I am Larry Malik, I'm one of the program directors, I oversee the community psychiatry track over at UC San Diego, and we have Dr. Singh and Dr. Malik, I'm related, Dr. Malik here with us today, and we're going to talk a bit about EI in the residency training and medical education at large, and we hope to kind of cover a bit about why we do this, what's the benefits, what's the state of the workforce, and then we'll have a small and intimate conversation about what's working at your programs, or what your experiences are as long as ours, and the struggles, the challenges, the successes, and all the like. No financial disclosures on our end here, and yeah, kind of a summary of what we hope to kind of cover, and you know, I think looking at this, you know, the reason that we're all here and we care about these things, you know, is so there's increasing emphasis and understanding of the importance of diversity in the workforce, and in health education, and kind of where we've seen the gaps and been highlighted to us by, you know, AMC, AMA, there's a president's executive order, you know, I mean, there's been a real increase in emphasis the last two or three years, but this really started, you know, 15, 20 years ago, particularly when the AMA and the AAMC kind of highlighted these issues as an importance for all of residency education and medical education at large. This is the APA's position statement on diversity and inclusion in the workforce, and you know, some of the highlights here, I mean, they want all institutions to increase diversity inclusion in the workforce, support the policies and the promotion in psychiatry in particular, to bring more URM into leadership, into medical school, and you can kind of read through the rest here, and kind of what the, to bring in the best practices that support those career developments and the psychiatrists from those URM groups, and I think that, you know, that's important to kind of highlight. We'll talk a little bit about that support, right, I mean, it's one thing to get people in the door, but how do we keep them engaged and keep folks working, particularly, you know, for the purposes of our talk and for our focus today, and, you know, in academic centers, in healthcare leadership, and in residency leadership, right? And so coming, you know, kind of back to the crux of it, right, we're all clinicians, we're all psychiatrists, or kind of, you know, providers, whatever the term we want to use, we know that our, the folks we are treating in these populations do receive lower levels of care, higher rates of illness and disease burden, they're dying at earlier ages, compared to their kind of other white populations and non-minoritized groups. Why is this? We know about social determinants of health, you know, we can see the CDC's definition here in the Healthy People 2030 initiative, you know, that we know that there are social, economic, environmental disadvantages that are conveyed to different groups that are not based on the disease itself, right? We know this is based on where they live, who they are, what they bring, and, you know, what they don't have access to. And of course, this leads to increased morbidity, mortality, decreased life expectancy, higher disability and functioning, or dysfunction across the board. But will having more diversity in our medical trainings really help address this issue? Spoiler alert, yes. So the, we know that access to care increases when we have more folks of URM backgrounds as physicians. URM physicians are more likely to be working in underserved areas, working with Medicaid populations, working with the communities that they came from, and working with those groups that, you know, that we want to target and that need that extra level of support. Kind of same thing here. You know, we know that where folks work also is impacted by, you know, where they came from. And we know that black, Hispanic, Asian American physicians will end up working at higher rates in historically underserved and specialty designated service areas. This is looking at California in particular, but this is not unique to California. In addition, you know, to kind of working in those places, patients also get the benefits of working with URM and black and brown providers. They have higher rates of satisfaction, higher follow-up rates, chronic disease management, their understanding of the disorders and treatments are improved when working with folks who have language or racial concordance with themselves. So it benefits the patients. We know that. It also benefits the learners. We'll kind of run through a couple of these different slides here, but the, having an improved diversity in the student body does have a benefit to the individual, but also to the student body at large and to all the learners. And this is seen in medical school and healthcare, but also in other special, or other professions and other educational environments. So with having that increased diversity within the student body, we know that the benefits again here, kind of increased engagement, understanding of others, you know, they're all part of the conversation together. It's not just a kind of a homogenous group that is all kind of learning and feeding within each other without the benefit of those diverse opinions. So there's a couple of these different ones here. This one's a little older from 2000, but it showed that at Harvard and UCSF, students had increased understanding of the alternate viewpoints, more intellectual conflict, kind of a healthy debate, but also understanding of disease problems, what the, where the health inequities were and what the challenges were for the different groups that they get to work with. Again, another study from JAMA, also sort of this sort of intent to better understanding, but also an intent to work in those areas and better understanding and attitudes towards being part of the problem, being part of the solution and working with, working with those different groups and being prepared to do so. It's another study from, I think, 2012 or 2008, excuse me, that also showed that white students were more likely to work and have better attitudes towards equity and cultural competency in more diverse student bodies. And this goes from having a more diverse workforce, but also having a more diverse faculty as well, right? And so we know that there's a gap for our minoritized residents and students that we're working with, and that gap can be shrunk a little bit if there are faculty who look like them. Just as the patients benefit from having providers that come from URM backgrounds, that the students and the patients get from that benefit from that mentorship, from that connection and understanding and learning from folks that look like them and can kind of relate to them in a different way. And I think there's, one of the things I've heard, if you're like me, you go to some of these different talks, too, at these conferences, hearing these things, and one of the things I've been able to, it's been impressed upon me, which I think is worth thinking about, there's the moral sort of argument about why we want to do this, right? We need to have folks represented the same way that we have our classrooms and our residency training programs reflect the population at large, because it's the right thing to do, but it's also the financially beneficial thing to do, if that's a struggle you hear from your institutions, right? This leads to retention, this improves the outcomes that we talked about for the patients we are serving, increases follow-up and decreases no-show rates, and also, but yeah, but I think that retention, I think that a lot of institutions are trying to do, having a more diverse student body coming in the door, we're more likely and easier to retain them and bring them in than having to search high and large and then going in other ways about having to do the recruitment effort in that way. I think here, we're going to transition over to Dr. Singh, who will talk about the state of the workforce and kind of how we got to where we are today. Okay, thank you so much, Larry. So what I'm going to do is kind of, with that background