Okay, we're going to go ahead and get started. Hello and welcome. My name is Dr. Toye Harris, and I'm pleased that you're joining us for today's Striving in Excellence series, Advancing Mental Health in the African American Community by Fostering Inclusion in Workplace and Educational Settings. We thank the American Psychiatric Association for this opportunity to join you today. As a child and adolescent psychiatrist and also Chief Equity, Diversity, and Inclusion Officer for the Memorial Hermann Health System, I'm serving as today's moderator. I'm very pleased to have with us three esteemed colleagues and friends from across the country. We have Dr. David Acosta, who is the Association of American Medical Colleges Chief Diversity and Inclusion Officer. He's also a family medicine physician by training. We also have Dr. Napoleon Higgins, who's also a child and adolescent psychiatrist who owns a private practice where he treats individuals and families across the life cycle. He's also the Executive Director for the Black Psychiatrists of America. And then we also have Dr. Alicia Monroe, who is the Chief Integration Officer at Old Dominion University, and she is also a family medicine physician by training. I was trying to estimate, and collectively we have about 140 to 150 years of experience in medicine and health care, and so we look forward to our dialogue today. So now a little housekeeping before we get started, none of us have any financial disclosures to report. Funding for this series was made possible by a grant from SAMHSA of the United States Department of Health and Human Services, and we want to note that the contents of this webinar or those of us speaking do not necessarily represent or reflect the official views or endorsement by the U.S. government or SAMHSA. Today's webinar has been designated as one continuing medical education credit, and credit for participating in today's webinar will be available for up to 60 days, and it can be claimed following the webinar. We want you to note that a PDF of today's slides will be available in the chat. Captioning for today's presentation is available. And we certainly want you to please feel free to submit your questions throughout the presentation by typing them into the question area found in the attendee control panel. We are dedicating approximately 20 minutes at the end of the presentations for questions and answers. The objectives for today's session are on the screen. We certainly acknowledge that across populations in our nation and in the world, we are facing a mental health crisis. During today's session, we will take a closer look at African Americans and the connection between inclusion, mental health, and well-being, looking at barriers for achieving belonging and inclusion at work and in clinical practice, and also identifying solutions and strategies as well as promising practices in these spaces. To set the stage for our session, we wanted to share that although the rates of mental illness for African Americans are similar to those in the general population, there are differences with respect to quality of outcomes and access to services. Mental health is of international concern and has been included in the United Nations Sustainable Developmental Goals. Lund and colleagues you see here on the screen developed a conceptual framework for the social determinants of mental health or non-medical drivers of mental health that are aligned with these goals. The article goes into further detail connecting the demographic, economic, neighborhood, environmental events, and social and cultural domains with these goals. They hypothesize pathways and potential interventions for mental health outcomes. Keep these in mind as we go through the session. We will primarily be discussing demographic, environmental, and social and cultural domains today. Next, it is my pleasure to turn it over to Dr. Alicia Monroe, who will now move further into the academic space and provide tips for inclusion among higher education and health profession schools in order to optimize workplace inclusion. Dr. Monroe? Thank you so much, Dr. Harris. I really appreciate the opportunity to be with all of you this afternoon. Just as Dr. Harris has already indicated, as we focus in on academia, I'm going to provide some snapshots of data related to college students, medical students, and I won't present much data on residents and fellows who are training to be physicians, but I will provide some promising strategies that really do incorporate inclusion that have been found to really respond to some of those factors that contribute to distress and or mental well-being among students. So, as we know, mental health globally is a crisis, and certainly among college students, it's no different. The National Center on Education Statistics reported that of the almost 20 million college students enrolled in 2019, a large majority reported concerns related to depression, anxiety, suicidal ideation, and substance abuse. And the National Institute of Mental Health has indicated that suicide is now the leading cause of death among college students. And certainly among students at risk, research shows that nontraditional students, Black men, people with nontraditional gender identities, and women tend to be more susceptible to anxiety and depression. Next slide, please. So, one of the tools that some colleges and universities are utilizing, and frankly, the institution where I currently reside, uses this national data. Many of you may be very familiar with the Healthy Minds Study. It's an online study of the mental health of students enrolled in post-secondary education. This includes both community colleges as well as four-year colleges. In addition, it is data that is provided from participating institutions. So, an institution has to choose to participate, and then the students can provide a random sample of a subset of its student body, or frankly, the whole student body. And it tends to include students that are both graduate students as well as undergraduate students. And as you can see from this data, in the most recent report that I was able to obtain from 22-23, over 76,000 students were included in this self-report study. It's important to note that the screening tools that are used in this online study are all validated instruments. So, lifetime diagnoses of mental health disorders was at 47 percent, so almost half of the students enrolled in college do indicate that they've had a lifetime diagnosis. I think it's important, I'm not going to read the data on this slide, I'm just going to highlight