagement that one and one that fosters positive emotions. Change cannot occur overnight but takes a systematic approach that builds on education and experience at both the unit-based and organizational levels. As program directors we can lead the fight for change related to patients, colleagues and the communities that we serve. Thank you very much. Hello, folks. Hopefully you enjoyed that session. I'm grateful for the education that I garnished from our participants, and we look forward to this Q&A session. So I think, you know, panel, to start us off, we had some great questions posted. One of them I thought was very interesting, partly because of the format of this session. As we're all aware, you can vote on these little questions and make them move up or down as you vote on them. You know, someone brought up this idea that, you know, how do we make sure that this education about implicit bias doesn't get lost? You know, Jayco is focused on handwashing, and Jayco is focused on HIPAA, and they would vote all of those things much higher. How do we make this just not a checkbox or, you know, we just defer to some type of reading strategy to get rid of implicit bias for our trainees? Any thoughts out there from the panelists? Yeah, Brian, I completely agree with you, especially because I know when I do my annual training or some of my training, I know we're, you know, some of us are just clicking through and trying to get it done, and I don't think that really works with this. That was like one of the surveys showed that there's a pretty low percentage of response when trainees just had to go through a didactic lecture. I think it's worth investing the time and really having those group discussions. We did that at my hospital, New York Presbyterian Hospital, and not just having the trainees do it but really modeling and having the leadership be involved, the residency program directors, other preceptors, attendings, bringing everybody into it and having sort of safe, open discussions frequently, so that those are expected conversations that should be happening and even having somebody moderate by bringing up some different cases and points and getting the conversation going. But I agree, just having it as an extra checkbox probably isn't going to do too much to move the mission forward. Yeah, and I would say, sorry, that it probably, you know, it depends on the institution. If you want to make it a priority, you have to make it a priority. And it's true, there's a lot of other things that are going on. But because it's so hard to fix, because it's so part of like, you know, I'm 40 years old, you have to fix 40 years of what I have been seeing and feeling and witnessing and try to get me to slow down and retrain my brain. That's not going to happen in just a small session one time, once a year to check off a box as described. If you want to fix it, then you have to put in the work to fix it. I totally agree with that. You know, having those conversations, you know, having the conversations in rounds and you as the attending or you as the chief president or you as whatever it is that that is your role is, is you bringing up the conversation on a routine basis, not every week, but you know, every once in a while just to say, hey, you know, this, this happened to me, okay, what do you guys think about it? That would be much better than checking off a box and and doing it once a year when the rest of the year, you know, you're, you're very difficult to deal with. Yeah, let me, let me push you guys a little bit further because I agree with you. I think really where you make a difference in this is that idea of mentorship and changing a culture. And obviously those opportunities come up at various spots. And so, you know, the example that I can share is, you know, sitting in evaluation meetings and with our, you know, competency committee talking about trainees, all of a sudden I can look at an evaluation and then talk to the committee about, well, did this come out because of this person being a female? And that's why they were seen as more humble or, you know, whatever other phrase was used instead of being more aggressive. And how can we continue to model that behavior to make our cultures different? I guess is the question I'm asking all of you to think about or share examples with. That's a hard one to tackle for sure. I certainly don't have all the answers. I think one thing we need to make sure that we're doing is making sure that the people who are doing the evaluations are also sort of representing some of the trainees. So I know oftentimes it's an attending, but if it's, if it's, if there's always a discrepancy between the gender or race and maybe adding in other evaluators or peer evaluators that can maybe provide a different perspective and enhance the evaluation, that might be a first step. I think the other part of that is like the 360 evaluations that we give to our residents and fellows is that it's not just the attending that evaluates, it's everybody. It could be a nurse. It could be, you know, whoever. And having that evaluation is really important to pull it all together. Yeah, again, I guess my, my clarification, and I apologize, you know, my example was the opportunity then to educate your own faculty members. I think sometimes our faculty members, and I've sat there in a competency meeting and told the faculty in general that us as a culture, we need to do better with that. I think Marcia, you mentioned during rounds, if you're on rounds and this comes up, taking that opportunity real time to have that education at the bedside, maybe not in the didactic lecture, and I guess ways that we can continue to make our cultures different at our institutions. Well, there was another good follow-up question about that. So, so, you know, if we want to look at our own cultures, I mean, how do we design studies that look at our own cultures? Do we want to look in the mirror and see that our own institutions aren't doing well with this? Does that harm us? Thoughts on how we can, you know, evaluate our own ability to be more introspective and how we're approaching implicit biases at our own shops? Let me start by asking, Brian, and I don't know if you know, but have we made, is there an opportunity to have leadership, educators, fellowship, those people take that implicit bias test. I mean, example and leading by example, to me is number one in terms of how you change the culture. If I'm seeing, you know, some of the microaggressions in front of me every day from my leadership, you know, that it kind of, you know, snowballs and continues in an unbiased fashion. So yeah, a practical way, perhaps, I don't know about the study question, but to start is making sure that our leaders, our leadership educators, that they took that test because we're asking the audience to be aware of their biases. And those people obviously represent leadership, but maybe a mandate or requirement just to understand where you are starting from so that you can better educate and provide feedback to your faculty members or in real time. And so that you can appropriately design a study, you have to first understand the context of the