Welcome to the panel on Addressing Racial Bias and Discrimination in Graduate Medical Education. I am Dr. Constance Dunlap. And on behalf of our panel, I would like to first thank the Scientific Program Committee for selecting our abstract. And I also want to thank Austin DeMarco, the Interim Director of the Office of Scientific Programs, and his staff for their always superb assistance. And let me just start off by saying that this is a panel that was inspired by a presentation that Dr. Frazier, who's one of the fellows, and Dr. Gupta did last year. And that was about mentoring underrepresented trainees in medical education and the importance of mentoring. And in the process of discussing it and discovering that there is so much bias and discrimination, we decided to submit a panel focused on this topic. These are our participants, and I'll introduce them with a little bit more detail before each of them speaks. The first is Dr. Sade Frazier, Dr. Drew Gupta, and our esteemed discussant, Dr. Frances Liu. None of us have any financial conflicts of interest. So racial bias and discrimination in graduate medical education are serious problems that can negatively affect the lives of students and professionals in the medical field, while also having a significant impact on the quality of medical care patients receive. While it's generally known that racial bias and discrimination are pervasive in society, most students entering the graduate medical education arena are often unprepared for these experiences. They're caught off guard. They don't readily have trusted resources that they can access. And they end up enduring a great deal of pain as they navigate challenging and sometimes debilitating situations, sometimes situations that cause them to become suicidal and also result in suicide. Among the many consequences, bias and discrimination can ultimately decrease the likelihood of black, indigenous, and people of color trainees pursuing a career in medicine and also contributing to the dearth of clinicians to treat underserved communities. Rising allegations of racial bias and discrimination in graduate medical education have prompted the Accreditation Council for Graduate Medical Education, ACGME, to call for immediate action to address this problem. I just received a note to remind you that we are being recorded and also when you have questions during the Q&A to please make sure you come to the mic. Thank you, Dr. Lu. So as such, in February of 2021, ACGME issued a statement mandating training programs to foster a, quote, professional, equitable, respectful, and civil environment that is free from discrimination, sexual, and other forms of harassment. But before I get into that, I do want to just tell you what our objectives are. By the end of this presentation, you should be able to recognize incidents of racial bias and discrimination experienced by trainees. You should be able to describe the health and mental health impact of bias and discrimination. We are going to provide a framework of evidence-based approaches that you can consider, and these can be implemented to address bias and discrimination in your training programs and places of work. We also will provide strategies that you can consider to mitigate racial bias and discrimination in undergraduate and graduate medical education. I do want to just go back to the ACGME statement that really mandated a professional environment, and I want to just follow up and say that the Association of American Medical Colleges also provided an actionable framework involving four steps, and I'll come back to that. Before we get to that, our first participant Dr. Sade Frazier, who was not able to be with us, she actually had a baby recently, and so she did agree to record her segment. And in that segment, she shares an experience that she had in training. And so I'm actually going to play that. It's about 15 minutes. My last day of residency was June 23, 2021. My PTL started the next day. I went out to an event, something that I couldn't do through much of my training. And when I got back to my car, I reached into my purse to plug up my cell phone, you know, use GPS, and I saw text messages from an unknown number. I read the first message that you see on this screen at least three to four times, attempting to wrap my brain around what it was that I was seeing. Dr. Frazier, you were correct in assuming that you were discriminated against during your residency. My heart started racing as the number of traumatizing experiences from residency flooded back at once. I sat in my car as I was not able to drive in that state, and I called a co-resident that I was close with and asked them if they've received anything similar. What is covered by those red circles is the face of the program director and the chief resident engaged in a video chat of which the screen grab was sent as a part of these anonymous text messages. This second slide contains communication between two individuals. I've covered the names, utilizing different colors to indicate who is being discussed, and when two of the individuals involved in the conversation are referenced. The blue is the program director, according to the anonymous sender. I will read the text exchange to you all as the messages are blurred when enlarged on the screen. My worry with her is her accusations. If it would have been a couple of months ago, it would have been different. Now I have this thing that I don't wanna be in the position where I'm defending myself that I'm not biased towards you, because now I am, and that makes it complicated. So she was the one started complaining to Redacted that chief resident doesn't have much outpatients because Redacted told me, and Redacted was convinced that she might be right, and was asking if staff is discriminating. I told him it's BS, I don't know how they schedule patients, and I have nothing to do with it, but I saw he brought that up in the PEC meeting. So I spoke with him after PEC that how you have so much administrative stuff, and you're doing a lot of coordinator stuff too. I don't wanna end up in a position where I'm always defending myself. I also have to work on minimizing my barging into your office because she has passed random statements and eye rolls as if there is favoritism or I'm discriminating, even during our conversations with human resources. She would drop subtle words like, Dr. Program Director, you spend time with other residents and go the extra mile for them. So why you didn't come to my office and never sat down with me and provided any support, et cetera, et cetera. So this time, I'm just a little, I don't know, what's the word here? Not mad though, maybe conflicted that I don't want her to prove she's right, so I need to watch my actions. I just have to be more responsible. Again, it's 1610, it's Redacted, racial expletive, Redacted, blah, blah, blah. I can't be just so casual about everything. In the end, I received over 15 text messages, which were a combination of screenshots of discussions between the Program Director and the Chief Resident, according to the anonymous sender, as well as text messages that were the anonymous sender's own words. The next day, I reported receiving the messages to human resources, a human resource representative that is assigned specifically to graduate medical education issues, as well as the GME DIO. Following that email, I received additional anonymous text messages asking me for the physical address of the office that I reported the text messages to because they had over 1300 pages of text messages they wanted to submit. I also received a phone call from someone within the hospital system indicating that the Program Director was aware that I had reported these anonymous messages. Retaliation was and remains a very real fear, and I've been extremely transparent about concerns for prior incidents that occurred in the program. By August 26th, 2021, the Vice President of Team Member Labor Relations, the Senior Vice President of Human Resources Operations, the Chief Experience and People Officer, and the Chief Executive Officer of the hospital system were all made aware of the anonymous messages. My training experience didn't start out as explosive as anonymous text messages. It was innocuous. It started with microaggressions. Microaggressions are brief, everyday exchanges that communicate negative messages to people of color. They can be verbal, nonverbal, or environmental. Some examples of microaggressions that trainees of color may experience include, you know, being asked where they are really from, or having their accent or English skills questioned. Being told that they are articulate or exotic. Being assumed to be a patient or a family member rather than a healthcare professional. Having their expertise or knowledge challenged. Being stereotyped or made to feel like they don't belong. Discrimination can show up as implicit bias, which is the unconscious bias that affects our decision-making without us even realizing it. Implicit bias can lead to trainees of color being treated differently by faculty, staff, even patients. Some examples are, you know, being given less challenging assignments, assigned to less desirable rotations, given less opportunities for mentorship