Hi, everyone. We are so honored and privileged to be with you here this morning to discuss the topic of challenging racial violence in mental health. I am Dr. Karina Espana. I am a Child and Adolescent Psychiatry Fellow at UCLA and an APA SAMHSA Minority Fellow. I'm Dr. David Nagarkadigud. I'm an Assistant Professor at Oregon Health and Science University. I'm an Outpatient Psychiatrist with a focus in Primary Care Consultation. And I'm Dr. Maitland McKinley. I am the current Medical Director for Little Rock Air Force Base Mental Health, and I am a Psychiatrist with the Air Force. So funding for this initiative was made possible by a grant from SAMHSA, and so the expressed in written conference materials or publications, and by speakers and moderators, are not necessarily reflected of the official policies of Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. government. And just so everyone knows, you can get a CME for this. You can get one AMA PRA Category one credit. Here is some visuals to help you see how to download handouts, as well as some visuals on how you will be participating in Q&A at the end of our session today. We have no financial conflicts of interest to disclose. And we'll begin with just an introduction. So we're going to be embarking on sort of a vulnerable journey together over the next hour, and as we start, I want us to take a moment of pause, and so a pause to recognize that racism is a common denominator of violence in our country, and that the foundation of racism is white supremacy. And we identify this as indisputable, and that's going to serve as sort of a shared platform for what we envision can be done in our hour together today, as we consider healthcare as a system that may harm individuals who lack privilege within it, and our role, collectively and individually, in promoting anti-racist practices. So today, we're focusing on racial violence in mental health treatment settings, and this session is going to demand that all of us step beyond sort of a standing commitment to equity, and it's going to ask that we're actionable, courageous, curious, and motivated to critically think about this topic together. There's a risk here, though, right? There's a risk that with diversity and equity training is that it can be a distractor from the policies and the structures that perpetuate racist practices. So there are limitations. This can perpetuate sort of complicity in larger systems, and so our eyes should all be open. We should be motivated to be both dialogue as well as action forward, and today is just simply an introduction to sort of the extensive work that each one of us has to do. The objectives today are going to be to define three levels of racism and manifestations of racial violence in the workplace. We're going to describe the impact of racism on the mental well-being of healthcare providers and patients, and we're going to develop strategies to respond to incidents of racism in mental health treatment settings. We're going to do this by first starting with building a shared language together so that we're doing some concepts so we all kind of go in with having some common understanding as we then transition to my colleagues leading us through case presentations, and those will be active in nature and involve a polling, so please stay tuned for that and be ready to participate when that time comes. So we will first start off by building a shared language together. So based on the work by Kamara Phyllis Jones, she's provided a definition and a conceptualization of racism that we'll use today. So racism is a system of structuring opportunity and assigning value based on phenotype or race that unfairly disadvantages some individuals and communities. It unfairly advantages others, and it undermines the realization of the full potential of the whole society through the waste of human resources. Now, importantly, I want to make a note here that race is a social construct. It's just based on skin color, and race is used to justify racism. It's a product of social context, and it really has only been assigned meaning because society has awarded it one, and as we talk about racism, we're going to use the conceptualization from Dr. Jones and think about the institutional, personally mediated, and internalized levels of racism. This is a graphic that shows kind of the way this is structured, so it's institutional being the kind of arching category, and then personally mediated and internalized. First, we're going to think about institutional racism. This is defined as the institutional policies and practices that create different outcomes for different racial groups, and that often manifests as disadvantaged and differential access to the goods, services, and opportunities of society compared to a racial or ethnic majority. Now, the institutions may never mention any racial group, but the reality is that their effect will create oppression and disadvantage for people from groups classified as people of color and advantage for white people, either intentionally or unintentionally, and it often functions within established, respected societal entities, so it doesn't really receive as much public condemnation compared to sort of individual racism. There's a lack of a single identifiable perpetrator, so it emerges as a collective action of a population, which makes it challenging to then rectify because that differential access becomes sort of integral to the institutions and ultimately is common practice and chronically reinforced by conformists and by newcomers. It often manifests as inherited disadvantage as well as an action in the face of need, so some examples of this would be a lack of policies and procedures to address racist encounters and reduce housing due to redlining as well as Jim Crow