issue, I believe, before you can even get to the, how do we understand it better and how do we systematically come up with a plan to mitigate it, fix it, et cetera. And maybe even charging our professional organizations or accrediting bodies with aggregating some of this data for us. So, you know, put it all out there in the open. What proportion of your candidates are this, or do you have implicit bias training? How do you facilitate your interviews and screening of candidates and things like that? And maybe benchmarking where different organizations stand. And obviously there'll be discrepancies based on geography and the type of program, but it might help for it to come from a national perspective rather than each organization maybe, you know, reviewing their own programs. Or from your CEO. You know, I think, you know, if it doesn't start at the top, if your organization is not committed to this, then it's not going to happen, you know? If your organization doesn't value their employees, then it's going to go unchecked. Yeah, let me, let me ask you that same vein since you're talking about, you know, reaching all the way up to the hospital leadership or the organizational leadership. You know, as our trainees leave our programs and they're looking for career pathways, they're looking for jobs, you know, how can we help them evaluate an institution? What questions should they ask to understand if maybe they've been in a more protective culture and now they're walking into the wild, wild west where implicit bias is going to impact them? Or maybe they've been in the wild, wild west and they're now going to walk into a more comfortable situation. How can we help them evaluate that or understand what they may be getting into as they sign contracts? That's a tough one. I will say that we discussed early on that implicit biases are certainly natural. Your brain, based on your experience, we are all really smart people, has sort of already programmed some things. So even on the interview trail, and I've heard from different trainees say this in the, you know, remote forum, Zoom, or whatever application you're using, there's some spidey senses, there's some things that you're picking up based on what you see here and your, you know, your perception. But your question is speaking more to a systematic process of like specific questions that might be targeted to helping you understand if that institution values implicit bias, either training or has a mission to equalize in all aspects, not just race, not just gender, but in all aspects. So I think that's tough. But I don't know if the literature is saturated or has some resources for us, but that's a great point. But the truth is, people also have their sense. I can share my own personal experience. When I was looking for training programs, I paid attention to who was there, how they looked, what their backgrounds were. I processed that in my, you know, Excel sheet of like pros and cons of if I'm going to, air quote, fit in that environment. And again, I didn't ask, I don't know that I remember the specific questions I asked, but I processed some of those things. So I don't know how the other panelists feel about that. But if there's ways, people are already doing that, how to more systemically do that appropriately. I hope there's resources out there that can be shared with the audience. Hanyu, let me push you a little further on that, if you don't mind, because I think you bring up a great point. This idea of, you know, looking for someone that matches your impression or perspective. And, you know, Corinne did a good job, you know, I'm a female, I'm white. And I mean, you look for those people, maybe when you interview, but if those people aren't there, does that mean that the institution is just genderism or racism? Or could it be that they're trying to work on their implicit bias, but they haven't had you willing to come and work with them? And so do we put our own bias on that institution by just looking for people that look like us, and don't explore it more with the white male that's sitting in front of you or whoever else you may be talking to, and trying to understand that? And I'm curious from your perspective, as you've gone about that and looked at different places. No, I appreciate the question. I want this discussion to be hard. This is not an easy topic. This is not supposed to be comfortable and nice and PC. Let's tell the truth about what's happening and figure out how to fix it. Because I believe that we all want to try to fix it and do good. So that we can help our patients. We haven't even talked about implicit bias on our patients. We're just talking about trainees right now. So yeah, my personal story, I, you know, my family's in Florida. For some of you who don't know my name, hopefully, maybe is letting you share, but I'm originally from Ghana. English is my first language. So those microaggressions of your English is so good. Thanks. Okay. And I appreciate that. But my point is, when I was looking for programs, yeah, I did make a bias and paid attention to places that didn't seem to have adequate representation of everybody. Again, not just race, not just gender, but of everybody. That was important to me. And even further, just to give the other panelists time to talk about their experience. That's part of the reason why I'm staying where I am. Because I recognize that there might be a person like me who's looking to make sure that all groups are represented or equally diverse. And I want to make sure that they don't make a pass on Washington University, because we don't have that. So I use that bias. And I guess from a mitigation standpoint, I want to help other people who may have that bias. But I mean, I do, to your point, if a place doesn't have that, that's, they may be working on it. But that's what I'm saying. If you're trying to fix something, if you value it, if you're serious about it, we are all smart. You know that you have to put in the time, you have to put in the work, and you have to get it done. The environment you have exists because of the structure that is around it. So if that's a goal of an institution, to get more X or get, you know, whatever, there is work that has to be done at every level, starting from leadership to obtain that goal. You know, 100%. I agree with you. And I think, Brian, to your point, it's true. I think it's the first step for a candidate or someone who's looking around would be, what have you done with implicit bias? Are there programs in place? What are some of the, you know, specific outcomes that have come from your implicit bias training programs? And I think as long as they're working towards that goal, and it seems genuine, and, you know, they have some metrics, or usually people light up, and if they've been talking about it, they can, you know, pretty genuinely speak to it. And I completely also agree with any of your point. If you want to make it happen, you can make it happen. There's data that shows that after people go through these programs, there is a reduction implicit bias, both from candidate diversity pools, things like that. We've all seen this whole concept of mannels, you