a few of the numbers. Any depression using the PHQ-9, 44 percent. Certainly major depression, almost a quarter, at 23 percent. Anxiety disorder, 37 percent. As we go down to, as we skip down, you can see those that have been on psychiatric medication, almost a third. And as we look at those who have been engaged in therapy or counseling in the past year, about 37 percent. When they took a look at students that have been involved in either therapy, medication, or had completed screens for depression or anxiety, there were about 60 percent of them that were actually engaged in, 60 percent of the students. What many of the students reported, however, is that there was a question on the exam with regard to stigma. And they were asked something to the effect that, would I think differently about someone, someone else, if I knew that they had received a diagnosis or care? Almost 40 percent of the students reported that they would. So there was a perception that there was a public stigma about other people. But when asked a similar question about their own healthcare seeking, it was a lower number at 6 percent. I think it's important as we think about this data, validated measures are used, prevalence data is what's provided. And it really looks at not only mental health issues, but also attitudes, outcomes, help seeking behavior, and perceived stigma, as we've indicated. What's useful about this study and the way in which it's used at my current institution is that our institution participates on an annual basis, and then our director of mental health benchmarks the data of our students with this nationally representative sample. And what she reported when she came to our board meeting, she indicated that there were some where there are differences, greater need, we serve a large first-generation population. And there indeed was significant elevation of prevalence of some of the disorders that are recorded here in the Healthy Minds Study. And she uses this data to build her case for increasing resources and diversifying her care. Next slide, please. So some of the strategies that are being utilized nationwide is that there are many institutions that when they've taken a fresh look, because as we all know, during COVID-19, there was an escalation nationally and globally of mental health distress and depression and anxiety. And college campuses were not exempt. In addition, the increase in demand for counseling services that really mushroomed during COVID, frankly, hasn't really declined. There's still a very high demand for mental health care on college campuses. But what's been found is that even when services are made available, students aren't always aware of where they are when they need them. So in one study, when they looked at how aware their students were of the availability of crisis care, either for the student personally to seek care, or when students had a classmate or a peer who was in distress, they didn't know where to go. In this particular study, I'm showing you the demographics of the students who frankly didn't know how to access care. 70% of the white students, 62% of the black, and 61% of the community in general. What they found is their strategies included partnerships with student organizations and on some college campuses, that includes Greek organizations, and including African American sororities and fraternities, mental health and peer ambassadors, wellness groups. Because when I had an opportunity to interview some directors of college mental health, what they noticed is there are many students who are seeking counseling, mental health services, but frankly, they may or may not meet diagnostic criteria, but they're in distress. So often they may be concerned about academic issues, there may be general wellness issues, there may be family concerns, but their personal need for in-depth counseling may not be there. So many colleges and institutions are really fostering partnerships with student groups, African American serving organizations as well, in order to lower barriers and increase information penetration. Institutions are also removing financial and geographic barriers. Many institutions sponsor and provide mental health services that are free. In addition, they offer 24-7 tele-counseling services or video counseling services. Some institutions are also, because of the role of discrimination, microaggressions, and imposter syndrome, the contributions of those things to the well-being of many students of color, particularly African American students, many colleges and universities are creating inclusive, safe, or brave spaces where students can discuss interpersonal challenges or family challenges, financial challenges, violence, or just stress, academic stress. Colleges and universities, one of their inclusive strategies is really to normalize help-seeking, establishing affinity groups, drop-in groups, reading groups. Wellness programming has been emerging on college campuses in general, and inclusive recruitment of diverse providers, because we all are aware that culturally competent services are important, culturally relevant approaches, and often students feel more comfortable being cared for by providers that they can identify with. Next slide. So again, these are, I'm sorry, one back, it went to, okay, but same-day scheduling, open access scheduling, a range of needs, on-demand follow-up, creating a culture of well-being, and also training faculty as first responders for students who are in mental health distress, and also specific counseling at some institutions related to racism and discrimination consultation. Next slide. So now I'm going to transition to medical students, and certainly many of you are familiar with data related to mental health and mental distress, certainly the suicide rates among physicians, oh, okay, I was just looking, I just saw a note, there's a question. I just wanted to provide a little bit of data from the literature specifically as it relates to medical students' mental health. And one study that was a meta-analysis that pulled data from a number of studies that noted a range of depression from about 9% to over, almost 56%, found that a pooled prevalence was about a quarter of students, about 27% of students. And depressive symptom prevalence was a little bit less than that, wherein another study, clinical prevalence, was about 22%. And many medical students screening positive for depression who actually sought psychiatric treatment was really only about 16%. Suicidal ideation, about 11%, distress in general, over 50%, burnout, over 50%, anxiety, over a third