that he so generously provided, is kind of take us through what our prior state has been and then take us fully forward into the present and the current state of recruitment for Dr. Malik, our earliest person in training, kind of talks about the future and what we can do in terms of intervention. And just for a little bit of background, my name is Dr. Michelle Singh. I am an assistant clinical professor of psychiatry at the University of California, San Diego. I run a psych urgent care there at the San Diego VA. Okay, so just thinking about the historical and structural background of what we're talking about, we know that there are inequities that have been built into our system on purpose by design in medicine. And when we look at what actions have been purposefully taken to perpetuate these inequities, we can see a few significant historical events that I'm going to highlight that really show what's been built in and what's really been baked into the rules and the structures that we all live and work in. So just a couple examples for historical context. We have the Flexner Report, so a little over a hundred years ago. Initially it had a fairly, what sounds like a good purpose, right? Standardize med ed, improve med ed. This sounds like a wonderful objective to have. However, what this ended up leading to downstream was the majority of historically black medical schools that were even open at the time, closing due to lack of funding. And this continued to be perpetuated as a result. This was kind of an event that led to these further downstream consequences, like physician shortages in black communities, reduction of access to black medical students to actually join the medical community. And so what we have is 2.5% down to 2.2%, even as recently as 2008, so not so long ago. And for reference, I think African Americans are about somewhere between 10 and 15% of the population. So this is definitely not proportional to the population that we have in the United States. So that's one kind of, again, element that's been built into the structure of the population of physicians that we have. So who are in the rooms that are even having these conversations? So another group, again, structurally built, is the AMA. The AMA supported segregation as national policy up until about 60 years ago, not quite 60 years ago. National Medical Society, so San Diego Medical Association or what have you, actually banned physicians, black physicians, until about 50 years ago. And the American Medical Association also barred or supported barring black students from medical school through the 19th century. So we see what's kind of really baked into the layers of the structures that we're working in here. Moving forward, closer to modern times, so 2004, Sullivan Commission showed that, so if you combine the population of African Americans, Latinx Americans, indigenous people, while that adds up, or at 2004, it's more now, but 25% of the US population, but only 9% of nurses, now 6% of doctors, and 5% of dentists. So there's clearly a gap, right, in terms of the workforce looking like the population we have at large, and that's, again, by design. The fact that underrepresented groups in medicine make up only 4.2% of faculties tells you more than you need to know about the work that needs to be done moving forward. It's not all bad news, right? So we are starting and increasingly recognizing the fact that these structures exist to perpetuate inequities and we're trying to get down to those elements and restructure. So a little over 10 years ago, the AAMC encouraged academic medical institutions to consider diversity. Again, consider who we're letting into the room and how are we framing not only what we're teaching our students in terms of diversity consideration, but who we're teaching. How can we get diversity into the core workings of your institution when the core of your institution is either racist or embedded in racism, right? Even if that goes back to 1910, you know, nobody from that time is around, but we're still in it. So in the last 10 years, there has been this push, efforts have been made to bring in more diverse student bodies, faculty to make academic faculty look more like the patients that we are treating, improve the culture and the learning environments to reduce discrimination, to reduce harassment, to make medical schools and residency programs and clinics more inviting and to be the kind of environments where people want to learn, where they want to engage. So moving forward, we're almost here to the present, 2024, we've moved forward about a hundred years. Six years ago, we have 7% of people joining medical school. So up from two, two and a half percent from the 10 years previous identified as black or African-American, 6% were Hispanic, Latino, or some kind of Spanish origin, 0.2% American Indian or Alaska native. So we have made progress, right? We're shifting, but we're not quite there and there still is work to be done. Again, particularly when we see at the faculty level and what we know about who's in faculty is those are the folks providing mentorship. Those are the folks who are providing opportunities to make that connection, to get that foot in the door, right? And so we see that medical school faculty continues to be majority white, majority male, particularly at those higher ranks that the professor, associate professor, at the program director level. So the people, again, in the room making the decisions, but progress is being made. It's not all gloom and doom, right? And we're going to continue to talk more about efforts that are going to be made. So while I'm presenting all of this depressing data, I do want us to keep some kind of hope in mind. Okay. So we know, again, about two-thirds of physicians are male, 56% are white. What I will say at least about the gender gap is actually female medical students are now starting to overtake male medical students. So this will change as time goes on. But we still have a lot of work to do when it comes to getting URM applicants, URM residents, and again, URM faculty. So we can see some of the statistics here. And of course, bizarrely, despite the continued need to do this very important work, a little over a year ago, or not quite a year ago, rather, the Supreme Court made a really impactful ruling on the role of affirmative action. And so we see, we kind of saw a change in philosophy, even some fear and some uncertainty about how the ruling would legally impact institutions who were trying to bake these considerations of race, of inequities, as an element of their recruitment, right? So then the program directors or the faculty who are recruiting residents have fear that, well, now there's a Supreme Court ruling, so considering diversity in our applications, or thinking about these elements in our application or even talking about, talking about their experiences of race would be illegal or would open the university to a lawsuit. I don't know if any of you went to the talk yesterday about the Supreme Court decision specifically as it relates to med ed, but it was very interesting. I went yesterday and it was very interesting for me to hear that a lot of the legalities have been over-interpreted out of an abundance of caution when it comes to residency recruitment. It's understandable. I don't think anybody wants to get sued or anyone wants to put themselves in a position of running afoul of the Supreme Court. So it makes sense to me why there would be some hesitation when it comes to considering race as an element of what you're thinking about when you're composing your rank list or considering your applications or considering who you're going to give an interview to as an element among all the other things that the applicant's going to bring to the table. So the APA came out with some pretty strong language with regards to the Supreme Court decision and basically saying that holistic review or a holistic race-conscious admissions process is effective. The APA supports this assembly of a diverse mental health workforce, which Larry kind of laid out all the benefits of. So there is data supporting why the APA wants a diverse workforce addressing