know, all white male panels or all male panels, and how some speakers are standing against it and say, I'm not going to do a talk if you can't diversify the panel, and they have diversified the panel. So some of this is also finding sponsors to say, well, I just couldn't find a woman speaker on this topic. Well, here's, you know, a list. Some organizations are keeping lists. Here's, you know, 200 people that are experts in this topic that you could reach to. So I completely agree with that. I think that if there's a genuine desire to make it happen, that you can start taking those steps and maybe not immediately seeing results, but showing some of the fruits of that labor. And I think having that spidey sense, hold on, I think having that spidey sense that they were talking about is really important, that when you go and you interview, you know, if they close down to questions, that's not a place you want to be at. You know, you want to be at a place where you can ask questions and you can give your opinion, okay, and it's received as opposed to, you know, that's not how we do it here. So to your point, Brian, I think it's asking the right questions and training our trainees to ask those questions and look around. Marcia, maybe as a follow-up to that, because someone brought up a great point in the chat box of, you know, we can make people take the Harvard implicit test and get our faculty to buy into that, but does that just become another checkbox, something else they have to do? Maybe in a better structure, how do we, you know, obviously we've created this artificially today with SCCM, how do we create a safe space? You know, as Enyo said, this is dirty laundry, but it's just dirty laundry we should all talk about. You know, we all use various examples, sweating, farting, whatever was thrown out there, but how do we make the room fresh enough that we can talk about those things and have the conversation real-time with our faculty groups? I think that the big part about that is you as the mentor, you as the leader need to open the group up to this, okay? If they can see that there is not going to be any kind of repercussion from it, you know, they're not going to make fun of you, they're not going to ban you from the group or make education harder or ask you questions that they know you can't answer, okay? So there's no repercussions from it that you as the leader can bring those, these topics up and make it a safe space. You know, you are the, you know, you're the captain of the ship. You're the one that leads this, and so having these conversations, whether it be in rounds, whether it be at M&M, like whatever the case may be, having these conversations is going to go a long way as to say we don't have any implicit bias or we have it and we know it and we're good with that, you know? Yeah, and follow through. Follow through and make sure that there aren't those consequences that people are worried about. Make sure that all of the staff from high to low know that, you know, there's like a zero tolerance to that, like whatever is said is sort of in a safe space. I also think like one thing we do is, you know, if you have a critical care pharmacy residency program, see if you can, you know, link up that resident with a non-critical care preceptor so they have someone outside of their immediate program that they can check in with and it is expected that they, you know, check in and that person can kind of, you know, help them mitigate things and they're getting a little bit more of a bird's eye view. Agreed. No, I think those are all great comments and thoughts for the institution side of it. Let me change our venue a little bit, you know, we talked somewhat there about getting applicants in and I think, Corinne, in your talk you listed some ideas there of ways we could do better of trying to blind ourselves or help out when we're trying to get applicants in. You, I think, shared the example of the orchestra and the high heels and the walking. It was either your talk or anyone's, I forget now, but that actually had that component of you just take your shoes off and maybe that helps blind you. How do we just overcome the bigger issue that maybe someone didn't get the opportunity to have the elevated board score because they never were allowed to do the board prep course or there's so much that embodies the system in general that we can't just blind ourselves, that we have to be even more proactive about it, almost that idea of reverse discrimination. Comments or thoughts since you had brought that up? Great, great questions to tackle. I won't take any as example because I loved that example with the orchestra and the heels. I think some of it is blinding. I think some of it, you know, what we did when we tried to evaluate our candidates coming into applying to our residency, we actually went to the pharmacy schools to try to understand, you know, why aren't you applying or, you know, going to schools with more diverse backgrounds and seeing maybe they, we need to target them earlier and tell them more about residency opportunities and things like that and make sure that, you know, we are providing those opportunities. We also talked about, you know, there may be somebody who doesn't have as much extracurricular because they were a caregiver to their parent for maybe a year or more. And can we integrate some of those experiences even or some non-traditional experiences into sort of your program rank list of when you do the screening that can diversify right from the get-go from when you're screening the candidates and make sure that it's not, you know, just test scores, GPA, the schools you're coming from, but some of those other opportunities that would make you a great candidate and maybe diversify the pool. But I haven't found the ultimate solution and definitely interested what my co-panelists have in mind to do. Well, I will say I, great question, tough question, hard question. Ooh, ooh, that's my immediate kind of visceral response. But I was thinking about that example about the orchestra and the heels. And I was thinking about the issue of board scores and people not having the same opportunities. And I think I was, or kind of the way I'm trying to wrap my mind around it is that it, for the orchestra, there's one goal only, that is to play the music. And so when the question or the task is very specific where you can, you're just looking at that capability, I think the blinding makes sense because I would imagine, I don't play music, that what they're looking for is who plays the music the best. And it's just that one thing. Perhaps your life experience is that one thing. Perhaps your life experience goes into how you hold the instrument or some other things that are not heard. But music has, in my opinion, I presume in that study, has that one goal of hearing. Whereas being a clinician or in this sort of training environment, it's not, you know, the test itself, let's say the board exam, that's not the only goal. That's not what is predicting who will be a good clinician or who will learn or provide care to the patients, which at the end of the day is our ultimate goal, or pick whatever scenario you're