of students. And certainly among medical students and medical professionals in general, there are lots of barriers to seeking mental health care. And in one study, they talked about restrictive sick leave, absence policies, clinical schedules, stigma, medical culture, survival of the fittest mindsets, as well as confidentiality concerns and licensure concerns. Next slide, please. So these are some promising strategies that really do help to foster inclusion within the medical student or medical education space or undergraduate medical education space. And one institution actually instituted universal brief mental health screenings at the time of admission. They have an early detection program, and they seek really to overcome barriers in care seeking by screening everybody, by offering a visit. This is at the Keck Medical School, and they call it a Keck check. But they normalize visiting a psychologist as a first-year medical student, even before classes begin. So 70% of the students attended a Keck check. And of those 70%, about 50% were referred for a mental health follow-up, 10% to occupational therapy, and about 8% to academic support. So that was a promising strategy from one of our University of California schools, from the Keck School of Medicine, not a University of California school. Sorry about that. So wellness programs in U.S. and Canadian medical schools are also a strategy that's showing promise and certainly doing a lot of preventive programming. About 62% of schools, this was a survey done of U.S. accredited and U.S. and Canadian accredited, LCME accredited medical schools. And what they indicated is when they surveyed all the medical schools, they found that about 62% of the school survey of the respondents indicated that they provide some preventive program, but the majority of their program, or a greater percentage of their program, was actually reactive when something bad happened. About half do some cultural programming, and some, about 56%, provide less focused on structure, but just individual sort of ad hoc services. Some studies have also documented that the curriculum in medical school is associated with stress. So changes in curriculum has been a really big move, and I'm sure many of you who are currently in medical schools have noticed that the LCME has leaned in on a 40-hour work week, number of contact hours, time off from students, unscheduled time, emphasize learning communities, electives, changing grading patterns, moving from grades in years one and two to pass fail, has been associated with a reduction in anxiety and depression. In addition, teaching mindfulness and providing courses even in training in mindfulness is frankly some of the options that are made available at some of our medical schools. And last but not least, there's an interesting initiative that was actually developed at the University of Chicago. And it was specifically designed to reduce stigma. And there are three elements, they have stories, they have faculty and peers talk about failure, they normalized failure and an increased counseling utilization from 8% significantly, from 8% 32 or 389 to 75 students, about 12 to 15%. So they had a significant increase in the number of students who were willing to access care. Next slide. And so this is really in the trainee space where this was about residents. They had a confidential opt-out program where all residents were offered care and they could confidentially opt out if they didn't want it. One institution, Indiana University offers comprehensive mental health services. And as you can see, 38% of their graduating medical students and 27% of their graduating residents and fellows, about a quarter of their residents and fellows actually use their services. And last but not least, because financial pressures are a big concern and create issues related to mental health. And some residency programs have actually implemented financial wellness programs and assisted residents in gaining financial information on how to pay down high debt. Next slide. Now I'd like to turn it over to my colleague, Dr. Higgins. Thank you so much for that conversation about our students and how they're doing. And so we're going to try to add on that if we are able regarding the issue of mental health wellness and in our community. And I'll be speaking more so towards the black community, then seeing that I come from that community. But you'll find that these concepts and information is open to the point of most will be able to identify with the issues that go on with being unique or different. Next slide. So I would say that, as a point of disclosure, I have been raised, grew up, went to school all in the black community. My first time actually outside the black community at a large portion was when I went to residency. So black elementary school, middle school, high school, college, medical school. And then my first time outside of my immediate culture would have been when I was a residency. And so what you find is that often you can feel different inside the workplace because you have a different background. You're coming into a room with other people with other backgrounds of the majority culture being white, and you find the need to show that you deserve to be there. And some of that comes from imposter syndrome or stereotypes that you've heard about black people, the issue of you are a part of affirmative action that people bring you in in order to show that we brought someone black in who did not deserve to be there. And so because of these stereotypes and these cultures and these things that we see on a regular basis, you find the need to exceed performance. Also wanting to make sure that you communicate effectively, which then causes you to have difficulty with being your true self around others because your dialect of American English can be different. How you put subject word agreements together, how you speak the language, realizing that none of us are actually speaking English like the people in England. But if you sound like a black person speaking English with the dialect of being from the South or deep South or Houston, Texas urban area, then people see that part of English and may be judging you accordingly because you don't sound like them. And so you find this need to have to follow protocols and standard procedures to the point where you'd want to make sure that you're not making any mistakes. And so by doing this, it's almost like you're walking on a tight rope or I would say even walking on a sidewalk. Well, walking down a sidewalk is not difficult, but the fact is that if you