the very real mental health inequities that minoritized individuals experience. And while we're not going to talk about those directly, I think this is likely a group of people because you're here at 8 a.m. So to listen to this talk, so I don't think we necessarily need to review specific disparities. So hopefully I don't need to preach to the choir, but nonetheless, the APA discussing how research supporting that race concordance between physicians and patients and cultural sensitivity are associated with improved communication, better overall mental health outcomes. And this is particularly important when it comes to issues of patients coming to us with race-based traumas. I had a patient in residency for therapy who felt like it was so much less work to explain to another Asian woman, because I was her therapist. So to talk to another Asian woman about her experience, she felt like she could open up a lot more without having to do a lot of work of explaining the background of her experience. And so we can share that experience together and she felt comfortable communicating with me because of that. And so APA made this statement about affirmative action, and if nothing else, I would like to say that I think it's important that we really look at what the legal intricacies are, if that's what the program is hesitating about, because of course, no one wants to run afoul of the Supreme Court ruling, but we need to be mindful about what the rulings say and what they don't say. And again, there was a program director or a faculty at that talk yesterday who was saying, I actually sat down with a lawyer and went over kind of what I could and could not do in order to remain compliant with the law, right? Which makes a lot of sense to me. So we're now fully in the present, right? What can we do to make sure that the folks who are in these talks, are in these rooms and the classes that we're recruiting, how are we going to assemble that class? And although we're gonna talk about some of the challenges of practically implementing holistic review or some challenges that were mentioned, it can be done and it can be done successfully. So this is an example of a flow diagram from an internal medicine residency program that kind of wanted to be mindful and thoughtful about who they were recruiting to their residency class. And so this was kind of their flow. And so the main things that they wanted to weigh, someone who passed step, this was when step was scored, kind of eliminating these pretty objective and reasonable red flags on the applicants, and then really weighing important factors to them. And some of all these important factors is, is this a physician who we want treating our patients in Houston, right? And these things aren't all directly about the color of the applicant's skin either, right? So commitment to the underserved, substantive leadership roles, Spanish language proficiency, actually weighed six out of the eight points that they were considering. So these elements, these four elements were put together to think about how we're going to successfully cultivate a residency class that's going to treat the population of Houston, right? Because that's where this residency program was. So this was their model for offering interviews and then later scoring them. So anybody who got two or more of these was selected for an interview. So did it work? Did it work to create a more diverse class? Did it work to kind of increase the proportion of underrepresented in medicine applicants? Yes, yes it did. It was successful. So the proportion of URM residents matriculating increased nearly threefold. So they had a baseline in 2015, 2016 before they implemented this. So of their 40 residents, five were underrepresented in medicine. And then after they implemented this holistic review, they had 31.7%. So 13 residents. So almost three times the amount of URM residents. So 13 out of 41 after the intervention. And this is so critical, right? Because 31.7% starts to actually look like the population of Houston. At least much more than 12% would. So at least we know it's feasible. At least we know it can work. And as you can see, this is tailored to the considerations of the institution, right? It's not necessarily going to be critical everywhere that you have residents who speak Spanish. Maybe you're in an area where you wanna weigh French, right? So you're Canadian, you're in French Canada, you wanna weigh French proficiency. Substance of leadership roles and commitment to the others served. That all makes sense to me, representing the diverse population of where it is that you are training, right? And so some areas that might mean more indigenous residents, some areas that might mean more Hispanic residents and some places that might be more black residents. What is your area looking like? So this seems fairly straightforward to implement, at least on the surface of it. What do we, we know that this is not how recruitment is done universally. We know that this is not how it's being done across the board, right? And we were wondering, the three of us, we were wondering what the specific challenges were and what the barriers were that people involved in recruitment and retention are actually, what the barriers are. What do people consider what the challenges are? So we sent out a survey. We sent out a survey to, I'm gonna butcher this, AACP. Yeah, okay, I didn't butcher it. So we sent out a survey to AACP. And as of the time I pulled this, there were 53 responses. Not everybody answered every question and we can go over kind of why. So we had 21 of those 53 folks were either program directors or some kind of clinical faculty that was directly involved in trainee education, recruitment, something. So these are people who are directly involved in the room making those decisions. So again, talking about people who are involved in the structures that we're maintaining. Then there was a third group of folks who had some more peripheral contacts with medical students, residents, but they weren't necessarily directly involved in recruitment itself. So maybe I take on, I precept a couple of students, but I don't go to the rank list meeting. I don't interview candidates. Those would be kind of examples of folks who are in this third category. And as you guys can see, that's the most common category. And then there was another category of folks who had no involvement in residency or medical education at all. So maybe they got a private practice or what have you. Those folks were shifted out into all but the first question that I'm gonna go over because the rest of the questions have to do with recruitment. So they wouldn't really have much to say about that. So the first question we asked, and this is a very small, I'm sorry, guys. Was I believe education on diversity, equity and inclusion as it pertains to mental health is beneficial to trainees. And so this was a one question besides what is your role that everybody answered. And so it shows the ratings of importance on a Likert scale across these three groups. So either clinical faculty or zero involvement. And later I'm actually gonna show kind of the breakdown between those groups. So these were the overall respondents. There is a selection biases to the people who are going to be in AACP. There is a selection biases, the people who are actually going to open up a survey and answer. So it's not too surprising to me that we had a lot of strongly agrees, right? Because if you don't really care or you don't think it's important, you're a lot less likely to go through and fill out the survey. But I'm not gonna spoil it, but there were some pretty interesting things that we found when we actually split out people who are directly involved versus people who had no involvement versus people who kind of had this kind of peripheral involvement in the middle. So of the people who had involvement, some kind of direct involvement. So there were 24 responses out of the 53. We kind of asked, what does your program do in terms of educating your applicants on DEI or what is the role of DEI in your educational program to residents and medical students? And so what we found is, you