in, whatever employment situation you're in. And in that case, I think it can be challenging. I like what Corinne was saying about more integrating the other things that people come to the table with as value. Scores are not the only value. The lived experience, the ability to multitask or to whatever adds value to that person's, you know, portfolio, if you will, of being a human. And I think sort of understanding that these other things, depending on how the institution defines them, also goes into it and should have equal merit or weight. I'm certainly not suggesting, in my opinion, that you sort of just dismiss some pivotal criteria that's used to, you know, place a hierarchy or to select people, but just also value the other things of what makes it human. I really liked your slide, Corinne, where you were talking about I'm this, I'm this, I'm this. And as you were talking about that, I made my own list. Maybe I'll encourage the audience to all do that as well. You know, like, so for me, I put I'm Black, I'm African, I live in St. Louis, I love ultrasound, I love the Steelers. There's a whole list. Anyway, we should all make our own list and think about what are those things about us that are even perceived by other people, perhaps, or that goes into how we're thinking about other things that really, you know, kind of comprehensively makes us the great educator or great clinician or great practitioner that we are. So I don't know if I really answered your question, but I think my point is that it's tough, but it probably depends. And I'm not sure for the reverse discrimination point, I'm not sure it's quite that simple in terms of the word. I think it's all how it's structured in terms of the value of the question or the thing that you're using to grade or evaluate or recruit your applicant. I think, Corinne, the point that you made there, which I love personally, was the idea of, you know, whether we call it a sponsor or mentor, either one of those, but I think all of us can be aware enough, as we've said multiple times, we all have bias. We should go backwards ourselves and find the person that we're going to help and we should push them forward. We should help that person out. And I think, you know, as been alluded to, I know for me as a program director, getting a call from someone else I know that says, look at this candidate, regardless of everything else on their applicant, helps. And I think we need to be proactive in that sense of trying to sponsor those people, be it pharmacy, be it residents, whatever background, to get them into those opportunities, knowing that we can help out. And I think that's a key part of something that you said there is a nice applicable thing that we can do. And I think one of the things, just to jump in really quick, is, you know, on Corinne's slide, she talked about interprofessional, okay, is working together. And I think that it does make us more likely to respect our other colleagues when we do interprofessional education. And I think that that is super important in residency, in everything, you know, on rounds, making sure that the pharmacist is there, that the bedside nurse, that, you know, like your whole team is there, is really important in promoting less bias and realizing that the pharmacist can be helpful. I mean, you know, it's, it's fabulous, you know, and you come up with these things. And it's like, I wish I had thought of that, you know, so it's just the constant, constant exposure to the different, the different professions that I think is going to increase our awareness over time. That's an awesome transition. So yeah, I think let's, let's talk about that. I mean, part of the goal of this session is, you know, to look at trainees, but outside of trainees, we also wanted to look at that interprofessional component that happens. And I think one of the reasons why we have our panel set up the way we did was to get interprofessional folks together to talk about this. You know, how do we get rid of the implicit bias that happens between our own professions when we're standing there on rounds? You know, that the pharmacist can actually, yeah, they can help. I mean, how do we get rid of, how do we get rid of those things? How do we work together to take that part out of our brains and make sure that we're doing a good job as a team? I like what was said about exposure. It's exposure. You have to be livid and get advice from the nutritionist. So you're like, oh, I didn't think about that and realize that you don't have, you know, like the training you have is in a specific area. And that's great. And you're really good at that area and probably get a lot of areas, but the other people bring, again, value to that, that enterprise, to that discussion. So I think you have to have exposure or perhaps studies. There's lots of studies that show that these interdisciplinary teams benefit the patient, benefit the team, and even outside of healthcare, it's proven in all other specialties. Diversity in either profession or experience or whatever is good for the mission of advancement. So I would say exposure. That's how you get that done. Yeah, I agree. And also, you know, one thing we've done is we give everybody a speaking role. So, you know, the resident does things and the pharmacist says things, the nurse says things for every patient to really solidify that for each patient. It really is multidisciplinary and everybody has an opportunity to bring something to the table and is expected to do that. I also think, you know, some of the things with exposure, sometimes we see each other, oh, the resident or the nurse or whatever, kind of getting together, either doing educational sessions or team dinners, ordering lunch together, some of that, like, space where you're not the pharmacist anymore with, you know, fighting with a resident or something. You're, like, eating lunch together in the break room or listening to a lecture together or even going out for a team happy hour. Those are real team building opportunities where you have an opportunity to interact with each other as people, just relaxing and having some food or something like that. And I think that has really strengthened things coming in the next day and, you know, having a better relationship. So one kind of non-traditional approach. I immediately cringed because of COVID right now. No eating together because of COVID. But after COVID, not that COVID is going away by any means. Right. But then you can talk about your commonalities as opposed to the disagreements that you have over patient management. You know, your commonalities. You know, I like to run too. You know, I've traveled to Paris myself. You know, like, whatever the case may be. I've been to Ghana. You know, like, though, you know, like, those types of commonalities that we have as opposed to the differences or the disagreements we have regarding patient care, which are going to go away anyhow. You know? Also, maybe extending it to, like, interdisciplinary research. So if, you know, your group within your unit is working on a research paper, bring in a nurse or bring in a pharmacist. Or if a pharmacy group is reviewing a drug, bring in an