and leadership, passed over for promotions, subjected to negative stereotypes and assumptions, even being excluded from social events because of assumptions of trainees' interest. These are different articles that are reflective of the discrimination that takes place within medicine for black physicians. I'll call your attention to the top left where it states, it was stolen from me. Black doctors are forced out of training programs at far higher rates than white residents. There's a CNN article from February of this year that states only 5.7% of U.S. doctors are black and experts warn the shortage harms public health. And a quote from Michael Dill, the Association of American Medical Colleges Director of Workforce Studies states, one reason why the percentage of U.S. doctors who are black remains far below that of the U.S. population, that is, black can be traced to how black people have been historically excluded from medicine and the institutional and systemic racism in our society. Here's a quote from one of the articles. Black trainees experience a year's long cycle of gaslighting. Begins when a black resident makes a mistake in medical knowledge or patient care. Their mistake is publicized amongst other trainees, faculty, even ancillary healthcare team members. They're then more closely observed and scrutinized by superiors. And unsurprisingly, this leads to the identification of more errors. Meanwhile, residents who are not suffering the pressure of this emotional abuse are more likely to perform better. Their accomplishments are publicized and mistakes are downplayed as isolated, rare events. This may cause the black resident to believe that their shortcomings are intrinsic qualities and cannot be changed. Residency becomes something she must survive. Eventually their overall performance is evaluated at clinical competency committee meetings, a form that could help identify gaslighting and curb implicit biases. However, these committees are subject to groupthink. Once one attending begins to criticize the black trainee and another agrees, dissenting faculty do not rise to the trainee's defense in favor of maintaining solidarity. When someone thinks of overt discrimination, they often think of the Jim Crow laws, whites and blacks not being able to sit together, separated water fountains. Overt discrimination is defined as discrimination that is intentional, direct, and explicit. Being denied a residency position because of your race, being harassed or bullied also because of your race, being called a racial slur or having a racial slur used in your presence, being physically assaulted because of your race, and discrimination against religious dress and black hairstyles. Systemic racism is a system of oppression that benefits white people and disadvantages people of color. It is embedded in our institutions and policies and it can be a profound impact on the lives of trainees of color. Lower rates of acceptance to residency programs, lower rates of academic promotion, lower rates of compensation, unequal treatment by patients, as well as colleagues. These are some of the historically black medical schools that no longer exist as a result of the Flexner Report. Flexner, who was not a physician or a scientist, set out to standardize medical education utilizing Johns Hopkins School of Medicine as the standard. Almost half of the medical schools in the US closed after the release of the Flexner Report and all but two historically black medical schools, Howard and Meharry, were closed. Flexner believed only black doctors should treat black patients. Flexner's report led to less black physicians being trained than if more black medical schools were available as they were not allowed entry to most medical schools. Good afternoon, everyone. I'm Sade Frazier. I'm so sorry that I'm not able to be there in California with you, but you have this recording. So let's get started. My last day of residency was June 23rd, 2021. My PTL started. Thank you. Before we go to the next segment, I wanted to just say something about Dr. Frazier. And you know, while the recording at times may not have been clear because of the technical challenges, what she conveyed is something that I think, I don't think it's hyperbolic to say that probably every trainee who identifies as a historically racialized person has had some experience with bias, if not overt discrimination. I also think that it's fair to say that whites who may not be the object of this have witnessed these incidents. And we want to just make it clear that this is really, really very common. Let me say something about Dr. Frazier. She is a board-certified psychiatrist. She is completing child and adolescent training at Westchester Medical Center in Valhalla, New York. She's a former diversity leader fellow in the APA. She was also the past chair, vice chair of APA's minority fellowship program. She has a number of accomplishments. And so you can appreciate, I'm sure, the pain that she experienced as she was finishing training and discovering that she had been the object of this kind of discrimination. On a bright light, she can be found making memories with her vivacious children. She has two and her loving husband. And so we're gonna refer back to her segment as we go on. But what I would like to do next is move to Dr. Gupta. And let me just introduce him. As I said, he was one of the fellows that we worked with last year as well. Dr. Gupta completed his undergraduate and graduate education at Tulane University in New Orleans, after which he completed medical school at St. George's University in Newcastle, England. He completed general psychiatry training at the School of Medicine at Mount Sinai Elmhurst Hospital, where he served as senior chief resident. And he is also an APA diversity leadership fellow, as well as a resident fellow member of the APA Council on Psychiatry and the Law. He was also a member of the APA Presidential Task Force on Structural Racism. He is currently completing fellowship training in forensic psychiatry at University of Pennsylvania Hospital. And his professional interests include health care policy, medical education, minority and immigrant mental health, correctional psychiatry, as well as psychodynamic psychotherapy. And Dr. Gupta is going to go over two parts. The first is he's going to cover the impact, and then he's going to talk about the mental health results of bias and discrimination. Dr. Gupta. Thank you so much, Dr. Dunlap. And good afternoon, all. Thank you for joining us this afternoon. I am Dhruv Gupta, Forensic Psychiatry Fellow at the University of Pennsylvania. Now that we have looked at the various forms of racial bias and discrimination that can be experienced by trainees in graduate medical education, we'll shift to taking a look at the health and mental health consequences of such experiences. So looking generally at health consequences, experiencing racial bias and discrimination can signal the presence of a dangerous, a hostile environment that can result in both physiological and psychological stress responses. And it's important to note that the cumulative burden of chronic exposure to racial bias and discrimination creates a state of perpetual stress that can then contribute to physical and mental illness and also flattened self-confidence. Here we'll take a look at a figure that comes from a highly cited meta-analysis by Pasco and his colleagues. And it looks at the relationship between perceived discrimination and mental and physical health outcomes. Let me orient you to the oval boxes that appear in this figure, in this diagram. But before we do that, just bringing you really quickly to the oval right here. That's this perceived discrimination. And it results in mental and physical health outcomes. It's to point out that perceived discrimination can literally be, can be considered as a social determinant of mental health, as it can be seen that perceived discrimination can result in mental and physical health consequences. So let's start off with looking at pathway A right here. So perceived discrimination in certain cases can result directly, can lead directly to mental and physical health consequences. And this is often the case when there is a pre-existing history of an individual experiencing repeatedly, perpetually instance of racial bias and discrimination. Moving on to pathways B and C, here we see that the relationship between perceived discrimination and mental and physical health outcomes can be mediated by a heightened, by a heightened stress response. So what's taking place is the exposure, the experience of perceived discrimination creates a state of heightened stress response that then goes on to result in mental and physical health consequences. And chronic heightened physiological stress responses, such as cardiovascular reactivity, elevated cortisol levels, as well as consistently negative emotional and physical states are often a product of this very pathway from B to a heightened state of response to C, to mental and physical health outcomes. Now let's take a closer look at pathways D and E. The relationship between perceived discrimination and mental health, mental and physical health consequences can also be mediated by negative health