know, a lot of the institutions have DEI committees that the residents or faculty could join. So kind of opting in to being involved in DEI initiatives. So again, you having a self-selected group of people, that was the most common response. A lot of other folks said, well, our faculty, we serve underserved populations. And we've talked about kind of how that's obviously very important to do, but you want, again, the physicians looking like those populations. We had a few folks say, all of our lectures have to have some incorporation of DEI considerations into their presentation. And then other folks had formal educational tracks. So a formal curriculum, a course with more lectures. So a formal lecture series, didactic series, was also fairly common. So we kind of had all sorts of things. You know, some folks had treats or other things. I've heard of various interventions that residency programs have had. Every person that responded indicated that there was some kind of program that their institution had to support DEI initiatives. And so again, those 24 people, we asked either is your department benefiting or do you think it would benefit from holistic review? So whether or not the person's, we didn't separate out for this particular question whether or not the program actually had it. It was just what do you believe? Either your program has holistic review and you're commenting on how that's played out, or you don't have holistic review, but what would your opinion be if your program just implemented it one day? And again, I do wanna strongly emphasize the selection bias of people who are answering a survey like this. But I found it interesting that we had 15 people either agree or strongly agree that holistic review either was or would be beneficial. And the remaining nine did not agree in some capacity. And that was anywhere between strongly agree to neither agree nor disagree. So there's even among these folks who are answering this survey, there is not agreement about the potential impact of holistic review. Even though the paper that I shared is far from the only piece of data showing how holistic review can support the goals of recruitment of diverse classes. Have I said that enough? So then we asked these folks, why? If you said some kind of form of do not agree, why? And some folks felt like, you know what? We're good. We have a diverse class. We are satisfied with the diversity of our institution. There was one person who expressed concerns about affirmative action and the legalities, which I briefly mentioned and the SCOTUS talk yesterday kind of emphasized. Some people felt it was too complicated to implement holistic review. And so they wanted to keep their recruitment practices as it was. Very, very, very commonly and even in the other was I don't know how to implement it. I think it could be good, but I disagree. I think the actual implementation process would either be too complicated or impractical for our department. That was actually most of the other responses too, but I wanna share one particular response I found interesting. Others cited insufficient departmental support or felt like holistic review itself was not the answer to getting more diverse classes. I found it really interesting that one person, I don't know, I'm gonna read this quote was we do not have the adequate resources to support people from marginalized backgrounds. And I'm still trying to digest what that means and what the implications are of that response. And I appreciate the honesty of that response. It sounds like that person potentially could be supportive, but basically saying we don't want to try because these are people who would need something different or some extra support. So I am still again, trying to digest that response, but I found it quite telling. And that was one of the other responses. So we asked also of the people who were somehow involved, we got 21 answers. The vast majority of folks had not implemented holistic review. So we had three programs who had formally implemented holistic review. There's actually a definition, believe it or not, a very specific long-winded definition of holistic review on the AAMC website. We provided the AAMC website to the folks who are responding to the survey. There was a good number of folks who said, yeah, we've implemented principles of holistic review. We might not be following the letter of the definition, but we think this is important. We've incorporated principles, so at least we're holistically informed. Other programs are having some kind of dialogue, but hadn't made anything like concrete. Other departments said, we're not planning on this, we're satisfied, and a good number of people, and as you can see, the most common response was other. Well, so what does other mean? Went through all those comments, it was, I'm not sure, I'm not familiar, or other. So meaning, they weren't sure kind of what the department was doing, so it was lack of familiarity among the respondents of what their program was actually doing. Were they staying, were they keeping their processes, were they changing their processes? Unfamiliar, so meaning the program was not advertising if they were making any changes. And then lastly, before we get back to that question of separating out people involved in programs versus not, asking, hey, among your applicants, among the people that you're interviewing, do the folks applying to your institution feel that your diversity program, your curriculum, your didactic, so going back to that slide on, we have three or fewer lectures, we have a formal track, we have a DEI committee, so does this actually get trainees to the table? Does it actually make your medical students want to apply? And answers were all over the map. Actually, most folks said no, so either neutral, 13 people were either neutral or strongly disagreed. So I actually find it interesting that someone strongly disagreed with diversity being a reason for applying, but I'll leave that thought there. Okay, so this is what you really, this is what you guys really wanted to see. So among kind of program directors, faculty kind of strongly involved in a program, this was the Likert scale of DEI training importance, so we had, this is the percent of program directors, so about a quarter of them strongly disagreed that it was important, and almost half of them strongly agreed that it was important, so the answers were all over the map. Again, even amongst these people answering the survey. Interestingly, the kind of more peripherally involved folks were much more weighted towards agreeing that training was important. And then finally, people with no contact with residents, there was much fewer disagreement, 20%, on strongly disagree, but then all the other folks hit agree or strongly agree. So there is a different amount of enthusiasm for recruitment of diverse residents among people who are actually building these residency classes versus people who are not involved or only peripherally involved. So I thought that was very interesting to kind of see the different attitudes of folks when it comes to recruiting. So I'm going to turn it over to Sahana to talk about what we do at UCSD to support what we think is an incredibly critical goal for recruitment and how we can recruit, support, and retain a diverse class of residents. Thank you. So my name is Sahana. I am a fourth year psychiatry resident at UCSD. I'm also the chief of our diversity committee. As Dr. Singh sort of mentioned, so commitment to DEI is really more than just putting out like a statement on your institution's website that can be performative in nature. The goal is really to back that up with tangible actions and policies that really create this culture of inclusion. So I'm gonna talk a little bit about, let me see here, our diversity committee because this is really the body that sort of spearheads a lot of these policies that we've tried to implement. So just a little bit of background on our diversity committee. We actually created this in 2020. It was formed by a group of residents following the death of George Floyd at the hands of police and sort of the wake of the Black Lives Matter movement. And so I