attending or bring in a resident. I think that also helps even from a research perspective, see what other perspectives they can bring and help strengthen those bonds. Yeah, I love that idea. I mean, and again, part of what I want is our audience to be able to take away things they can apply tomorrow and then have a bigger view of things they can look downstream. But I have found that so useful in our pharmacy program at my shop and my critical care program, we share faculty. In fact, I have some of our pharmacists listed as core faculty as part of my ACGME roster. I have some of my pharmacists do core lectures. My pharmacy team has some of us as faculty interview their candidates for their residency. I just think that cross-pollination all of a sudden shows that you want to work together, that you value each other. And that's huge. And I think those real-time things of trying to make sure you have that collaboration helps out on multiple levels. Well, let me transition even further inside of this same well. So, and I am not an expert by any means, and Marcia, I'll look to you to help out a little bit, but I know inside of APP groups, inside of nurse practitioners, there are multiple levels of certification. Inside of pharmacy, there's various ways that you can get into critical care. Inside of physician critical care, different backgrounds, internal medicine, emergency medicine, how do we make sure that there's equality amongst the groups of us working together? How do we not look down on a co-intensivist, a co-pharmacist? How do we try to be equitable and work together in those realms and not have implicit bias about what someone else brings to the table? I think it all starts with respect. Respect for the person, you know, respect for their position. You know, you may not like them as a person, however, you need to respect their position and bring them into it. I think it's all about respect. Yeah, I think that's reasonable because I think a lot of times when the disagreements happen, you know, we all care about the patient. We all want the same thing, whether there's, you know, a restriction on medication or too many labs are being ordered and they don't make sense. And I think if we can, you know, develop some real clear communication and respect that we all want that and make everybody feel like, you know, they do have a role just because you're not the, you know, attending that has like the final say, you're, we want your input and it's being considered and discussed at least, you know, not, oh no, we don't really wanna talk about that on rounds. Like, okay, let's discuss it. Maybe we're not gonna go that route, but, you know, thanks for bringing that up. I think really subtle, simple things like that actually go a long way. And I think I would add even practically to kind of dovetail on Brian's point about maybe not always the same opportunity. Sometimes I might make a comment as the attending physician on, I think I'm right, I'm sure I'm right. And then I'm educated that actually, you know, I'm wrong. I need to also be okay with that. I need to be open that I don't know everything. I'm not always right. And there may be new data, new experiences that can help alter what we do share in common, as mentioned, which is patient care, trying to do what's best for the patient. So I would say not only sort of like making sure, you know, with exposure and make sure the teams are there, but also education, perhaps the perspective that, you know, somebody gave, let's say a resident or somebody like giving an idea during rounds, you know, I have to do what we just learned in our lecture series, slow down, don't just scoff at like, that is so dumb. And that's gonna create disrespect, just slow down, take a deep breath and think about there's some reason why they said that, perhaps they have limited knowledge, use that opportunity to educate them if you can, if the information is readily available during rounds or immediately after about actually the most recent data shows this, or actually the background is this. I mean, everybody's trying their best or in most instances, everybody's trying their best. And so perhaps, you know, in terms of like not, you know, looking down on them, it may be because you had a bad experience or they did something with patient care that's not clear and use that opportunity also to educate the group about what is out there. I mean, literature is literature and, you know, how we interpret. So that may be one way also within the groups to help build respect because an implicit bias, some of the mitigation strategies that were talked about, it's exposure and knowing that, you know, this person is really smart and educating them so that they all sort of know the same information. So that may be one way I think to help. Great answers. I'm trying to double dip here and actually pay attention to the chat while you guys are talking. So one thing that was brought up during this component of our discussion was whether we as panelists can help those at large out there with this idea of interprofessional collaboration. So, you know, advancement going at an academic center on a physician standpoint from clinical to assistant to associate to full professor, you may need to have collaboration with other folks. Similarly on the pharmacy or APP group, are there any resources or any comments folks have that we can help make sure that we're helping a pharmacist progress appropriately in their career track similar to a physician may want the help of a pharmacist? Any comments or thoughts there from the group or things that we can post for those real time folks out there? I think my mind was initially going to within, you know, certainly joining and being a part of SCCM because of its real mission and sort of the interdisciplinariness is awesome, giving you exposure and access to, you know, people at different walks of life and different clinical practices. So again, that exposure has been so helpful, but within SCCM, of course, there's different sections and groups. And I think, you know, just involving yourself in some of those, like for emergency medicine, let's say we have a forum where people can interact and in our group, the SCCM EM group is not just clinicians, it's APPs and pharmacists and dieticians and all the things like that. So even in the sections within SCCM, there are opportunities to sort of collaborate and to gain exposure to other specialties. And that may be one way to use that forum in a more local fashion to be able to make those contacts for promotion advancement that you were describing. And to that point, SCCM does actually almost mandate that papers now that are submitted cannot just be one discipline. And I think that's really nice that, you know, from the get-go of getting a project approved, that's gonna be like under the SCCM umbrella, there is a requirement that there need to be a multidisciplinary approach. I think within your own institution to sort of achieve that goal, some people are just really kind of stick within their own departments and what projects am I doing for pharmacy, what are our quality projects, but even setting up regular meetings maybe with the medical