elevate that sidewalk and you make it 200 feet in the air, now all of a sudden you're walking this tight rope, it's a sidewalk. You know how to walk a sidewalk, but the fact is that you're now coming from a different direction. So it's where this level of anxiety is going on because you find yourself being different. And so you find this level of biculturality, if I can use that as a term, but by being bicultural, you're having to walk in the culture of a culture that's not yours versus a culture that you're actually from and that you're needing to have work in community groups, go to your church. You're listening to music that other people don't listen to. You're watching television shows that your peers may not be familiar with. And this can cause difficulty because you can find yourself being different. Next slide. So by being different, it creates this atmosphere of tension that can occur inside the workplace, feeling unstable in that you don't feel this level of comfort inside of the room. People talk about things and know things that you don't know. And then also you have information that they don't know. I say one of the largest jokes that I can remember is the issue of the television show, Friends. I never really got, I'm not saying it was a bad show, but I never really got into it like my peers did. And the main reason that was because Friends came on at the same time as a television show, Martin. Now, if I had the choice between watching Friends and Martin, I always chose Martin. But the problem about watching Martin is that no one else watched that show and everybody else would have conversations about Friends. So what I would do is watch Friends or I watch Martin and take Friends. So I at least knew what my peers were talking about because they would be so excited about what was gonna happen on the next episode. So you're fighting between this cultural stereotypes, you're fighting off accents, you're having difficulty finding mentors because once you elevate to a certain level, many times as persons of being different, you may not have other mentors who are in that area. Like you're the only one and you can feel alone. This will cause you to be feel pessimistic on where you belong, how do you advance inside these organizations and cause overall disillusionment in the entire system. Next slide. So I did wanna cover a bit about microaggressions. And the fact is that these, how do you say? I'll say it this way. So the person who created the term microaggressions was Dr. Chester Pierce. Dr. Chester Pierce passed away in 2016 at I believe the age of 83. He created the term in 1970. And the fact is that the term became more popular after his death and towards the end of his career than it ever was when he actually said it or wrote it down. And he wrote it in a journal called The Heavy, The Black 70s. And then there was a section called The Black Power Revolt. And how he described it was based upon where he was in life and that you have to realize you have the lynching and the martyrdoms of Malcolm X, Medgar Evers, Martin Luther King, Robert Kennedy, who was his classmate at Harvard. And he talked about how some of us are being killed immediately and being lynched is the term that he used. And some of us are being slowly lynched over the rest of our lives. And that you're dealing with aggressive behaviors that are called microaggressions because in themselves, they don't seem like anything occurred. So someone could immediately explain away their decision-making of why they said or what they did. But the fact is that as a person, as a black person going through life, these little slights cut at you throughout your entire lives. So they're commonplace daily slights that may not be acknowledged in the room, but you can find that persons can dismiss whatever you actually said. And it puts you in an inferior dependent helpless role that controls space and time, your energy, your mobility. And overall, it seems ambiguous, but you know what's occurring throughout your life. And so it's a difficult term to understand, especially if you haven't seen it actually occur. And I'm seeing that a lot of people are using macroaggressions as microaggressions when the fact is that microaggressions is something different. And I find that people are actually changing the term from actually when he originally said it. So that can be well-meaning faux pas versus overt racial aggression. And well-meaning faux pas is that, one, I'm not from your community, I have blind spots, I offended you in that it was really not my intent. You know, some of that can just be based upon ignorance. And it's not, I would say this, there is not room. I mean, even though it's an excuse and a person may really not know, but this is always a teaching lesson and teaching time to let the person know. And then you have overt racial aggression that occurs. You know, I just walked at the hotel restaurant last night, walked down, sat down. And next thing you know, it was mostly white rooms, sat down at the table because it was a bar area. Next thing you know, I started rolling. I'm like, I don't even know these people and they don't know me, but I just so happened to be in a hotel in this city, sat down. I guess I was in the wrong place. I don't know what happened. But the fact is that that ambiguity happens. And that is what considered to be microaggressions. Next slide. Imposter syndrome is something that we often talk about in which people doubt their skill level despite them belonging. They feel like they don't belong. But I would say that more than just experiencing or thinking that you are a fraud and that you don't belong, I think a lot of this pattern also includes the person's own bias, where they can't see themselves nor their peers in their position because they don't have a reference or a framework of being in that elevated position. And we all require a bit of imposter syndrome in order to believe that we can achieve things that we've never seen before. But I think also that's an issue of self doubt and not believing in yourself and believing in others around you that you were just placed on a pedestal. I remember a joke that was said that, if you ever see a turtle on a fence post, best believe he did not put himself there as impressive as that turtle may look. And sometimes we can feel like we're on this fence post, but I tell people, no, you climbed up that ladder, you belong there. And that should not just be one of you, that should be tens of you who are there. But it's only you at this point. And the point is to try to make a better way for others and