laws. I also want to make a quick note here on this slide is that it's oftentimes used interchangeably with structural racism. I want to make a brief distinction is that structural racism recognizes the totality of ways in which societies foster racism, oftentimes through mutually reinforcing and overlapping institutions, housing, education, health care, criminal justice, etc., and that will then energize the racism that occurs institutionally, interpersonally, and internalized levels, and so it's not exactly located to a particular institution, so if you think of structural racism kind of as the larger umbrella, and institutional racism is an element of structural racism, and it's the most profound and the most pervasive form of racism. It's cumulative, it's pervasive, and it's durable. Next, we're going to consider personally mediated racism, so this is oftentimes the type of racism we're most commonly thinking about. It's the racism that occurs between individuals. It's defined as prejudice and discrimination, and I'd like to contrast those concepts with bias, so bias is a predisposition or a preference in cognition. It can be negative and positive. It can inhibit partial judgment, and that will oftentimes result in unfairness, and it can result in discrimination. This can be implicit in nature, that is unconscious in nature, or explicit over conscious in nature. As we contrast this with the idea of prejudice and discrimination, which defines personally mediated racism, prejudice is the preconceived opinion or belief that's rooted in unfair assumptions, kind of about the abilities, the motives, the intentions of others according to their race. It's usually negative. It's an active dislike of a certain thing, and it can be intentional or unintentional, and it normally will result in discrimination, so discrimination, the easiest way to think about it is that it's prejudice in action. It's treating someone less favorably based on a group, class, category that they belong to. Some examples of this would be a lack of respect, suspicion, devaluation, scapegoating, dehumanizing, and our next level is internalized racism, so this refers to both the conscious and subconscious acceptance of negative messaging from the dominant society about the abilities and worth by stigmatized members of, by members of the stigmatized races, and so this can be distilled down into concepts of self-hatred, and it really put the locus of responsibility on the oppressed. It gives rise to patterns of thinking, feeling, behaving that result in, you know, discriminating, minimizing, criticizing, finding fault, invalidating, hating oneself, hating others while simultaneously valuing a dominant culture. Some examples of this would be self-devaluation, the idea that I don't belong, resignation, that I can't succeed, hopelessness, that my future is already decided. Related concepts to this have me thinking about double consciousness, and this was first explored by DuBois in 1903, and it describes that individual sensation of feeling as if your identity is divided into several parts, and it makes it really hard to unify one's identity into a single identity, and so in the context of race, it can be difficult to unify an African and American identity while living in a society that has historically repressed and devalued them, so not only does it reflect, though, the views that someone has from their own perspective about themselves, but also how they might, how they must view themselves, but how they might be perceived by the outside world or a white world. Also related to this would be imposter syndrome, which I think is a concept most of us are familiar with, too. The next concept I want to briefly discuss is this idea of intersectionality, so in 1989, Kimberly Crenshaw first introduced intersectionality theory as it relates to law, and so since then, it's become more of a mainstream topic beyond application to law, and I highly recommend reading her work to understand more of the context of this term, but in her words, it lends a prism for seeing the way in which various forms of inequality operate together and exacerbate each other. The idea is that people possess multiple layered identities, and that includes race, class, gender, sexual orientation, ethnicity, ability, among others, and those will intersect and interact in someone's life and society and social systems. It can't be examined in isolation, and so it helps clarify how someone can simultaneously experience privilege as well as oppression, and as many of us know, this word privilege, I wanted to make it clear how we talk about privilege is that privilege is an unearned social power. It's given by the formal and the informal institutions of society to all members of a dominant group, white privilege, male privilege, etc., that results from systemic marginalization of another social group, and that doesn't mean that you haven't struggled or worked hard. It just means there's some things that you won't have to experience just because of who you are, aka it's unearned. It's given to you whether or not you want those privileges and regardless of your intent. The next concept I want to talk about is this idea of racial violence, and I'm using that term today intentionally because it informs us of how we should think about racism in terms of it encompasses all forms of racist hate speech, and that violence is not just limited to physically mediated violence, and so in this article by Williams, he talks about how workplace violence is really, you know, we know it's a well-documented hazard in medical training, but we don't incorporate racism into its conceptualization, so when we label racism as disruptive or hateful, it decontextualizes the effects of that racial abuse, and so it sets in motion sort