director or the nursing director to say, you know, I'd love for this year's quality project to be pharmacy and nursing, we both get credit, everybody sort of wins and maybe there are different perspectives. So maybe reaching out and setting up a meeting with somebody who maybe traditionally you don't report to is not part of your reporting structure or, you know, not someone that you've traditionally worked with on a specific type of project, like a finance project, a quality project, or even research and setting that expectation. And maybe there's no projects right in that moment, but it plants the seed for, oh, you know, I need a pharmacist on this paper or we would love to get pharmacy involved or yeah, let's get nursing involved. And I think if we all did that a little bit more and extended ourselves, that expectation would build more and more. I agree. I think that those are really important. And if you have a question about say the pharmacist or the resident, you know, you can look at their, go back to their training program or, you know, look online and see what some of their, you know, all of our societies or all of our certification bodies have different information on what we do on, you know. So I think it's important that if you had, if you didn't understand that you went to the society webpage. No, I completely agree. And again, I can think of real time things we've done at my own shop. You know, again, inside of our fellowship program, we have an ACGME requirement that everyone has to do a QI project. That's a box they have to check during their training. And we've been lucky enough that there's been collaboration with our nursing colleagues, our pharmacy colleagues, our APP colleagues, and many of our QI teams have two, three, four people on that team together, working together, which I think benefits all of their careers and allows some of these walls or, you know, these biases to get broken down as they continue to work together. You know, I have to give my own sense of gratitude. Beth Taylor, one of our co-chairs today of the Congress, registered dietitian at our shop. She was amazing to myself, I think to Enyo as well, but earlier in our careers, helped both of us out at our shop. You know, I look to our nursing colleagues, Carrie Sona, amazing the things she's done to help grow our fellowships and our trainees. I've had pharmacists that have been mentors for me, Lee Scrumkey, wherever you're out there in the netherworld, we miss you and you've done a great job at, you know, mentorship. And so I found those relationships, those professional relationships to be building and growing and helpful throughout my full career as well. Well, let me switch venues here on one other component. So we got into the idea of microaggression and some talks about that. And we had some comments here in the chat. So the first one, I don't have a great way to word the question, but someone brought up the idea of the institution destroying the culture and the institution causing problems with aggression. You know, an institution may come in and fire somebody or they may wanna come in during a QI meeting and blame somebody. Oh, the pharmacist mixed the wrong medicine. Oh, the physician made a bad bedside decision and they destroy some of these bridges we've tried to build. You know, how can we rise above that? How can we help the institutions out as the first question for us to kind of address as a panel group? These are really tough questions you keep asking. So yeah, but they're good, insightful for us to think about. And I, you know, it's hard. So institutions are made of individuals was my thought as you're asking the question. And individuals leading by example can help change that culture of the institution. So yeah, if I get an email or something like that and it's, you know, it's accusatory because that's what sort of root analyses try to do. Whose fault is it that something happened? Yeah, sure. But gather the facts. So how do we sort of get around it? I really liked, again, what I heard about just taking, take a deep breath, look at all the facts before any quick judgments are made. Remember these implicit biases occur when you're rushed, when you have to make a decision about whose fault it is when you have to cut somebody. And so how do you fix that? As discussed, you slow down, you think about it, you gather all your facts and you get, you know, differing opinions if your space allows you to, to think about it. So how do I rise above the institution as they try to destroy the culture? In my space, as the attending with my team or being the medical director of a unit or whatever my realm is, my level of influence is, I need to take those steps because I can't undo a firing. I can't undo that email, but just how I respond to it, I think from the lens of mitigating implicit bias can go a long ways to chipping away and repatching some of those broken things that you're talking about. And I think that many institutions, particularly for event reporting, like adverse drug event or patient harm, have really made efforts to make it a like no harm, no, you know, they incur it, you can report anonymously. When we have those meetings to try to identify what went wrong, we always try to look at the process. So not, why did you verify that order when the dose was clear wrong? What in the process was wrong that caused you to be able to make a mistake that probably you look at it now and you know that you wouldn't have made, or maybe you didn't know, and why didn't you know that? And how did we as the institution fail you by not providing the infrastructure to allow you to do that? So taking the individual away, you know, sometimes there is, you know, there's negligence or there's something that's more clear cut, but more often, it really is a process-based and making sure that it's very clear that when you report, I report myself sometimes, oh, how did this happen? I overlooked this. I wanna make sure it's recorded so that, you know, this doesn't happen again, or that this order is very tricky. You know, I always tell nurses if, oh, should we report this, this happened before? Yeah, it's okay, report it. You know, you wanna use objective language and not so-and-so did this and whatever, but it's super important to report. And when you report, to make sure that there's that understanding that we're all gonna look into this together with the purpose of not having punitive harm happen to an individual, but just preventing it from happening again. And I think the institution and the leadership of the institution messaging that by, you know, their actions and not actually causing punitive and changing systems can help build the trust to know that we are actually working together. Agreed, and it all comes down to the next patient. If this occurs with the next patient, it all comes down to our patients. If we don't have patients, we don't have jobs, you know? So it all comes down to the patients. And how can we keep this from happening to somebody else? No, I agree. I like all of those answers. I think, Ennio, your answer there, I think in your own sphere, what you can influence and you're exactly right. You know, the