continue to believe in yourself. Next slide. Code switching. This is something that African-American students or people who are different often do in order to fit in. So some would say code switching, is that selling out or is that a coping skill? Well, the fact is that, one, I was not interested in friends, but I can tell you this, I was not gonna walk into a group of my peers, there's 30 of them in the room, looking for the opening, the first episode of the next season and say, no, I don't like friends. So they were like, yeah, hey, did you hear about such and such and such? And I'm like, yeah, sure. I wonder how that's gonna work out. And I'm like, what are they talking about? All right. But the point is you're trying to fit in to a space that doesn't fit you. And the question is, is it justifiable or not? I remember I read the book, How to Win Friends and Influence People. And I did this while I was in residency and I followed some of the words of thinking that they said. And the next thing you know, I got this level of how mature I was and how much I had grown. And I was able to do that within the organization, within the residency. And it wasn't that people were forcing me to do that. The point is, let me get through this in the best way possible and find out a way to be able to fit in the space. Not that I have to change myself, but the fact is that sometimes the full me may not be acceptable, especially when you're the unique one who is different. That may not be accepting of who you are. So the pressures of being black physicians, someone was asking me a question and I said, well, only about 2% of psychiatrists are black. When you're looking at training and going through training, that means that you're running, that at a certain point in your education, you're not seeing people who are like yourself. You're often being the anomaly and being very different. I had a friend of mine, I was thinking of medical school, who was from Kenya. And he said, how can I be from Kenya and make it to this level? And then black people who are from this country are not making it to this level. And then a friend of mine told him, he said, you being from Kenya is as far away from becoming a medical doctor as me being from Miami-Dade County out of the projects. I'm just as far away from being a medical doctor in my own country as you are as being a medical doctor from your country. So the fact is that even though you can grow up in the US, you can be an anomaly from where you come from, you can feel isolated and find the need for continued success because not only did you go to medical school, but your whole church went to medical school, your own neighborhood went to medical school. And if I said it in a way that people would say it where I'm from, your own spot where you'd be from, all your peoples went. Now, when I say that inside of the medical school or residency, I can be seen as very different. And that can cause you to become a target. So these pressures of continued success, this pressures of actually performing in a community that you're not from can cause everyone to look at you differently because I'm no longer from the community or surrounded by the community where I'm from, but I have to go back to that community and I'm sitting in a community where I don't feel comfortable because the people do not have a similar culture or background as myself. Next slide. So there's loneliness at the top. The thing is that you're trying to find guidance, finding those next steps in that career path. I recommend to all black docs, every black person who's in those anomaly type situations or all people in those anomaly situations, you have to find your community. So within that community, I had another community of people that I engaged with coming with the church or because it was close to Houston, I did know people who lived in Galveston that I hung out with from childhood. So I needed to find that community inside of my community. And the funny thing is that much of the people that I worked with really didn't have much understanding of what else I did outside of that, which was really a lot of good community work, you know, but it was not something that I necessarily shared. Not that it wasn't, no one wanted to hear it. I just didn't find the need to share the other community work that I was doing outside of my residence. Next slide. So we have to look at the need for, at an institutional level, cultural humility, understanding that we don't understand all people. I am a black heterosexual male from the South, cisgendered, who is married. I have a ton of blind spots from spots and things that I do not know, all right? So I have to acknowledge that I do not know everybody's situation, but also with that, the more diverse, the more people that I meet, the better I become at understanding people. And we need to run into that, all right? We want to be amongst people that we don't know or see things differently so that we can clearly understand. Implicit bias training, I think, can help and let us know that we all have blind spots. Everybody has a blind spot, a blind, multiple blind spots. And the only way you can find your blind spot is that you actually literally have to turn your head and look to the side to see if there's another car there because the fact is that some people don't drive cars. Some people may be on a motorcycle. Some people may be on a bicycle. Whatever it may be, you have to turn left and turn right to find where you need to be at. Training is going to be very important. Hopefully, this is part of it. STEM-based enrichment programs to increase the diversity of the workforce. You can try to increase the amount of black psychiatrists in, you know, from your recruitment and residency, but you can't do that from your recruitment and residency, but you're only recruiting a small amount of people and everybody wants the top talent. Actually, what you have to do is change the system that is bringing people up as we discussed with the last talk with Dr. Monroe. The curriculum and vignettes need to be more well-rounded, making sure that we're touching other parts of the communities that may not even be available to us in our current communities, and making sure that we go into that underserved, into those underserved communities to understand who these people are, how they function. And what is most important is what is important to them, not what do you feel is important to them, but what do they feel is important to them in your engagement. Next slide. So on an individual level, you need to have mentors and sponsors and