behaviors or maladaptive health behaviors. As a result of experiencing discrimination, individuals may engage in maladaptive health behaviors. This could be in the form of aberrant eating habits, not sleeping the right amounts of time, engaging in high risk behaviors, or refusing to see physicians. There are several examples. And that, and as a product of that, there are other significant mental and physical health consequences that do take place downstream. And just at this point, before we move on, we'll look at strategies during the second half of this presentation. I definitely do want to point out that within the diagram, there's a spot much before you actually result in the mental and physical health consequences, but then pathways B and D, where support systems, stigma identification, group identification, and coping styles can come in place. And we'll take a closer look at these particular strategies in the latter part of the presentation. So having looked at the mechanism by which perceived discrimination can result in physical and mental health consequences, let's take a closer look at some of the actual health consequences. So starting from health and cardiovascular consequences, perceived racial and ethnic discrimination is linked to poor health and coping behaviors such as smoking, excessive alcohol consumption, and recreational substances, which may actually increase one's risk for cardiovascular disease. And also there's consistent evidence from the literature suggesting a strong link between perceived discrimination and lower resting heart rate variability. And heart rate variability is the time interval between each subsequent heartbeat. The lower this number is, the lower the variability is, the worse it's considered in terms of physical health and outcomes. Perceived discrimination, racial bias, has also been found to be linked with coronary artery calcification. It's also noted that experiencing discrimination can result in same-day cortisol increases, which goes on to suppress one's immune system and affects cardiovascular health. And chronic exposure to racism may be actually implicated with hypothalamic pituitary adrenal axis dysregulation that in turn can damage bodily systems and lead to physical outcomes such as cardiovascular disease and obesity. And interestingly, if you look at the biological mechanisms, studies have indicated that higher lifetime levels of discrimination can actually result in higher IL-6, interleukin-6 levels, which then go on to elevate C-reactive protein levels and fibrinogen production. And that goes on to accelerate plaque formation, creating the perfect nexus downstream for additional cardiovascular adverse events. And the key point here to take is, these are all changes that cannot be assessed via self-report. So when someone comes in having experienced physical, just experienced discrimination, racial bias, they talk often about the emotional consequences that they're experiencing. But this goes to highlight the extent to which such experiences can be damaging to one's health and cannot be self-reported. Racial bias and discrimination can result in a wide array of mental health output as well. Some of these listed here are symptoms, but there have also been studies that have been correlated with various diagnoses as well. And qualitatively, studies show that experiences of racial bias and discrimination during training lead to feelings of isolation, devaluation, and beliefs that group membership hinders ability to succeed, membership to that particular group that is exposed to discrimination and racial bias. And now I'm gonna briefly discuss some great studies that will show how each of the pieces from PASCO's diagram fits into the bigger picture. So in this study that was published in the American Journal of Public Health, Sawyer and colleagues demonstrated that merely anticipating prejudice can lead to both psychological and cardiovascular stress responses. So perceived discrimination, even without behavioral confirmation, activates the sympathetic nervous system and hypothalamic pituitary adrenal axis. And that contributes to an increased level of allostatic load. And what is allostatic load? It just refers to the cumulative burden of chronic stress and life events. And that then goes downstream through pathway C to result in mental and physical health consequences. And as we know, increased allostatic load is a predictor of a number of negative health outcomes. It could lead to increased anxious and depressive symptoms as well as exacerbate cardiovascular responses and decrease immunological functioning. In this particular study that was published in the Journal of National Black Nurses Association, Johnson and colleagues noted in a group of 350 African-American women between the ages of 18 to 71, that there were higher rates of emotional eating behaviors in women who reported higher perceived discrimination and higher stress levels, also known as hangry eating. And as noted earlier in Pasco's diagram, perceived discrimination can result in a heightened state of stress, but it can also lead individuals to engage in maladaptive health behaviors. And this study is precisely an example that does go on to demonstrate that. And this study that was published recently, relatively recently in 2019 in the New England Journal of Medicine, in which you young and colleagues surveyed approximately 7,400 surgical residents assessing mistreatment, burnout and suicidal thoughts during the past year. They found that experiencing mistreatment, including racial discrimination, even just a few times a year, was associated with a twofold increase in the odds of both burnout symptoms and suicidal thoughts among residents. Workplace mistreatment, such as discrimination, abuse and harassment, goes to create a hostile environment, resulting in poor physiological and psychological outcomes, including suicidality. And racial bias and discrimination are a source of significant distress, and it's to be pointed out that it's not always necessary. There is an ample time oftentimes for the pathway to go from perceived discrimination to heightened response to then mental and physical health outcomes. In such cases where there is history of prior experiences of discrimination, racial bias, or you're experiencing it relatively frequently, the mediating response doesn't necessarily have to be present. It can go directly through pathway A, from perceived discrimination, resulting directly in adverse health outcomes. And in this particular slide, I do want to point out that there's been a dual pandemic, a syndemic recovery from two epidemics that's been going on. One, which has been the COVID-19 pandemic since 2019, and the other is the racial epidemic that's come to light since the onset of the pandemic. And since 2019, we have seen the intersection of a pandemic that has caused significant distress to healthcare workers. As you could see on the right half of the slide, there's been exhaustion, burnout, worrying about exposing family members, inadequate support. But at the same time, the pandemic brought about rampant levels of discrimination within community. So it's just to highlight that the current milieu, the time that we are working through right now, it's not just the consequences of discrimination that individuals are facing, but really a heightened level because adding to it is the burden, the exhaustion that comes from COVID-19, but the discriminatory experiences have also really shot up and have increased. And we took a moment to look at pathways A, B, and C. And at this point, what I really wanna point out is what to me is the most exciting part of this diagram is the fact that these strategies can come in handy well before you even reach the points of a heightened stress response or health behaviors. So we could intervene with strategies of social support group identification coping styles at points B and D itself, well before a point in which you will have mental and physical health consequences. And this is really the cool part of the study. And the rest of this presentation will go on to focusing on trying to identifying ways in which we can create environments of social support where we could foster group identification and create positive coping styles so that trainees are able to better care for themselves, but more importantly, systems create an environment that is more conducive to learning and training where individuals don't go on to actually experience mental and physical health outcomes. And if there is some form of discrimination, racial bias that does take place, there is a plan in place and action can be taken right away to mitigate some of the downstream consequences. So move on to the next part of this presentation, which was switching into strategies, which Dr. Dunlap will discuss. But prior to doing that, we'll talk a little bit about a framework, looking at ways in which racial bias and discrimination can be addressed in training programs. So it is my understanding, and as psychiatrists, we all know this, that the best way to address a concern, destigmatize a process, is by really talking about it, creating awareness surrounding that issue. And to do so effectively, it's essential to build a certain skillset. And