think residents really wanted to hold our institution accountable and advocate for more DEI initiatives to be implemented. So residents formed this committee. There are faculty advisors on it as well like Dr. Singh and Dr. Malik. And our goal is, or our mission is really to develop psychiatrists who possess cultural humility and structural competency when they're providing care to their patients in order to mitigate any sort of disparities. And so we do this by focusing on three main areas, community outreach, education or curriculum development, and then recruitment and retention. And I know Dr. Singh already wonderfully discussed the importance of recruitment and the process of holistic review, but I'll sort of focus on some of these other sections. So with community outreach, this is really important because it's essential that we're working with a group of patients that is representative of the population that we are living amongst. And then the other piece is that in order to really provide the most comprehensive care through these community outreach experiences, we get to learn about the systems that our patients navigate and the barriers that they face to help give us a better picture of how to provide that care. And so at UCSD, we kind of do this in two sort of ways. The first is ensuring that we actually have direct clinical experiences working with a variety of different patients in a variety of different settings, including those who are underserved. So rather than working with one type of, or one group of patients that's not necessarily representative of those who live in San Diego, we really try to ensure this diverse array. And so we partner with county-funded clinics, which in San Diego really are serving those who are classified as severely mentally ill. And there's a number of different clinics that we can rotate through that are county-funded. I'll just mention a couple here. So Survivors of Torture International is one that we have the opportunity to rotate through, and it's specifically focused on working with refugees and asylum-seeking patients, which is a pretty big population within San Diego. We also rotate through Jane Weston Clinic, which is like a urgent care, but specifically focused on psychiatric issues as well, and tends to serve patients who often are homeless. There's the opportunity to rotate through assertive community treatment teams. We also have something called START programs, or crisis houses, which I don't know if other states have things or programs similar to this, but essentially it's like an intermediary between inpatient psychiatric hospitalization and outpatient services. If a patient goes into the emergency department and they're not quite sick enough where they need to be admitted, but they're not stable enough where they could wait a few weeks to see their outpatient psychiatrist, we can actually send them from the ED to these crisis houses where they can stay at, usually for about three to seven days, and they can get plugged into local mental health resources. So if they don't have a psychiatrist, they can get connected to one. They see one of us there, and they can get started on medications, or have their medication regimen altered or changed to sort of target what it is that they're going through. And then we have our general adult outpatient clinics as well as those clinics that serve more children and adolescents. We also partner with federally qualified health centers, which comparatively to the county funded clinics, really are working with patients to have more mild to moderate mental illness. So again, we're getting that spectrum of working with all different types of patients, not just in terms of their background, but also in terms of severity of mental health. And so even with that one, we're one of the FQHCs that we're working with. We're actually working to build a maternal mental health program that takes on a collaborative care model because there isn't really one that exists within the community. Most of these types of programs are associated only with academic centers, or you can get those services privately. And then lastly, we have the opportunity to rotate through Owens Clinic, which is a UCSD run clinic that is specifically focused on working with those patients who are diagnosed with HIV. But then often with that, there's a lot of outreach to the LGBTQ plus community. And so in addition to the medical services built into this clinic, they offer a side-by-side with this mental health services. So again, this is one piece of the community outreach is just making sure that our trainees actually have direct experience working with these more underserved populations. But the other piece of this is outside of the clinical experience. And just having opportunities outside of this treatment setting where there can be a big power dynamic at play to really get to know our community members. And so the way that we've done that is by partnering with local community organizations. So for example, we've partnered with our local LGBTQ plus center. We've partnered with an organization called Breaking Down Barriers, which actually has teams that are dedicated to serving certain populations. So there's a team that does Latinx outreach or a team that does outreach with African refugees in San Diego. And so we'll partner with these organizations and then do things like ask a doctor sessions where patients and even staff of these different organizations can ask us questions about mental health. And so again, this can kind of help to break down any of the stigma that might exist towards mental health in these communities and give people a chance to feel comfortable. We've attended community health fairs. We've done some educational sessions for high school students as well at our local high schools. We've done homeless outreach. I know we've been talking about trying to build like a street psychiatry program. And then obviously because in San Diego we are so close to the border, there's the opportunity for border health as well, particularly through our school of medicine. They kind of have an organization that can bring medical students and residents down to the border to provide mental health services. Okay, so turning a little bit to that second area I mentioned, which is education and curriculum development. So this kind of goes hand in hand with community outreach, right? Because like, as I mentioned, you get these direct experiences working with our community either through a clinical setting or through community health fairs. But learning about these systems that our patients have to navigate can be much more comprehensive if there's structured learning opportunities where we really get to know the details of these different systems. And so we've implemented a diversity series which consists of about four to five lectures throughout the academic year. And it's required for our residents to attend during their resident round slot. And these lectures are focused specifically on DEI-related topics. So we've done topics like maternal mental health and reproductive justice, particularly given the climate of all the changing laws that are occurring. We've done a lecture before on the history of racism in psychiatry. We've done one on refugee mental health. So a variety of different topics, again, that help us to understand these systems and their barriers much more. We also have health equity and justice journal clubs. So outside of these sort of required mandatory lectures that are incorporated into our didactics, we have the opportunity to do these journal clubs that are run by not just residents, but oftentimes we have guest speakers come or faculty members who lead these clubs. And similarly, we've done topics on, we just actually had one a couple of weeks ago that was really great with a professor who's from University of Michigan, Dr. Polos, who talked about disability awareness. And then outside of these more sort of structured lectures or didactics, we have more hands-on learning experience as well. So we've done op-ed and advocacy workshops. We actually not too long ago took a group of residents to Sacramento to kind of learn about