guidance. You need to seek out that community and make it a point. This is a person from East Coast LGBTQ plus community, and you're in Houston, all right? If you have somebody of similar background and knowledge of that person on your staff, make sure to connect them. That is an important thing to do so that people can feel comfortable and safe, have someone to speak to who's had their past background or knowledge or the best they could. And if it's not in your community, what I don't see is where you reach out to the outer community. So if you don't have it at your institution, maybe there's a doctor on staff in your, either on staff who's not a part of the training or someone in the community who actually can be helpful for guidance. Show your vulnerability that you don't know. And we need to ask for help from an individual level and the institutional level. And it's important to balance your life. As much as I loved residency, I also loved walking out the building to get into whatever else was going on in my life. And we have to make sure that we don't make medicine all encompassing. There are other needs that a medical resident and medical student has well outside of the training institution. Next slide. I wanna thank you all for your time and attention. Hopefully I didn't go too long. Thank you, Dr. Higgins. At this time, we're going to turn it over to Dr. Kosta. Thank you, Dr. Harris. And again, I'm so inspired by the information and the wonderful messaging from Dr. Higgins and from Dr. Monroe prior to this. And so my approach, I'm going to end this session with, you know, here's a particular strategy to really look at the institutions. I'm going to concentrate mostly on that. I'm not an individual because I think Dr. Higgins covered some of the other things extremely well as well, too. So as has been discussed, again, there's been a significant rise in mental health issues, depersonalization, isolation, and burnout that's occurring across all of our health care providers, even our students and our trainees, as Dr. Monroe alluded to as well. And as the National Academy of Medicine's Action Collaborative on Wellness and Resilience has been identified, this is partly due, majority of part is due to the institutional environment. And that's what I want to concentrate on. So at the AAMC, we really focused on this even prior to the NAM report. And we created these foundational principles of inclusion excellence, which is another validated tool that's out there that measures the lived experiences of staff, students, faculty, residents, and fellows, as well as administration as well about their learning and workplace environment that they are exposed to on a daily basis. And in turn, if you think about this, this is also the environment that their patients are also exposed to as well. If we're going to promote a healing environment, for both our learners, our staff with mental health issues, this does require a workplace and a learning environment that intentionally practices conscious inclusion and invests in being equity centered. And I'll explain what that means in just a second. So the tool itself really can work at many different levels. It can work at the institutional level, it can work at the department level, the clinic level, and other facility levels. And really to identify those areas that are in the environment that may need further work to achieve an environment that is safe, one that is accessible, trustworthy, inclusive, and equitable. And all this work really starts with creating a system that, again, everybody can bind to and really understand it. Next slide. So essentially, the foundation principles of inclusion excellence were really developed to help identify and describe what an inclusive and equitable environment can look like in academic health centers and facilities as well that are associated with them. And they were really developed in order to answer probably the most frequent question that we got at the AAMC when the concepts of diversity and inclusion were first introduced to academic medicine known as Diversity 3.0. The most common questions were, well, how do we know what inclusion looks like in our environment? How will we know when we're there? What does success really look like? And so the efforts from these foundational principles, there are nine altogether, they were developed in order to try to paint that vision for folks to really understand what does it look like once you're there. And here's just a summary of those nine particular principles that I'll go over really briefly with you. So, and I'll start with the second bullet, and that is in an institution that practices conscious inclusion and equity-centeredness, well, we find that there's a sense of belonging from everybody within that institution where belonging is valued and where they feel that everybody feels that they're a part of the fundamental fabric of the institution. And there also have the opportunities to feel that they really can reach their full potential. And this is not just the learners and not just our early faculty, but it's everybody within that institution, including our staff that is so important for us as well. And this can occur in that institution because authenticity and intersectionality are valued and encouraged. That is authenticity, I can truly behave to who I truly am, meaning that we all have multiple identities. It's the intersection of those identities that really helped me make decisions, create that worldview, the perspectives I have that I bring to the table. Because when we start thinking about code switching, identity interference, we choose, we decide to choose as a minority what we're gonna bring to that table because we don't wanna be stereotyped or assumptions be made on that. And so authenticity and intersection can occur and can be evaluated when there's a civil and a safe learning and workplace environments that becomes the norm. And these are spaces that encourage and allow voices to be shared openly without the fear of being judged or without the fear of retaliation. And as Dr. Monroe alluded to, fostering that safe, brave space is really critical to addressing mental health and especially with our staff, with our learners as well in creating a culture of trustworthiness where people can really bring their true selves to the table. At the same time, there's also a dignity consciousness that is practiced by the institution internally by all. And that means that there's an understanding that one's dignity is respected and no one's dignity is violated. This means that everyone feels validated