let's look at a couple core values that can be helpful in developing a framework to address racial bias and discrimination. Let's start off by looking at the difference between cultural competency and cultural humility. So cultural competence assumes that cultural sensitivity is essentially a level that can be attained. It's a competence, it's a standard, that once attained, you have enough of it. There's no more building beyond that. However, cultural humility, on the other hand, assumes that cultural sensitivity is an ever-evolving process. There are experiences, there are points of learning that go on to take place, not today, not just tomorrow, but for months, for years, for a lifetime. As you interact with individuals, as times change, it's a process that you engage in and you make yourself open to learning. And that is really the core value that we would like to bring to light in terms of building the sense of cultural humility that will allow you to understand from another person's perspective what they're experiencing and what would it make you, what would it be like for you to experience that? So highlighting the difference between competence and humility, now let's take a look at a related concept of cross-cultural training. And what is that? It asks us to maintain cultural humility and establish a sense of comfort working with someone from a background different from our own. Maintaining humility, you're keeping yourself open to learning. And with training, you're actively utilizing that humility to create a level of comfort that allows you to work with someone from a background different from one's own. And highlighting this is an excellent model that was developed by the University of California, San Francisco, right here. And UCSF PRIDE values, PRIDE stands for professionalism, respect, integrity, diversity, and excellence. And why am I presenting this model as opposed to any other institution's model? Because this is one institution, at least from my understanding and having come across extensively in literature, where they really live by the fact that if you have a policy in place, it's only as good as it is implemented. This is an institution where not only is there a system in place, but it is implemented. Every individual is asked to know the PRIDE values and to integrate that in their everyday interactions with each other, with patients, with patients' family members, with ancillary staff. And what it does is it creates not only a form in which to conduct oneself, but also creates a form for accountability. And just a little bit about how it came about. It was back in 2016 when UCSF adapted a common set of values in an effort to reinforce the concept of what they call One UCSF that would unite members of the community, build a culture of collaboration, and this is asked of everyone who's there, working, learning, and teaching. And here's a wonderful diagram from an article looking at diversity, equity, and inclusion efforts within the field of cardiology that was published in the Journal of American College of Cardiology. It highlights opportunities to change culture and support diverse trainees through awareness and allyship and advocacy, and it's focused on retaining a diverse workforce. But some of the strategies that have been discussed here, which Dr. Dunlap will discuss in more detail, really do help also mitigate racial bias and discrimination that does exist and or could be found within the work setting or in graduate medical education. It's essential to lead diverse teams with intention, reviewing expectations, facilitating goal setting, and minimizing rivalry among trainees. Also, if there are reports of mistreatment, it should be responded to in a very active manner. If there is lack of adequate mentorship, there should be adequate mentorship opportunities available and individuals should be sponsored, they should be sponsored aggressively in the sense that those that are in a position to be mentoring should build on the core values that we have discussed and offer a safe, supportive space in which such incidents can be addressed, and also to advocate for change at the level of the leadership. One of the worst things that tends to happen at times is after an individual has such an experience of experiences of racial bias and discrimination, they are the ones who are then left to advocate for themselves, and its concept is known as minority tax. You're the individual who's experiencing this, and now you're left in charge of also pushing the change at the systems level. So there has to be change within the leadership, not only when the individual is experiencing it, but also at a systems level. With that, I would like to pass on the rest of the presentation to our wonderful chair, Dr. Dunlap. Thank you, Dr. Gupta. So, I'm going to talk about some strategies, but let me first say that Dr. Frazier has shared a personal experience, and I just want to say that in the process of preparing this, we're also concerned about how much to share, and I think one of the concerns is that there's a fear of retaliation, and so often these reports are not very clear. These reports are not shared during training because of a fear of retaliation, but we also noticed that during the COVID pandemic, there were a lot of reports, I think primarily because of social media. People have been experiencing things throughout the country, and so there's more awareness, again, because of social media. And so, unfortunately, while bias and discrimination are not new, there is some good news. It's only good if we acknowledge that this is a concern, and then we actually take action, and I just want to share an example. I teach a third-year medical school course, and it's an opportunity for students to talk about diverse populations, and so some of the examples that we have discussed, I'll give you an example of, in parts of the country, someone white is asking to be treated by a white doctor. There are patients who are black who want to be treated by someone black because they are now aware of disparities, and they are afraid that they're not going to get adequate treatment. Another interesting example are, I've had experiences where someone from the Middle East, let's say, who does not identify as white, is told that, a patient tells them, I don't want to be treated by someone white, and what's interesting is that the person doesn't identify as white, but once you come to this country, there's a caste system, and so they're navigating that, so there are all kinds of things that people are experiencing, and we need to give them an opportunity to actually have support for navigating these situations. So I've already mentioned the AAMC statement, and so following the deaths of Ahmaud Arbery, Breonna Taylor, and George Floyd in February, March, and May of 2020, as I mentioned, the AAMC issued a press release from Doctors David Skorton and David Acosta, acknowledging our country's history of structural racism, and in that statement, they announced that, in this slide, they announced that we must employ, the AAMC must employ anti-racist and unconscious bias training, and engage in interracial dialogues that would dispel the misrepresentations that dehumanize our black community members and other marginalized groups, and they followed up with four concrete action steps, which are summarized here. And the first is to engage in self-reflection and in the development of racial literacy to become an anti-racist organization, collaborate with communities, and speak out about systemic racism. On February 7th of 2021, the ACGME publicized its commitment to this effort by calling on the GME, Graduate Medical Education, and the graduate medical education community to eliminate bias and discrimination. I'm gonna come back to that word eliminate in a moment. The statement included a reminder of the mandated requirement for a professional, equitable, respectful, and civil environment. In this next section, I'm going to discuss an anti-racist pedagogical approach to these matters. The anti-racist pedagogical approach is laid out very nicely and clearly in a 2018 article by Professor Kiyoko Kishimoto of St. Cloud University in Minnesota. And you can see that her approach, or maybe the AAMC's approach, is essentially the same as hers because it involves these four key components, self-reflection, a commitment to becoming anti-racist, collaboration within and outside of the organization, and a commitment to speaking out about systemic racism within and beyond healthcare, in other words, advocacy. And I just want to say something about pedagogy. It's a word that we don't usually use in medicine, but pedagogy is simply the art and science and method of teaching. And so this pedagogical approach is something that applies to didactics and teaching, but of course you know with medicine, the didactics also blend in with the clinical. And I want to highlight a few components of this approach. We all know what self-reflection means. In anti-racism work, a critical component of self-reflection is racial literacy, which means knowing our history. It means challenging what is considered legitimate knowledge. It means therefore looking at which and whose stories and experiences have been ignored