the process of advocacy as it pertains to mental health issues and meet with legislators and policy makers. There's also the opportunity for scholarly activity. So I know for myself personally, I never thought that I would be interested in research. It was never something that appealed to me, but I am very passionate about these types of topics. And so it was really great through kind of getting connected with the diversity committee that I then had access to mentors who could kind of guide me on how to do research on the things that I actually cared about. And so Dr. Singh in particular, and I have worked on a couple different projects looking at racial disparities that exist within San Diego. And then the last thing that I wanted to talk about here that we've gotten a lot of positive feedback from our residents is we've started doing something that we call our community bus tour, which we've now incorporated into our intern orientation where we will take our group of interns and we'll meet them at the emergency department where they will often be taking call or working overnight shifts. We'll start at the emergency department and then we will take public transportation to all of these different facilities or clinics that our patients actually utilize. So for example, we'll go from the ED and take the bus to one of the local bigger homeless shelters. We will also go to the Jane Weston Clinic, which I mentioned earlier is like an urgent care for psychiatric services. And that's often where we refer many of our patients from our ED. We'll take them to a crisis house as well. So as an intern, they get an understanding when they're sort of making these disposition plans of where they're sending their patients, they know actually what these places look like and what the processes of getting into there, is it easy or does it take hours? Is it feasible? So they can make more informed sort of treatment decisions. In terms of curriculum development, so we do have a curriculum committee at UCSD and there's a reserve spot on there for a diversity committee member. And so our goal within that position is really to advocate that all lectures or teaching that is done by staff incorporates DEI considerations on sort of every level. So in addition to these more very focused lectures that we have during resident rounds or journal clubs that we have, even when you're giving a lecture on psychopharmacology, talking about, okay, what's the cost of the medications that we're talking about and does insurance cover it? Because at some level, this topic is always applicable. I know a lot of other institutions actually have dedicated curriculums to diversity, equity and inclusion. And so I'm gonna briefly turn it over to Dr. Singh because she actually helped to create one of these curriculums at the University of Arizona. Yeah, so a couple of thoughts here. I'm going to briefly talk about the process of crafting a diversity lecture series. When I was in training at the University of Arizona, we did not have a dedicated lecture series or a dedicated set of grand rounds related to diversity. But, you know, be the change you wanna see in the world. And what kind of I had started to develop is what are the kinds of things that I had to learn about treating the population of Arizona as I went along and kind of trying to help trainees who came after me navigate a lot of those things that I had to intentionally seek out. So I crafted a five lecture series for the University of Arizona covering religious considerations, AAPI and other lectures of that nature, LGBT psychiatry. And I would encourage anyone here who's going into academic psychiatry that a lot of times there is moral support but it actually takes the effort from the people who care about it to make it happen. And I would encourage anyone who's involved in a program and you see a gap to make it happen yourself. These things don't have to fall into your lap. U of A also had a really cool, and I know Dr. Fernandez also participated in this track, a really cool Spanish language slash healthcare disparities distinction track. And because the residency program is in Tucson, just like San Diego, it has a very large Spanish speaking population. And so there is a program that was entirely paid for by Banner who owns the University of Arizona residency programs or hospitals in order to formally train residents to speak medical Spanish. And so you didn't have to speak any Spanish prior to starting the program. You would take a test rather, and if either you didn't speak any Spanish or your Spanish wasn't on the stronger side, you'd be shifted into one track. And if you had strong Spanish, you were shifted onto another track. But basically the idea was to help in a very real way connect with patients using their own language. And so every month we would have Spanish classes focusing on medical Spanish. Oftentimes we would practice doing review of systems or mock patient interviews with each other as residents. They also paid for Canopy, which is an app focused on medical Spanish with actually like a lot of lessons. It's actually quite expensive to pay for it yourself, but the residents got this opportunity for free. And then as a part of participating in that program, so every year for both of the two years, the learners would host healthcare disparity forums. And so we would go into groups and we would choose a topic that we felt applied to the population of Tucson and recruit community speakers, local experts, and host forums where we would present a brief didactic and then turn it over to community leaders who were doing the work of treating the population of Tucson for whatever it was that we were discussing that day, whether it was the HIV positive population or the border health, there've been a lot of different topics, but it allowed for an environment where we could explore whatever kind of excited us about treating the population of Tucson specifically. And I felt like that was an excellent opportunity not only to improve my medical Spanish, but also kind of learn from each other in terms of what we've been doing to, what we were doing to treat the population of Tucson. And then again, if you finish the program, you could actually formally be certified as a bilingual clinician with a test. So gonna turn it back to Dr. Malik. So just a note and to follow up on what Dr. Singh was talking about. So I think a lot of these programs do have, or a lot of institutions have these programs or tracks, like at UCSD, we have a community psychiatry track. So a lot of those clinics that I referred to earlier that are county funded, our community psychiatry residents almost exclusively rotate through those. But our general track residents also have the opportunity to do so as well. And I think the goal is that, again, there's sort of a self selection for people who want to join these types of programs. But the goal is that even for those people who wouldn't necessarily join these types of tracks, they still get those experiences and that education piece. Okay, and then let me talk a little bit about retention, because I know this is a really important piece to, again, once we get these amazing applicants and even faculty at our program from all of these different backgrounds, how do we ensure that they feel supported and that they're gonna succeed within our program? And it really comes down to, I think, two different things. Mentorship, which we briefly discussed, and then creating safe and supportive spaces. So with mentorship, I think one key piece that Dr. Singh already had mentioned and referred to is that there needs to be representation among our faculty where when our trainees come in, they see people who look like them or who've maybe had similar journeys to them so that they can kind of see what it's like to get to that point. But the other piece of this too, I think, is just having faculty who creates an environment where trainees can feel comfortable bringing up issues that they might be having during residency, because I think a lot of times, not just in residency, but in medical school and the medical field in general, there's this hierarchy that does still exist, and