for who they are and for what they bring to the table. And they are valued and respected for their contributions as they bring to the table. Next slide, please. An equity-minded mindset is also adopted by the institution, and that is the institution intentionally invests in their people. They invest in their people equitably across the board. It's just not targeted to certain groups that they feel that deserve it. But this investment is really focused on people's assets and their potential, what they bring to the table and not the old paradigm in which they concentrate more on their deficits. It's that whole paradigm that we have sometimes in academia, publish or perish, let's weed people out, sink or swim attitude. In addition, in an environment that is equity-centered, there is intentional look at the exclusionary practices that may be embedded inside policies, procedures, governments, operations, and even our traditions and the cultural norms that an institution adopts. These are identified, they're critically deconstructed, dismantled, and they're certainly addressed. This follows up with this idea of taking a systems-based thinking approach to this to create solutions that will ultimately mitigate some of the challenges that certain students or staff and faculty face that Dr. Hickens talked about, microaggressions, cultural stereotypes, racial biases, discrimination, isolation, and marginalization. And so once these practices are deconstructed and we find out these solutions, what's really critical about this, it's really to transform the institution away from the status quo that has sustained the inequities and challenges that the staff that we care about experience. So the institution is also one that invests in opportunities for professional and career development for everybody and are provided equitably across the board in order to help everybody achieve their full potential. Next slide, please. And then lastly, the important piece about this too is that a system of accountability really keeps this in check, that everybody in the institution really accepts the responsibility for ensuring inclusion excellence and are held accountable. And in some institutions that have been successful with this, possibly staff are rewarded for their work and their innovation towards inclusion excellence. So the nine principles provide really more detailed description, and I've made those available to you for the detail because we just don't have time to go through every one of those right now. I ask you to pay attention to those and see as you read through those principles, how does your lived experience inside your institution, how does it match it and how does it not match it in order to be equity-centered and approach inclusion excellence? Next slide, please. So this is my last slide, and this really is bringing the principles together and what it looks like. We not only developed principles and they're demonstrated on the left-hand side of the screen, there's a few of them. Basically, as we mentioned, the components of the nine principles include that DEI is a strategic imperative, they address authenticity and intersectionality, sense of belonging, the importance about how differences can be leveraged along with talent optimization, the equitable access to opportunity, effective communication, the practice of conscious inclusion, community engagement, and lastly, accountability as we spoke about as well. There's been a toolkit we used to just do workshops on this, but we realized in order to disseminate this further, this particular toolkit, and you'll see the components of that toolkit on the right side of the screen, really the components not only include in the toolkit these principles, but also an assessment. It's a nine-question assessment that only takes about 10 to 15 minutes to fill out, but it gives you an idea about where you are in that moment in time about people's lived experience within the institution. It has a scorecard as well. It really kind of find out where you are on the continuum. It also involves bringing, there's about 19, 20 pages of effective practices that have been identified and a resource that people can use as well. So this tool really measures that snapshot in time and how people experience their learning in a workplace environment. And again, the scorecard identifies where the institution may be on this continuum to achieve excellence as it relates to the culture and the climate of that institution. And once that assessment has been made and completed, attention is then drawn on how to improve that environment as staff collectively work on developing strategic action plans to address those areas that have been identified that may need further work. Dr. Monroe and Dr. Higgins did an excellent job in providing what some of those programs, initiatives, and approaches may be, and we won't go through those now. So the tool can also be repeated after these actions have been put in place. Essentially, once these action plans have been implemented, it's just a means of really measuring the trends on the progress that you've made. The tool itself can be accessed on our AAMC website, or you can just simply Google AAMC, F-P-I-E, which stands for the Foundation for Inclusive and Action-Based Education. With that, Dr. Harris, I will stop and move into the question and answer phase. Yes, I want to thank the speakers for sharing their insights. At this time, we're going to transition into the question and answer period. We have some that have sent some questions, and I see that some responses have been added here in the chat. I did want to, just for sake of discussion, Dr. Monroe, could you comment on the depression surveys for medical students and how those have been implemented at your institution or at others that you might be aware of? So, thank you. I am not personally aware of surveys done at medical schools, but I am aware of the use of screening instruments here at the university where I am currently. Their student health center actually uses a PHQ-9, and sometimes they use the PHQ-2. But one of the things that they have observed is that there is a high prevalence of distress, and their desire is to manage a visit, make sure that students get appropriately referred. So, occasionally, students will complete questionnaires and not show up for a visit. So, they're automatically referred to for counseling and to the student counseling center. But those are the instruments that I'm aware of in use. In medical schools, I'm not sure if the providers are using the PHQ-2 or the 9, but those certainly are in