and why. This is a timeline of key dates in US history. And as a broad overview, I like to look at the slide. Of course, there were some things happening before 1619, but just for the sake of this discussion, slavery lasted for 246 years, from 1619 to 1865. Legalized segregation lasted for 89 years, from 1865 into 1964. And we have only had legalized integration for 59 years, 59 years, since the 1964 Civil Rights Act. Many people think of Brown in 1954, but it wasn't Brown. Brown was just about education. The 1964 Civil Rights Act is what ended segregation, at least legally. And the take-home point from the slide is that when we think of the country's history, we are really young developmentally in our attempt to live together as a racially diverse society. And if we are to achieve what the AAMC and ACGME are calling for, the first prerequisite is knowing our own histories. And I say histories, because we are not all having the same experiences. This is a slide, it's a similar timeline, but this is for the APA, which was founded in 1844. And taking an interracial pedagogical approach, we would look more closely at the history of our organization. And just as a broad stroke, I wanna say, we know that Benjamin Rush has been considered the father of psychiatry. He was one of the original signers of the Declaration of Independence. And he was revered. He was on the logo of the APA letterhead. But in the 21st century, we became aware of him having owned, enslaved someone. We also, there's more awareness of him thinking that black skin was a form of leprosy. In other words, some primitive beliefs. In 1954, Charles Proudhon, a black psychiatrist and psychoanalyst, unsuccessfully appealed to the APA Board of Trustees to support an amicus brief in support of the Brown versus Board of Education decision to end legalized segregation in public schools. The APA declined. This is our history. And it wasn't until 2021 that the APA Board formally apologized for racism throughout psychiatry and cited their decision to not support the Brown decision. So taking an anti-racist pedagogical approach would mean that we own this history and we sit with the discomfort that arises in us as we take in and process its meaning. And most importantly, what it represents, which is the origin of our own organizational structural racism and its roots, the first step in dismantling it. And so why do we do this? Well, as a leading psychiatric organization in the world, we have a responsibility to face the hard truths so that we can assist our patients in achieving their mental health goals. We know about legislation suggests that we don't want students to talk about things that would cause them distress. We know that conflict and distress is required for growth. And denial is not the answer. And I wanna consider the case of Sarah, but here's a little video. It is less than 90 seconds. And this is taken from something called the Whiteness Project. And you can actually access this. It's a collection of videos by people who identify as white. You know, asking them how they think about race and racial dynamics. Yes. I never think about my race. It's not something that comes to mind for me. I just think about people as people. Probably my age and my gender has a bigger influence on what I think of in my identity. I don't really see people as black, asian, hispanic, or white. It's just kind of like boy, girl, 25, 15. You know, it's just people to me. I don't really care about the color. There's a certain point where you feel like your opinion loses its validity. Because I'm white. And there's a lot of times where they say you don't understand, you don't get it. I have a really great friend who's black. And we were in an argument about whether or not you can be racist towards someone that is a majority rather than a minority. And I was saying that you can be racist to any kind of person. And she was saying you can't be racist towards a majority. And then she started getting angry with me and accusing me of not understanding because of white supremacy. And that definitely made me feel very separate from her because I'd never really thought of myself as so different socially than my friend. And that was definitely weird because I felt guilty. And I felt like she was mad at me for something that I couldn't control. That was a request to lower the volume, apparently there's a memorial service next door. Okay, yes. So clearly from this little vignette, Sarah does not see race. And this is known as colorblind racial ideology. And the problem with this view is that not seeing race means she also doesn't see racism. The anti-racist pedagogical approach challenges the limitation of this mindset and a couple other approaches. And I summarize them as see no evil, hear no evil, speak no evil. And so the see no evil is accepting colorblind racial ideology. Hear no evil is reflected in taking an apolitical and asystorical approach by focusing exclusively on multiculturalism as a way of sidestepping race. And some organizations have done that. Speak no evil means focusing on diversity in lieu of confronting racism. So that means speak no evil of the past or the present to prevent the possibility of emotional conflict and discomfort. And again, educational gag orders are aimed to prevent this. However, this is not an either or proposition because we need to take a both and approach by supplementing multiculturalism and diversity with an active anti-racist approach. And again, remaining focused on self-reflection, I want to offer some tips that are helpful when working with both patients and trainees. And so one thing to think about is that we are each a combination of dominant and subordinate identities. We need to own them and we need to use them to connect. So some examples are like no one is monolithic. So you might think of a man that is, and this on the left you see kind of a hierarchy of identities. And the point is, so for example, you could have somebody who is a white man who may be considered dominant in terms of power, but identifies as LGBTQ, for example, and depending where he is, that may give him less power. You may have a department chair who is also a woman, and so she may be discriminated against because of gender. And so there are a number of permutations. But being aware and owning your intersubjectivity is a vital prerequisite for this next step, which is becoming aware that there are a number of variables intersecting at any one time. This Venn diagram includes gender, race, it can include sexual identity, religion, class, and caste, which may not always be obvious. But for some communities, especially communities that have immigrated from other parts of the world, caste can be very much at work. But if you're not aware of it, you may miss it. And so Kishimoto speaks about the interplay between course content and delivery method. And so you have these intersecting environments and identities, and so there are all kinds of possibilities. And while this approach is a didactics-focused approach, these are variables that come up and come into play when there's concern expressed about racial bias and discrimination. And the point here is that we are not blank slates. We carry our histories with us. And again, I'm thinking also about patients, but one of the reasons we talk about patients is because we just don't have a lot of information about trainees. That information needs to be made available. And now to my last segment, this is the social cognitive psychological approaches to reducing bias. And I want to say something about the implicit association tests. So what can we do? How do we recognize our own biases? And what can we do once they are identified? So in a clinical setting, there's less of a likelihood that we will witness overt expressions of racial discrimination. Less likelihood, but actually it still happens. However, well-meaning individuals can hold negative racial stereotypes. And the following strategies are a synthesis of the work of social cognitive psychologists, Dr. Diana Burgess and Dr. Patricia Devine and their collaborators. And they lay out a number of steps. I'm just going to highlight a number of them. One is to have a psychological understanding of bias, because I think we really misunderstand bias. We've established that racial bias is automatic and unconscious. It's the first step in promoting psychological understanding, which includes also the education about the ubiquitous nature of bias and the connection to systemic discrimination. And an important step is accepting that we cannot completely eliminate bias. That's not a reasonable goal. Each of us has biases. And I have to say, even though I've known about the implicit association test for a number of years, it's only recently that it has sunk in. Each of us has bias. And that test is actually designed to help you get in touch with that. Because it's unconscious and out of your awareness, you can't know until you are challenged to make decisions. And I actually encourage you to consider taking it. Because again, because it's unconscious, you can't know unless you actually have a mechanism for identifying your bias. And so that's to help get in touch with implicit bias. In terms of explicit bias, there are motivational