there are power dynamics at play. And so there can be a fear of repercussion that interferes oftentimes with trainees feeling comfortable speaking up and saying something. So having faculty really create this type of environment where they don't feel like they have to walk on eggshells if they wanna say something, and have faculty that make them feel supportive, that they can have honest and open communication about things. In terms of supportive spaces, so again, at UCSD, we have our diversity committee itself, which I think has been an excellent way for residents who have similar values or share sort of a similar mission to get together and get to know each other and feel supportive and build that community. But I think another unique thing that we've done is we've created something called BIPOC Forum, which is open to our entire department of psychiatry, so not just for residents, but faculty as well, and even psychology trainees. So for those trainees or faculty who identify as black, indigenous, or people of color, they can get together and again, form these different relationships and build community with each other. And so we usually meet about once a month. Sometimes we will meet over Zoom and we'll just kind of talk. There's been sessions we've had where people will talk about different microaggressions that they've experienced at work, and people have given ideas of this, oh, this similar thing happened to me, and this is how I dealt with it. So having that sort of support group that have gone through similar types of experiences. But oftentimes, we'll also just meet and not talk about work at all. We'll do fun social activities. We, last month, went to the Asian Film Festival in San Diego, because again, it's just a place to build relationships and build that community, especially for a lot of our trainees who maybe are coming from across the country and they don't know anybody and they don't have a support group. And particularly, if you're a part of URM or a minoritized background, that's even more daunting and scary. So to have a space where you can kind of immediately get plugged in with people who share similar backgrounds to you, I think is a really important piece here. So I'm just going to leave you guys with, I'm not gonna read through all of these, but these are just some quotes from our residents about sort of the benefits of all these different groups that I've talked about or things that we've done. I'll just kind of highlight a couple here. So somebody said, as a member of a minoritized group, the committee provided me with a sense of community. I also learned a lot from upper class residents and faculties about ways to better advocate for the most marginalized in a way that was authentic. And then, again, we have some more quotes here. I'll highlight, participating in the DEI committee has been a very rewarding aspect of my residency training. I've learned a lot about leadership and advocacy by being a part of the committee and making sure our voices are heard. So I'll leave you with that. Before we open it up to questions and discussions, I will turn it over to you guys if you have anything else you wanted to add. I can do take home messages at the end. Sure, yeah. Yeah, I think now, and thank you, Sam. Yeah, I think now we wanna hear from you all, if we can. Your thoughts are kind of what is happening at your home institutions, if you've had successes, if you've implemented things like this or other things. I mean, I think the, sorry, supposed to use the mic so they can get it all recorded. Yeah, and I think we've done some of these things at UCSD and just like at Arizona and other places, but by no means is it there's no mission accomplished type moment on these things. Like our diversity in the faculty is still not where it should be or want it to be. Diversity in the residency classes isn't where we want it to be either. And I think an exposure to all the residents to these different clinics or these different opportunities would be sort of the goal or the dream. We're still working towards those things and refining the things that we do. And there are challenges with our own administration and our own faculty and leadership who sometimes, there's turnover there and some are more supportive, some are less supportive. Some see the benefit or see it as something that is important to the mission of the university and to the department. Other times, that's nice, but can we do real research instead? Can we do the real bipolar work or whether those things, those attitudes still exist. But yeah, we'd love to hear from you all if you have any thoughts. And just state your name and where you're from just so we all know. Hi, my name's Elizabeth. I'm a PGY-4 and chief resident coming from VCU out in Richmond, Virginia. Just wanted to thank you guys for having this talk and having these conversations. We recently started a DEI subcommittee within our kind of larger group of subcommittees. So we had education, feedback and evaluation, well-being, previously known as wellness, and research and scholarly activity. But one challenge we faced as resident leaders, we had been advocating for the creation of a DEI subcommittee for about a year and a half. And the pushback that we received from administration was essentially our subcommittee should just be including that lens from the get-go. Why silo it off? And I think that is a great goal five, 10 years from now. But I think when you're creating a lens and creating those systems, you really need that devoted space. And it has been really great to see the difference from my second year to being a fourth year now. But I'm curious if you all could share your experiences with kind of dealing with that attitude or dealing with that perspective and how to go about having those conversations in a meaningful way. So I think actually very similarly, even when we were trying to, sorry, implement our diversity series, we got pushback about that and saying, oh, well, all of our lectures should be incorporating that, but they weren't. And so it was kind of just like, well, this is maintaining the status quo. I think what has been helpful in general in terms of when we've come up against pushback is, I don't know if like your committee has faculty on it, but I think, again, as residents, it's a little bit hard because there are power dynamics. So it's hard to just sort of have these conversations with leadership directly. And so I think having faculty a part of our committee and having them sort of liaison has been one way that I know we've approached that situation. Yeah, and I would add to that as junior faculty, the folks who are most interested in this should be joining faculty, should be the ones in those rooms implementing and creating the structures, right? And so I do think that because of the strong, strict hierarchy of medicine, the same sentence said as junior faculty is listened to a lot more loudly than the same sentence said as a chief resident. And, you know, I've definitely, seen a lot more headway being made by folks who are higher up. So I think if you can get junior faculty involved or even become junior faculty yourself, that would be my recommendation. One other thing I'll just add to that is I think what else has been beneficial is like actually aggregating the data and showing like, hey, our residents want this. So that was something that we ended up doing too where we had a survey or like our evaluations for all of our lectures and the diversity lectures were some of the ones that were ranked the highest. And so being able to then use that and, you know, go to our program director and say, hey, like this is what residents want. They find it beneficial can be another way that can be helpful. Yeah, there's strength in numbers. I think that's the other part of it too. I mean, like when it's not just, you know, oh, it's just one or two residents who are asking for the same resident, always asking for this kind of a thing, but if they can sort of aggregate that data, put a class letter, petition, whatever you want to call it, but kind of highlighting what those things are and kind of laying out, you know, solutions and steps too