emails that get sent in the middle of the night where someone is angry, not firing that same email back and getting the full story. You know, I think, Corinne, that idea of walking in someone else's shoes or trying to understand it, and then looking at it from a systems-based approach, you know, was this a staffing issue? Was this, you know, a change of shift issue? Have we thought about all the other factors that come into these things? Well, another question that came to us in the chat box was the idea of mindfulness and microaggression and how we teach that to our trainees. How can we help our trainees understand, again, not just a checkbox, but how can we make sure that our trainees understand about mindfulness and how can we promote those behaviors in them? And I guess, Marcia, since you were our expert on that topic, even though you've made people cry, can you help us all out? Sure. I mean, I think it's having that open conversation, you know, when the situation gets stressful, okay, and you feel like you're gonna pop, okay, and you feel like you're gonna have microaggressive behavior is being an example and saying, hold on a second, I'm gonna just pause for a minute just to regroup here. And having that for people to see, I think goes a long way, you know, and saying, I'm gonna regroup, I don't wanna say something that I might regret, okay. It's like typing an email and then waiting on it until you've thought about it a little bit more, you know. How many times did you not send that email because it was not, it was an angry, you know, it was an angry Kermie email, you know. So thinking about those things and being mindful and displaying that behavior to your residents, to your team, okay, that sometimes even I have to stop and pause, okay. Take a deep breath, look at the facts, do everything that you're supposed to do, get reset, get another perspective, so. Let me ask any of you actually, as I was curious this myself, has any of you witnessed that microaggression or the potential for microaggression real time at the bedside, in the interaction with the consultant as the conversation happened on rounds and either stepped in then and talked to a trainee or pulled the trainee aside? Can you give us thoughts about how you've approached it with the trainee to not put the trainee on the defensive right then and how you've used that opportunity as a learning experience for them? I wanted to actually answer the previous question, which was perfectly related to that. So Brian, it's like we were thinking the same thing. I wanted to first talk about being the recipient of microaggression. I'm sure that I have also made microaggressive comments unintentionally. I really liked, and I wrote it down, what was that quote that was stated? It said, separate your intent from your impact. And so I was thinking about that because if you haven't guessed, I have been the recipient of microaggression. I have mentioned to you all of my things. I wanted to talk specifically about from the trainee's perspective or even from the teachers and leaders, when you are the recipient of that microaggression, how do you act? How do you then not make an implicit bias against that person? People know what they know, they see what they see. And sometimes their response to you, even though it's a microaggression, it's true they don't recognize it, but they don't recognize it means that their intent may not have been bad. And so to Brian's question just here is that I have taken the opportunity when the time is right, it's not always the right time to do it, to just clarify or to make a comment. So I've done it with patients, again, who are like telling, they mean it as a compliment when they say to me that my English is good. But as a microaggression, that's not a compliment to me. I feel like you're saying that I shouldn't speak well and so you're surprised or they're like, oh, you're a really good doctor. I'm like, okay, but I also, I have an implicit bias that the minute I hear some words, I have microaggression about the microaggression that you're about to give me. And so how to be aware of that, that we are tense and wound up in these biases and constantly looking to see who's gonna offend us and how are we gonna react to it? So I would tell the recipient, take a deep breath, think about the scenario, think about that spidey sense of what was that person's intent? Were they really trying to throw shade or is it just ignorance that they didn't know? So for my patient, I said, well, thank you, but you know that Ghana, there's many dialects, but the primary language is English. So yes, thank you. Or correcting the resident or the other multidisciplinary team member. So we've done, it is important sometimes to do correction right in the moment, use the context and the appropriate forum to do it or how strong that microaggression is. Sometimes it's a little thing and sometimes it's like something that needs an email or like an office visit or, so use your context, but it's absolutely important to make that correction because the person doing the microaggression, number one, if not corrected, doesn't know that they have done it, thus will do it to the next person or the next patient and needs to have that correction in order to be able to stop it. So they also have to be made aware in the right context. Yeah, I agree. I think it's twofold in the sense that they're microaggressions because they're not always obvious. And I think making sure people are aware, until I was preparing for this talk, I read through so many, some of which I'm probably guilty of. I didn't realize where it was coming from and why it even classified as a microaggression. And I think calling it out, just like you said, and you're in a very polite way where it's informative, it's educational, it's just letting them know. I do think then, on the flip hand, there's also microaggressions that are a little bit more intentional. I know I've been on rounds or seeing a patient where I have a male student or resident with me and they're looking at them and not at me. And is that okay? And then the student will have to, she's actually my preceptor. And then it forces them to realize that I'm there. And it's so subtle. When I think of examples, I don't have many extreme examples. There are a few here and there that resonate. But the harder part is really the subtlety of the day-to-day, small, nuanced things that you almost wouldn't notice unless you're that person, sort of seeing it happen and it's calling that out. And having, like in that case, the student saying, well, actually, she's the person that you should talk to because she is the one in charge, not me. I think that's helpful as well. I have an attending that doesn't like to round. She likes to round, but every time she goes into a patient's room with a male resident, they always talk to them and they act like she's the nurse and not the physician. And she always, she says, come with me so that they don't think that I'm the nurse. And then that's her own bias. But, and patients have bias. It's not just us as educators, as leaders, it's our patients that have bias. And so, oh, I'm sure you didn't mean to, this is our