exercises that Burgess and Devine suggest. For example, a simple question is assessing concern about discrimination. Just asking, do you think discrimination is a problem in society? For someone who says no, that's one path in the algorithm. For someone who says yes, it's going to be a different path. But one of the ways to also assess motivation, that's a way to assess concern. But another way to assess motivation, look at internal motivation versus external motivation. So internal motivation to respond without prejudice is primarily driven by personal values and the belief that prejudice is wrong. So there are people who have that value. External motivation to respond without prejudice is primarily driven by a desire to escape social sanctions. In one way to assess that, in other words, escaping social sanctions is about reputation management. So one way to assess that is the use of what are called should and would subscales. The should subscale asks people how they believe they should act, feel, or think in response to challenges. They might say, I should not feel uncomfortable sitting next to a black person on the bus. But then you ask, you apply the would subscale, which is to predict how they would actually act, feel, or think. And you can actually see the discrepancy. But this is something that actually helps people to slow down and think about how they really feel. Another approach is what is called individuation, which means focusing on individual attributes, whether it's a patient or trainee, versus categorization. If we make the broad stroke that this person is black or female, we miss the individual characteristics of the person. And then also, they recommend accessing opportunities for interracial interactions, because that is actually what causes people to be more comfortable. It also helps them to deal with stereotype threat, which is the fear that they're going to act a certain way according to stereotypes. And the point is that all of this leads to enhanced confidence and more comfort in actually promoting environments that support better health care. So ultimately, this approach requires action. And then here's a recap, which is raising awareness about bias, which we all have, engaging in self-reflection, teaching some mitigation strategies, also reducing misrepresentation of race in the health care curriculum, which Dr. Liu is going to address some of that, focused on DSM-5TR. And then strengthening an organizational commitment, and whether that's a private practice or is a large health care setting. But ultimately, it's about creating trusting spaces in order to do this work. Now, what I would like to do is introduce our discussant, Dr. Francis Liu, who is the Luke Grace Kemp Professor in Cultural Psychiatry Emeritus at the University of California Davis. He's a Distinguished Life Fellow of the American Psychiatric Association. And Dr. Liu has contributed to the areas of cultural psychiatry, including the interface with religion, spirituality, psychiatric education, diversity, inclusion, mental health equity, and psychiatry and film. An interesting note is that Dr. Liu has presented at every APA annual meeting since 1984. He was awarded the APA Special Presidential Accommodation in both 2002 and 2016 for his contributions to cultural psychiatry. And in 2020, he received the APA Distinguished Service Award. In 2008, he was awarded, the Association for Academic Psychiatry awarded him his Lifetime Achievement in Education Award. He was also just recently acknowledged by the American College of Psychiatrists. And it goes on and on. Dr. Francis Liu. Okay. Well, thank you, Dr. Grace Kemp, and thank you to all of our panelists for being here. Thank you very much for your attention. Could someone close the door there? Because I think there was a complaint. We have about a half hour left, and I really want to leave some time for discussion. So I'm just going to reiterate what Constance brought up at the very beginning, is in February of 2021, the ACGME, the Accreditation Council for Graduate Medical Education that accredits all residencies and fellowships of all medical specialties, issued a statement. And I think I just want to go over this so you clearly understand it. They say that the ACGME has common program requirements, meaning requirements that cross residencies and fellowships of all specialties, not just psychiatry, and institutional requirements, because they have accreditation standards for the sponsoring institution of graduate medical education. There are two buckets of standards. And it says that they mandate that we have a professional, equitable, respectful, and civil environment that is free from discrimination sexual and other forms of harassment, mistreatment, abuse, or coercion of students, residents, faculty, and staff. And they preface this by saying that the ACGME has become aware of serious allegations of racial bias and discrimination in medical education. And that's why they're reiterating that. They're already accreditation standards, both at the common program requirement and institutional requirements. This is like the Constitution. So if you're experiencing this in your training program in psychiatry, you really need to look not only within the Department of Psychiatry for a response, because they're under the same requirements, both the common program requirement and the institutional, but also at the GME level, you know, at the GME committee level within the sponsoring institution, because there needs to be a concerted analysis and policies and procedures to deal with these kinds of experiences. This should not be a one-to-one sort of thing between the training director and the trainee. We know that there's a power imbalance on that end. No, there has to be an institutional, organizational response to what's happening here. And the trainee needs to be connected to their own peer group. I have a motto, safety and power in numbers. Safety and power in numbers. This should not be one trainee just dealing with it by themselves or himself, herself, and the training director. That's not going to work. It really isn't. So that's one thing I wanted to make very clear in the discussion here today. Now, another part, I'm going to just breeze through very quickly, some very important changes in the DSM-5TR that came out a year ago in March that reiterates what was said here today in many respects. Now, we know that the DSM-5TR is something that we as psychiatrists use with patients and families, but there are certain concepts here that apply to our relationships as teachers and faculty with the trainees, because that's a relationship as well, and that the stresses that the patients experience are stresses that our trainees and students experience. So again, the DSM-5TR is something like the Constitution. If it's in there, we know that there's some reality there that we need to pay attention to it. So I just want to just point out some very important changes that, again, reinforces and gives you a language about what was talked about here today. First of all, what was entitled cultural issues in the five was changed to cultural and social structural issues together. Now, what are the social structural issues? I'll come to that in a moment. And then in the introduction, section one, and I want to go over section three, the emerging measures and models, where we have a revised outline for cultural formulation. So here, as I said, what's in yellow was added, and there's a new section on impact of racism and discrimination on psychiatric diagnosis, and how this was attended to in the TR. So we have these statements here, and we have this idea of racialization, and that racialized identities are important, because they are strongly associated with systems of discrimination, marginalization, and social exclusion. Remember those things. That's what we've been talking about here today. And that racism exists at different levels. This is described in this section. So it's not just only the personal and interpersonal, but also the systemic and social structural levels, and that racism and discrimination are important social determinants of health. That was the theme of the annual meeting last year, social determinants of mental health. And therefore, clinicians should make an active effort to recognize and address all forms of racism, bias, and so on in our assessment, diagnosis, and treatment. And I would say that that's applicable in our work with our trainees. So these were some of the changes that were made, and there were two committees that worked on this. So we have the term racialized as opposed to racial, and ethno-racial is used, Latinx is used, Caucasian, non-minority are not used. And then in the other conditions that may be a focus of clinical attention, which has now been relabeled the Z codes instead of the V codes, we have why we should pay attention to these conditions or problems is that in the yellow there at the end, if it plays a role in the initiation or exacerbation of a mental disorder, or if it constitutes a problem that should be on the treatment plan. So if our students are experiencing racism or discrimination here, then we need to pay attention to this, because it could cause the problems that was talked