of algorithms and scripts that address disruptiveness, but it's overall avoidant and complicit in the very entrenched nature of white supremacy in medical institutions, and so Williams says, hey, if we then name this as violence, we're going to allow for more helpful communication scripts, more collective and institutional responses that address the needs of a patient, address the needs of trainees and other providers, that address the racism directly, and then support those affected in the aftermath, and we do so knowing there needs to be unit and institutional responses as well. The concept of minority tax is important to mention because minority tax is being defined as the tax of extra responsibilities placed on minority faculty in the name of efforts to achieve diversity, and it lends itself to considering the role of a bystander or a witness in situations involving racial violence, and so communication scripts are not only powerful and necessary for the person on the receiving end of racial violence, but they're also necessary for bystanders to utilize as well. There are many, many versions of communication scripts, and it's very important to sort of review them and craft your own, and it's helpful for institutions to formalize their own scripts and policies, and so I'm only providing an example of just one, and this one is designed by Dr. Souza, who first piloted this in sort of thinking about microaggressions in a classroom setting, and so the acronym is ACTION, so let's break it down. So A is asking clarifying questions to assist with understanding intentions. C is coming from curiosity, not judgment. T is telling what you observed as problematic in a factual manner. I is impact exploration, right, asking for stating the potential impact of such a statement or action on others. O is owning your thoughts and feelings around the impact, and N is requesting appropriate action be taken, and you read this, and I just kind of rambled off a bunch of letters and kind of, you know, words that match those letters, but what would this actually look like, so let's put it together in the form of the script, so A, asking clarifying questions to try to understand intentions, right? This would be, I want to make sure that I understand what you were saying. Where are you saying that, and C is coming from curiosity, not judgment, right? Can you please tell me what you were hoping to communicate with that comment, or can you please help me understand what you meant by that? T, telling what you observed as problematic in a factual manner, right? I noticed that, being very specific and kind of objective, right, and I is that impact exploration you're asking for and kind of talking about this potential impact, so you're saying, what do you think people think when they hear that type of comment, or what impact you think that comment could have on, O is owning your own thoughts and feelings around the impact, right? When I hear your comment, I think or feel this, or in my experience, that comment can perpetuate negative stereotypes and assumptions about, and I would think that's not your intent, and N would be requesting appropriate actions to be taken. I'd appreciate it if you consider using a different term, because that's inconsistent with our hospital policy regarding blank. This slide is meant to be sort of a place to start in terms of other resources to developing your own sort of scripts, and it can be adapted, right? These should be adapted depending on your setting, the situation, and so, for example, a script might look different if it's to be utilized on an inpatient setting, right, when a patient's requesting a different position based on race, and so it's important, though, that we know that requests that are discriminatory in nature warrant implementation and utilization of institutional policies, that these scripts really need to be seated and supported in sort of a larger established infrastructure, and what we've done so far today is what we've done is that we've reviewed important concepts as it relates to racism, right? We've worked on sort of developing a shared kind of conceptual language around this. We've considered one example of a communication script and how you might begin to craft your own, and so now my colleagues are going to review cases with you that bring many of these concepts to life across the continuum of mental health care delivery, and I also want to make a note here that the language in these cases might be difficult to hear, and so please just take care as you listen and participate. Thank you, Dr. Espana. So, I'm going to walk us now through a routine outpatient intake encounter. Both of the case examples that we'll be looking at today involve race and racism in a realistically messy context of other power imbalances. Our goal today is that these examples give us a chance to mentally rehearse, to practice skills that we need in our work. So, let's set the scene. You work in an outpatient clinic, a mental health clinic that's been in existence for five years. It does not have an academic affiliation. Your clinic accepts private insurance, takes Medicare, and there is some sliding scale payment available on a case-by-case basis. This is not a facility that offers medication-assisted recovery treatment. Next slide. This is your team. There are seven LIPs on the team, five psychiatrists and two psychiatric nurse practitioners. There's one nurse on the team, and typically you have two social workers. Right now, there is one person in that position, and they're working remotely and part-time. Next slide. You're scheduled today to have a med management intake, and you have a little bit of preparatory information available before you see the patient. We'll be seeing a 19-year-old Nigerian man who lives with