that you want to see, you know, kind of in that productive manner and not just fix this, this needs to get better, which I'm sure you're not doing, but I think all those kinds of steps help to move the needle with some of those faculty as well. Hi, my name's Ari. I'm a psychologist at UW Madison in Wisconsin. Thank you for your presentation. And would you be willing to share it online so we can reference it too? I didn't see it in the link, so that would be super helpful. Yeah, well, they'll update it or upload it after the talk. Okay, perfect. So my question is the supportive spaces and mentoring opportunities, we're working to get those in place and for pathways. And one of the pieces of feedback we've had, and I'd love to hear your thoughts on, are how to, ways to incorporate that into our standardized curriculum so that we have mentorship opportunities so it's not an add-on and not a minority tax to say, hey, come to all the seminars that you're required to come to. And if you'd like extra mentorship, you can do even more work by seeking out mentorship after hours and being able to weave that into the courses. So it's not asking for more. And I'd love to hear from a resident perspective and from faculty perspectives, how you've woven in those mentorship and safe space opportunities into the standardized curriculum. Yeah, so I'm not sure from the psychology perspective, but I will say from a psychiatry perspective, the ACGME actually has very clear language on what we require in terms of our education in psychiatry residency. And nothing gets a program administration going like a good old ACGME citation and a good old ACGME document. And so really highlighting that requirement and spelling out how potentially it's not already being met in the curriculum and how really this is an educational requirement. I think the other thing is if you already have identified faculty, regardless of if they're URM, maybe even if they're not URM because of the minority tax, who is willing to do the lectures and to spearhead it. If you have an identified person who'd be willing to take that on in faculty, I think that would be the other thing. But yeah, cite the ACGME. Yeah, I think from a resident perspective, what you're saying would be great in terms of having this not be necessarily an add-on. I think in terms of like the mentorship and supportive spaces at UCSD, they are an add-on at this point. I think we're working to make it more incorporated. Particularly with mentorship, I think it's probably a little bit easier there because we do have like different research projects that we have to complete that we need like an advisor for. And so just have that in and of itself as a way where that it's already kind of embedded into the curriculum. But again, we need improvement in terms of representation in our faculty or even faculty who are interested in doing research in these types of topics. So yeah, I mean, I think it would be great. I think it's something we're still working to do. Yeah, that was the example that came closest to my mind was the sort of the required individual research projects or even having research electives and having that be paired with shared interest or with mentors who share those interests or for the two of them to work together or others in that same sense. So I think that's the closest I can think of. I'm trying to think of other ways that could be done, but we haven't really built those safe spaces into it. I mean, there's a committee time. I think sometimes it happens on some of these Thursday morning didactics. So there's time to do well-being or residency or diversity committees and that meeting space is protected there, but that's not the only time that happens. Were there any experiences that anyone here wanted to share about trying to change or work within the culture of the institutions? And that's okay if not. Maybe we share some take home messages and some thank yous and then we can go through some of the questions if people want to answer them. I really think that to take a step, if nothing else, I think that taking a step back and looking at how we set up recruitment is just as if not even more important than who we're recruiting because we can't equitably recruit in an unfair system or in a system that is not designed to set up people for success. So that would be my take home message. I guess I guess from a resident perspective, I think obviously I sort of went through these quotes of how this has been really beneficial. But again, it can be really daunting when you're coming into a program. And so, for example, when I joined in 2020 was when this resident or the diversity committee was getting started. And so it luckily gave me the opportunity to be very involved from the get go of building some of these initiatives. But again, it can be really scary initially coming into a place you don't know. You don't know the faculty. You don't know how they're going to respond to things. But I think pushing through that and continuing to sort of advocate for these things and finding people, whether it be faculty or co-residents who have similar goals in order to accomplish these things is really important to do. As Michelle was talking, I was thinking of a couple other more formal things we were actually able to incorporate. Because with faculty and with lecturers that we have come in, there's a couple of things that we were able to change. I think it's sort of like, again, not creating the space necessarily, but sort of to better embed these things into what needs to be talked about. So one was there's a letter that goes to all lecturers that's called our DEI considerations. So having them think about if you're talking about anything, what are the considerations? And even if it's just acknowledging that, yes, I'm presenting this research and this genetics, epigenetic research is actually done on a mostly white population, great. At least we're acknowledging it and having that be part of the conversation. So that goes to them. And we were able to add that as an evaluation on the lecture evaluation. So there's a checkbox that's like, did the speaker address these things or incorporate cultural and diversity aspects into their talk? Because now if they're getting graded on it, if they're getting evaluated on it, then it becomes more important for their promotions and things like that. So they want those things to be measured highly. So at least hopefully they'll begin to think about it. I think even with that, the initial from some of the faculty leadership was we're going to have it in there as one of the checks. Well, you can put an option all of, well, it did not apply to this talk. So there's still even some pushback on that because what if we don't want to offend a lecturer? What if they don't have this in there? But I think trying to change that culture shift is tough. But I think it requires that constant pressure and having those spaces. And I think, as you mentioned, having those committees I think is important. One other sort of leg up I think we've had a little bit within UCSD is in our Department of Psychiatry. They had a diversity committee sort of for the department at large back through 2014. I think it was initially a diversity work group, and now it's one of the councils or kind of a more fixed position. But there's a leader for that that's recognized as a position within the department. And so there's a lot of good mentors and other folks there. And there's trainees in this council as well as faculty. But those people carry some weight now that they're kind of more senior faculty in there. And they can be utilized to help push one of the division chiefs or other folks to kind of think about how they're doing some levels of clinical care or kind of how we can incorporate more things into grand rounds or other stuff that are beyond the sort of resident residency control within the university. But, yeah, thank you all. Thank you all. Thank you for coming.

diversity

equity

inclusion

medical education

psychiatric residency

healthcare workforce

systemic barriers

holistic admissions

URM representation

DEI initiatives

community engagement

affirmative action