use in many institutional settings. Thank you for the question. Thank you. I'll throw this out to all of the panelists, actually. So, how someone listening, how can they get involved to be a part of the solution for these institutional structural initiatives that have been discussed? If you could mention, you know, there are people listening, and we know that this is being recorded. Others might want to learn how they can become a part of the solution. So, I'll open that up to anyone. We'll start with Dr. Costa, and then I'll ask each of you to share your guidance on that. Sure. You know, I think one of the biggest things that my organization does, the AAMC, is we're a convener. We're a convener of people who do this work, and we've already identified some of the content experts that are out there. I would love to hear from you because, again, the reality of the network, we need to build that network of those experts that basically help us along this way. And more importantly, we can even cite people that have been doing this work for some time that really have shown effective practices in that. So, again, I think taking a look at our site and what we have available is we've done a lot of work. One of our strategic plans really focuses solely on, think about strategic plan three, for example, really focuses solely on the institutional culture and climate and what can we do to provide resources, the data that is there that was shared today as well, and also some tools that we've developed, not only just assessment tools. We have three different assessment tools that build upon each other. I just mentioned one at the very beginning, but there's other ones that you can take even a deeper dive when you start identifying these, and those are available to really everybody, not just our members as well, but also reading resources, also things such as what Dr. Higgins alluded to is that a lot of this to begin with to get involved with that really requires that self-reflection about essentially how do I personally contribute to this? How do I personally deal with this when I encounter, whether it's harassment, mistreatment, whether I'm part of what makes people be marginalized and oppressed in my particular institution. And there's a way to also do some group reflection as well that how do we collectively do the same? And then what can we do about it as we start to create action plans for that? How do we have, we even have tools to basically, how do you have these crucial conversations and vulnerable areas that people sometimes avoid because they don't wanna be called out essentially, but there are ways to do that through restorative justice dialoguing, for example, crucial conversations, those sorts of pieces. Thank you. Dr. Higgins, Black Psychiatrists of America, how can people get engaged and learn more? Hey, come on out to BPA. You know, Black Psychiatrists of America, we're very, you know, obviously our focus is on the black community and mental health. And what you find is really by coming, being a part of our group, I call it respite care, you know, where you can culturally feel yourself to be comfortable in your own space and in your own skin, where people culturally will have a similar background, but also I believe that we're very accepting of whoever walks in the door. So I would say that's a part of it. Then also outside of institutions, making sure that you not lose yourself in your pursuit of your academic space or your pursuit of your title. So often we allow the title to define who we are. When you need to make sure that even in medical school and residency, you're still growing outside of medicine itself. So be careful of allowing the MD or whatever you're trying to do, PhD or master's, define who you are and making sure that you're growing even outside of that. Thank you. Dr. Monroe. So thank you. I think the comments of Drs. Acosta and Higgins have really been so thoughtful, really speaking to both personal, organizational, institutional, and certainly the ways in which the association can make a great impact. One of the things I think I'll focus on personally is I think we have an opportunity, and I think Dr. Higgins said it well, for us to really reflect on why do we wanna get involved? Is mental health in our family, mental illness in our family? Have we experienced distress? What's motivating us? And is there a need within us to help? Or is it an opportunity for us to really make sure that if we need to talk to somebody, we talk to somebody so we actually get healthy and get healed? So that's one thing, just checking on our own mental health and wellness. The other is I think looking at small spheres of influence, whether you are in an organization, Dr. Higgins spoke about the Black Psychiatrists of America, certainly Dr. Acosta is a leader at the Association of American Medical Colleges, but you may have a social group, you may have a community group, you may have an association with groups of individuals, and how can you operate in those spaces where you, first of all, you notice how people are doing, you ask them authentically to let you know, and then you try to de-stigmatize and normalize. Help seeking, so how can we encourage people to seek help? How can we make sure that if you're a physician and you're a part of an organization and there's a health fair, how can we provide information? How can we be an information sharer? How can we not normalize microaggressions, but to acknowledge that they're common and that often it helps if people can process them? So hanging on to pain is not a good thing, but processing it and being able to move through it is helpful, but I think it's important for us to, A, realize we're not immune, two, look for it in our own families and in our own spheres of influence, and three, try to do what we can to encourage those who may benefit from care to seek care. Thank you. I wanna pause and just read a quote from Desmond Tutu. Hope is being able to see that there is light despite all of the darkness. So I wanna thank the colleagues today for shedding light, giving personal reflections, as well as promising practices on how we can advance the mental health within the African-American community. This is the QR code that you can utilize to get your CME credit, and we hope that you are taking something away from the webinar, and we certainly encourage you to reach out to us as we continue to move forward. Have a good rest of the afternoon. Thank you.

Dr. Harris

Dr. Acosta

Dr. Higgins

Dr. Monroe

mental health

African American community

inclusion

diversity

cultural humility