his parents and his sister close to the clinic. He has no long-standing formal psychiatric history, but he recently had a 23-day hospitalization at the local academic hospital after he was skateboarding and was hit by a car and suffered a head injury. There are reportedly concerns for a psychotic disorder, and documents that you received have noted that English is a second language, but an interpreter will not be needed for this encounter. Miraculously, you've actually received a discharge summary prior to the appointment. As you're reading through that, you see notation that he was probably displaying symptoms of early-stage schizophrenia prior to his motor vehicle accident trauma. The hospital course documentation notes that there were incidences of agitation during treatment where he was verbally abusive towards staff. The RN in your clinic moonlights at this hospital. During your morning huddle, they fill in some additional background information that they recall about this situation. Their recollection is that he was verbally agitated towards the end of his hospitalization. There were no incidences of physical aggression. The first portion of the hospitalization, there were no concerns about verbal agitation either. They did not directly participate in his care, but they overheard other staff saying that they thought that his parents spoke limited English, and they remember an instance where a psychiatrist on the weekend was speaking with the charge nurse about this patient and seemed very disgruntled. He said, these people come in and expect the moon and stars. I just don't understand the lack of gratitude. Let's pause here and think. Looking at this building, looking at this team, what assumptions might somebody have about your practice setting? What power dynamics are relevant for somebody who's coming into this space? Let's try to put ourselves in the mind of a patient and family who are entering the mental health system for the first time. What concerns and ideas might they have coming here? Are there any aspects of the case that are concerning for us so far? We'll move forward. Let's meet our patient. Four months have passed between discharge and this initial appointment. He's accompanied today by his mom and his dad. As he slowly walks into the clinic room, you notice that he's drooling, and he doesn't appear to be saying very much. He hands you a discharge paperwork that he received that has a list showing new medications, haloperidol 15 milligrams by mouth twice a day for management of, quote, psychotic symptoms. We don't know yet if race has played a factor in this patient's care, but let's pause and check some of our knowledge about factors that could be relevant. This will be an audience response portion. I'm going to read through each of the options, and then we'll have the poll go live. Which of the following statements are true about differences in treatment based on race? Select anything that you think is true. On average, Black patients receive less intensive pain treatment than White patients. Black patients are more likely than White patients to be prescribed first-generation versus second-generation antipsychotic medicines. C, psychotic disorders are more commonly diagnosed in the U.S. in Black patients than in White patients. I'll go ahead and make the poll live now. We have three more seconds, and we'll go ahead and close the poll. Thanks. All right. So, let's take a look. So, everybody picked option B, and multiple respondents said that A and C were also true. So, let's take a look back at the slides. So, all of these are true statements. It has been found in multiple research studies that Black patients receive less intensive pain treatment than White patients. Everybody identified correctly that Black patients are more likely to be prescribed first-generation rather than second-generation antipsychotic medicines. And it is also true across multiple studies that psychotic disorders are more commonly diagnosed in the U.S. in Black patients than in White patients. So, it is also true across multiple studies that psychotic disorders are more commonly diagnosed in the U.S. in Black patients than in White patients. Let's check what we know about the body and about outcomes that correlate with race. Again, here we'll be asking you to select anything that you believe is a true statement. A, on average, Black Americans have less sensitive nerve endings than White Americans. B, Black Americans are more likely than White Americans to have a stroke. C, Black Americans are more likely than White Americans to have a mental health condition. We'll open the poll now. We'll do 5 more seconds and go ahead and close the poll. And then we can take a look at the results. So great, option B is true, you all correctly identified that one, and there was some interest in option C. Let's take a look back at the slides. So the only statement here that was true is that black Americans are more likely than white Americans to have a stroke. The first one, option A, is a historical fallacy that has no basis in fact. And C, the literature suggests that there are equal rates of mental health conditions in the United States among people of different racial and ethnic groups. And there is one publication in 2008 in the American Journal of Psychiatry that suggested that white Americans may have a higher lifetime and single year rate of mental health conditions as compared to black, Asian, or Latinx Americans. Let's get back to speaking with our patient and his family. So his parents are tearful. They fear that they've lost their son forever, that he's just not the same anymore. During hospitalization and the appointment with you, they took their son to establish with a primary care provider who recommended continuing Haldol, and