about earlier, either non-specific ones, symptomatic ones, or even impacting on mental disorders. But these things here are not mental disorders. Here are the categories of these Z codes, and under each category there are specific ones, and this links into the social determinants of mental health. So if you look in the lower left corner in one, you see one on discrimination or social exclusion, social isolation as one of the social determinants of mental health. And in fact, you have this specific Z code, and again, how many of our trainees, you know, this bullying, teasing, intimidation, how much of that ties in with this experiences of harassment or coercion that our trainees have faced? So this gives you a language that you can use. And then this one, I think, is right on the money, right on the money. Target of perceived adverse discrimination or persecution, broadly defined. It's not just race and ethnicity. That again, I think this is applicable to our work with the trainees. This gives you a language. This is a Z code category in the DSM-5 TR. Now in terms of the outline, you know, there are four fields of interrelated information, and what was added in the TR was treatment team and institution, the cultural features of the relationship between the individual and the clinician. So think about that. What are the cultural features of the relationship between the trainee and the supervisor and the other faculty and the institution? And so looking at cultural identity, I think what Constance brought up, this is what we find in the four, just a couple of references. Added in the five was an explicit mention of additional cultural identity variables. In the TR, it's even more complex, including the very important statement that towards the end there, note which aspects of identity are prioritized by the individual and how they intersect, interact. So intersectionality. Again, in the TR, that concept, very important of intersectionality. For the part C, which is about the cultural stressors and supports, a very important added in the second sentence, the social determinants of the individual's mental health, including, as you can see, exposure to racism, discrimination, systematic institutional stigmatization, or marginalization or exclusion. You see how that aligns with the Z codes? And the outline for cultural formulation says, we need to pay attention to these. Because if we can diagnose these, if we can understand them, how does this impact on our treatment plan or our plan of action to correct this? And then, finally, in this Part D, the cultural features, again, this asks us to look and look at the similarities and differences in the cultural identity of the trainee, let's say, and the supervisor. We need to understand that. Here it says between the individual patient and the clinician. Can you see that this concept, this principle, can also apply to the relationship between the trainee and the supervisor? And we need to understand the complexity here. This was added in the yellow. And then, finally, this is all held over from the five. Experiences of racism and discrimination in the larger society may impede trust in the relationship between the trainee and the supervisor. So I think many of these concepts that we have in our gold standard of the TR can be used in our thinking about our work with our trainees. So we have now about 17 minutes or so for Q&A and discussion. So if you could please come to the mic so you can be recorded here, please. If you care to, you can identify yourself as well. Thank you. Hello. I'm Madeline Hicks from Massachusetts. I very much appreciate getting at the practical aspects of how we can support trainees. My question for Dr. Liu or any member of the panel is, for a resident or trainee who's actually raised a complaint about racism or perceived racism in their training, is there an ACGME avenue for them to have an outside kind of support or monitor for the progress of their complaint? Because as you pointed out, it can't be dealt with within the department only. It needs to go to the higher institution. However, my impression is it's very possible that the medical school may circle the wagons. There are legal aspects involved. Things tend to get quite shut down. The resident can be pathologized for the very responses to the racism. Is there a more neutral party that residents and fellows can go to for outside monitoring as they navigate this process? Very good. Thank you very much for that very perceptive question. Certainly some programs do have an ombudsman person available to facilitate the process of these complaints. I think ACGME also has an external kind of process if there isn't sufficient resolution at the lower levels. But I do think that this is an area of ongoing work that's necessary. Because the documentation that ACGME has received is that this is a problem, not only for psychiatry but for other specialties as well. So we do need to actively put into practice what the ACGME accreditation standards are. They are kind of at the level of the Constitution. And we need to make sure that the trainees, again, think institutionally and working together and utilize those accreditation standards to support their efforts. Let me also, I don't know the answer to that. I appreciate Dr. Liu's response. What I can say, just in the process of preparing this work, I realize that it's important for supervisors also to know the common program requirements and to be familiar with ACGME guidelines. And I have to say, I've been supervising for 30 years and realized that this was not a part of my orientation. And I think that in addition to asking trainees to familiarize themselves, not out of fear, but just to know what resources are available and what ACGME can and cannot do, I think supervisors should also become aware. Yes, this whole issue of faculty development in this area is a crying need. We often know that our trainees are ahead of us in terms of cultural competence and cultural humility. And faculty development is an ongoing issue, yes. Yes, do you have a question? Anybody else? Please come to the mic. Hi, my name is Amanda Calhoun. I'm a fourth year adult and child psychiatry resident at Yale and rising chief. I do a lot of talking about racism in the medical system, racism that affects me and my black colleagues as well as patients. My question, though, is sort of twofold. So I find that amongst supervisors and folks in power, there are some like yourselves that are clearly very interested in protecting us and protecting patients when racist events happen. And I actually have seen a lot of overtly racist events happen clinically and outside of the clinical space. But there are also a lot of supervisors that are either complicit with racism or part of it. And so my question is, as a trainee and as a resident and a rising chief, thinking about how can I best protect trainees to know the lay of the land and who they can trust as supervisors and who they cannot? And so far, I've kind of just been flying by the seat of my pants and getting to know people and taking what I call a temperature check. But I sort of tell them you can't trust everybody. So my question is, what do you do if you're a trainee across the country and you're feeling like the people who are your supervisors are part of the problem? And how do you best protect yourself and your patients when you're seeing racism happen? Well, I think you've encapsulated the problem very eloquently. And it's an ongoing struggle. And I think this needs to be brought up systematically and upfront. This shouldn't come as a surprise. And we get into this individual, oh, this is some problem that this resident is having with this supervisor. It's kind of like localized. No, we need to see this as a systemic issue. And it may affect certain supervisors more than others. Of course, there's variability there. But this is a systemic problem, I would say, in our system here. And it needs to be handled systematically. I mean, you should be having conversations with the training director. I don't know what the status of your search is at this point. But anyway, with your leadership in residency training, you should have ongoing discussions, just making the leadership aware of these things. So how to plan together to mitigate this, and not just simply wait for the incidents to happen. And then there's all this brouhaha, and then he said, she said. And then the residents side with the residents, and the faculty side with the faculty. And you're off into polarization, and people just hating each other. I mean, that's just not going to work. Sorry to monopolize the conversation. Dr. Gupta, do you want to respond? Sure, I think that's a really great question. And it comes up so many times as chief resident and residency as well for two years. And in addition to having a stepwise plan and how to go about addressing such incidents, I think it's also really helpful as residents, you know, when such incidents come up, going back to Pascoe's diagram, the point at which the green bubble came up of strategies. If we can serve as a cohort of residents, as a support system, as, you know, shaping a sense of group identification, if we can collectively stand up and recognize the issues that we're