attending physician, this is our lead pharmacist. She's done critical care longer than I've been alive kind of thing. So it's reorienting them to how they should respond to you. You guys are great. You've brought me full circle to our final topic for our last couple of minutes here, patients. And I think, and you brought that up earlier, you've got now both delved into things at the bedside. And so I guess I wanted to just spend the last couple of minutes because that's really why we do medicine is to take care of others. And really it's a patient-centered approach. This idea that either microaggression or implicit bias impacts us at the bedside with those patients interactions with the judgments we make about them. There was a nice New England Journal of Medicine commentary that was just written in the past couple of months that talked about this idea of whether we should take racial components out of our presentations, our actual histories. Interestingly enough, my sister, who's working on a PhD on race relations, found that very fascinating in her world because she thought it took away so many other things behind that that just weren't fair. And was that a misunderstanding of us as physicians to just glossarily say, oh, I'm not even gonna say the word black or white or African-American because that makes me not biased by not saying it. Well, that's not true. I mean, how did these things impact us at the bedside? And how do we learn from that? How do we help our trainees with those patient interactions? Again, another hard question, but I'm curious thoughts from you guys. I'm laughing because, boy, yeah, I was thinking about how, it made me think about the word colorblind. I don't know if you saw my eye roll, but that used to be the word to let other people know that, hey, I'm on your side. I have no bias against you. It was meant for good. But for me, and I think some people who think like me, it's actually not, it's not good. And I think that's why I'm laughing. It's actually not, that's not good. I want you to know that I'm a female. I want you to know that I'm from Africa originally and that I live in St. Louis, Missouri, and that I like the Steelers. These are things that make me me. And for my patient, there is some disservice that's done when you just sort of 50-year-old person or male or whatever it is that you say, it's they're human. There's so many things that go into their life story that explains why they presented with their condition, how they treated their condition before arrival to you, how they all will accept the information that you're giving them, the medical advice that you're giving them and how they will process it going forward. So it's a hard balance. I do not have the answer. It's tough. But I do sort of, when I'm getting a presentation from a resident or a trainee about the patient, and they say, oh, it's a 45-year-old African-American male. I'm wondering, are you telling me that because that's relevant to the case presentation or you're telling me that to be pretty comprehensive? And I'm wondering your intent. And that's not fair to that trainee because they learned in medical school, that's how you present. So I don't know, it's tough. Patients do have biases. We have biases towards the patient and what the condition they have, what problem they have. I mean, this topic is so huge. We could spend an entire conference, multiple days about all the aspects, their condition, their past medical history, their allergies. We probably have implicit bias about their allergies. So it's a tough topic, but I think step one, just realizing that it exists, it happens, and just trying to be mindful. I don't have too much more to add. I don't have a solution for this either. I do, I always know when patients have, like when the family brings pictures and puts them up in the room, that's like speaks to the whole commonality. All of a sudden now you can relate, they're not a patient. And this isn't as much implicit biases, but it really brings it back. Like they have a family and kids and parents or it's their birthday and this is how they're spending their birthday. So trying to find the commonalities or thinking like, oh, I can't believe the family's called five times. If it were me, I would call every hour, every minute. So I think we really forget how differently we would act versus the patients. Same with like ageism. Oh, you know, are they 90 or are they 20? And then how are we going to treat them differently and how are we going to prognosticate maybe inappropriately differently? So I agree. I think mindfulness here really being intentional with what you're saying, how you're presenting the patient and trying to relate to them as much as possible. And maybe if we have to actively do that, you know, an epic, it has a picture of the patient, I guess you could argue that's good or bad. To me, it helps me relate and see that there's like a person behind the chart, you know, even if you're not in the room. One other thing on that is that, you know, especially when you're rounding, you know, is to speak directly to the patient. Don't speak over the patient. Ask their family at the end of rounds, you know, do you have any questions? Did you understand? You know, oh, you won't understand. You're not a doctor. You're not a medical person. But to speak in their language and to speak clearly, I mean, we do that a lot in training is, if you had to explain something to a family that's not medical, you know, you're gonna say, oh, your father has sepsis. You know, what does that mean, you know? So speaking the patient's language, and I think bringing the patient and their family into rounds is super important into mitigating some of this. Great insights. I appreciate all of them. Corinne, I was laughing in my head because when you talked about the ageism part, I speak loud naturally. My wife always makes fun of me for talking loudly, but I've had patients tell me, stop yelling at me. I'm never yelling at them, it's just how I talk. Guys, let's go ahead and wrap up. I wanna appreciate and thank all of you for your insights today. I know I've learned a ton, you know, the session from the spectrum of implicit bias all the way to mindfulness and microaggression. I hope our folks out there in SCCM land are able to take home some applicable things they can do. I think the disclaimer, again, our panelists and I would say is we are not experts by any means. I think we've all tried to say that this is a tough topic. I think all of us sat down and realized that, hey, why are we talking about this? Who are we to actually be the experts on this? And we're not trying to pretend that by any means. Hopefully our experiences have helped all of you out. And we'd love to hear more from you and your experiences. Feel free to shoot us emails, reach out to us. And we appreciate that SCCM allowed us this opportunity for the postgraduate educational seminar. So thank you very much and have a great day, folks. Thank you, everybody. Thank you.

diversity

evaluators

biases

assessments

group discussions

safe space

trainees

implicit bias

microaggression

mindfulness

healthcare

patient care

strategies

education

awareness