experiencing, that really creates a strong, much stronger way of addressing the concern. And if it doesn't go to the program director, sure, let's go to the department chair. I mean, I'm not sure what the institutional policies are. When do you need to go? Or perhaps if it's not getting addressed, go to human resources. If that's not happening, then maybe it's time to also contact the DIO or the DIO's office in the graduate medical education system. For instance, there should be within systems an anonymous reporting system where such incidents can be reported, where then it triggers a series of pre-established assistance where there's a response. Mount Sinai, for instance, the residency program where we trained, there was an anonymous feedback form. Anyone can log in, report, and then it triggers some sort of an investigation into addressing what happens, and then it comes back to you. And relatedly, it can also be helpful to just keep keeping, we always get told, just keep data. Data is what's needed. The number of times it's happening, each time it's happening, take some time to document it, and then it's painful, it's tedious, but it does drive change. I want to add an experience. I think it's important to also have different supervisors. I think most programs give you a number of supervisors. It's important to be discerning. Just very quickly, I remember for the first time in my life having a patient use a racial slur on an inpatient unit, and I was in psychodynamic supervision with another supervisor who recognized that my affect was off. She provided a space for me to talk about what happened and was very supportive. That was years ago. I didn't even think of reporting it. I think another thing that we need is a mechanism for reporting incidents so that we can also track them. But also years later, I'm a supervisor, and a young black woman is having some difficulty, and it looks like there's bias, and she's able to talk to me, and I'm actually able to help her navigate dealing with this. We also talked about the importance of what we call name dropping, letting people know that we've spoken to people. Because while they may not be concerned about the trainee, they may be concerned about their colleagues being aware of some of these problems. Yes, and again, I would just say that you do need to touch base with chief residents in other residency programs at Yale, and ultimately the GME Committee, because the GME Committee has to respond to this common program requirement, and the institution needs to have policies and procedures to deal with this. Yale really needs it if they don't have it, and I don't mean to single out Yale. Any institution needs to have ways of dealing with this. So it's not just an individual matter. We have, I think, back there and then here. We have about six minutes left. I'm just going to make a really fast comment in response to this. It's not just enough, this is Dolores Malaspina at Mount Sinai. It's not enough to just protect certain trainees from racist supervisors. They have to be educated or removed from a program. Remember that they are interfacing with black and brown patients and other persons who might be minoritized. They are communicating a certain set of values to their white trainees. This is a systemic issue when you have such a supervisor, and programs need to address it when it's brought to their attention, not just avoid them. Thank you. Thank you very much. Yes, okay. So a wonderful discussion this afternoon of such a critical topic for all of us, so that we have excellent clinicians, physicians, psychiatrists, and well caretaking for our population. Marianne Albaugh, I am a part of the Pennsylvania Psychiatric Society and the Pennsylvania Psychiatric Leadership Council. And at the death, murder of George Floyd in the midst of COVID, we came together as a group to figure out how are we, we were talking about COVID, but this was so immensely important. What came of a lot of our work is two things that I'd like to share as additional ideas for people to use, and that is that we initially developed a roundtable that asked residents in a safe environment. So we really worked at developing a protected space where they could speak openly, and then we could gather data so that we could then move forward with what was going to be most important. So we accessed black residents that identified as black to come to this roundtable. They did share very meaningful information, both positive and negative, about what helped them in their environments and in their studies to become physicians and psychiatrists. And the next step of that was we enlisted all the program directors of our institutions of training in Pennsylvania to come to a learning collaborative, and they have. And we've been meeting on a pretty much monthly basis with the exception of a few, you know, March is a match month, and so, you know, they get a bye. But they have come regularly, and we look at four areas, recruitment, retention, and as well as training and education. And the themes are bubbling up, they're open, they begin to trust each other, and they're sharing ideas. And I think it gets to this notion of what was just mentioned, which is institutional changes. And they, as one, perhaps feel squeezed in the middle that they don't have power to change what's up above and the problems below, but as a group, they can share dynamically. So I wanted to just share that, and it may be something that is worthwhile in other places. Thank you. Thank you very much for those articulate solutions to what we've been discussing. Excellent, excellent examples of institutional change. Yes, Dr. Hicks. Another strategy you could use that's quick and formal is if your department doesn't have a DEI committee already, you could begin one with other residents or supportive faculty. That's a leadership position that you've taken. It helps your CV and your advancement, but it also creates a group, and it will draw in faculty who will be supportive, so you can identify who's pro for you, and it gives you an informal kind of area. And also, you can use that to establish an informal kind of culture in your department. It kind of heads up to people who don't care about this, who are at risk of perpetuating, that this is being watched, or there's a concern on the part of residents, so no one's pulled out individually, and you have strength on your side. Okay. We have a comment here from Dr. Frazier here. She's able to... She's joining us over a phone call, and she has some remarks as well. Dr. Frazier? Hi, everyone. I hope you can hear me well. So, thank you so much for that thoughtful response in regards to getting the residents together and trainees and speaking with them. And it sounds really good in theory in locations that have faculty that are on board. In the particular instance that I spoke about at the beginning of the presentation, you're dealing with levels of individuals that are of the same mindset, and engaging in what was proposed in our instance would have made a huge target for us. So, if there's anyone that has any suggestions for situations in that manner for trainees who can't really turn to anyone within their system, personally, what I've been telling others is to make sure you have support outside of your system. Okay. Okay. Any further comments? We're pretty much at time, but I think we have one more comment or question or response to what Dr. Frazier said. Yes. No, it's just a general comment. I've been in situations where we've been asked to fill out surveys about DEI initiatives and stuff like that. And I know from experience that in theory it is anonymized, but when certain instances are very pointed and they become known among the resident body or the faculty body, it's not really that anonymous. And sometimes you're in an institution where, for example, it's a relatively small institution, and so how anonymous is anonymous really when you can use certain demographic markers to immediately identify who said what and or did what. And so to echo Dr. Frazier's point, the issue of sort of getting the residents to band together doesn't necessarily always work. The issue of reporting up the chain also doesn't necessarily always work. And the question is, is there more of a systematized, reliable approach to addressing these issues rather than treating it sort of piecemeal or on a case-by-case basis? I think we all need to go back to our institutions and look and see what is being done at the GME committee level across different residency and fellowship programs, because what I said at the very beginning, again, are common program requirements and institutional program requirements. So these things, policies and procedures, ought to exist outside of the Department of Psychiatry. And if it's not, they're not in compliance with those accreditation standards. And I think the ACGME hopefully will be paying more attention to that when they do site visits. Okay, our time is up. Thank you very much to our presenters here today. Thank you very much.

Racial Bias

Discrimination

Graduate Medical Education

Dr. Constance Dunlap

Trainees' Well-being

ACGME

AAMC

Dr. Sade Frazier

Dr. Drew Gupta

Cultural Humility

Cross-Cultural Training

DSM-5TR

Equity in Training