that PCP noted the team in the hospital probably knew what they were doing. I really think you should see a psychiatrist before making any big changes. They report that they called about 15 different places to schedule as they were advised by the inpatient social worker, but they only heard back one time to schedule the appointment that they have with you today. Here's another point where we're going to get to do a little bit of role play and think about how we would respond. After relaying the facts before, his mom said, we know they weren't treating him right in the hospital. They just wanted to rush him out even though he wasn't ready. And I know they wouldn't have done that to a white kid. How do you think you would respond? So in this one, you're going to pick just one answer. A, ma'am, in this clinic, we treat all people the same, and I'm sure they did their best in the hospital. B, navigating the mental health system is always tough. It's probably for the best that you prepare for that now. C, I really hope discrimination didn't impact the care that your son received in the hospital, and I'm sorry if it did. I hope we can all figure out together today how to get things headed in a good direction for him. D, honestly, it's his medications that shock me. We'll give you all a chance to respond. We'll close the poll in five seconds. All right. This is a good audience. Everybody picked C. That's fantastic. So let's look back at the slide and think through what's wrong with some of the other options. And the other options are realistic things that people would say. So that first one, A, it doesn't acknowledge the family's frustrations at all. It barely acknowledges the possibility of racism, and it creates a lie by holding up the inpatient treatment as exemplary when, in fact, we question the decisions that were made there. B, still doesn't acknowledge the family's difficulties and frustrations. It doesn't acknowledge race at all, and it slips into an assumption of chronic illness. And this is a patient that we have not yet evaluated. Option D is honest, but it doesn't begin to build in a positive direction in terms of treating this individual. C, acknowledges the pain that they have expressed. It doesn't deny the possibility of racism, and it continues into the pressing matter of figuring out how to treat a young man who is very likely overmedicated, who may have a psychotic disorder as well, and who likely has low trust of the system so far. Next slide. So we're going to stop this case here. We're not going to resolve this today. We've purposely looked at a case that is ambiguous. It is possible that explicit racism had no bearing in this situation. It's even possible that implicit racism was not a factor in the diagnosis, the response to his quote-unquote agitation, or the treatment that was selected. But this family has strongly suggested that they expect the possibility that they will be treated differently based on race. If we ignore this, we miss a key dynamic in our interactions. And this is a family that has actually been very generous and that they have vocalized their concerns. They have gifted us with the opportunity to respond. Navigating the mental health system is incredibly difficult. If it turns out that this family is beginning a journey of chronic mental health treatment, these first few interactions set the tone for years and decades to come. A general, patient-centered, trauma-informed care approach is going to be helpful in this situation. And at the same time, we need to walk into this room with the awareness that based on race, which is not a meaningful proxy for biology, this man is at higher risk of being diagnosed with a psychotic disorder. He is more likely to be treated with first-generation antipsychotics rather than the second-generation antipsychotics that we typically consider standard of care for psychotic disorders. And he is at higher risk of being assessed at risk of violence towards others. When we acknowledge these realities, we create space to build trust and to accomplish healing. I'm going to turn things over now to Dr. Maitland-McKinley to review a case that occurs in a training environment. Thank you very much. So we are going to be moving to a case that is, as Dr. Narakaragud said, in the inpatient setting. And so I'm going to ask everyone to get into a purely role-play mindset. And so this is interactive. And again, it's meant to produce a few moments of reflection. There are going to be multiple choice answers. And these answers themselves have multiple outcomes. And there will be benefits and drawbacks, much like in real life, to every decision. And some may reflect a particular framework. Perhaps if you have experience with them, you might recognize them. But there's no need to be familiar with them. Because what I'm going to ask is that people answer as they instinctually feel they might respond, not necessarily what you feel is correct. Next slide. So this is you. You are a junior attending. And you are on the consult service. This isn't your first time covering the service. But you've been on for about two weeks now. And it is busy, as expected. But luckily, you do have a colleague who's been on the service a little bit longer. And so they have taken perhaps a couple more patients on the list. They've also taken a PGY-2 resident and also two med students to help them. And that's more so so that both you and your resident can spend a little bit more time getting used to the service. And this is your resident. She's a PGY-3. You two haven't worked together too long. But you've gotten enough time to sort of learn each other's practices. You've also heard from your coworkers that she has excellent fits and manner. And so far for these past two weeks, you agree. Her skills in pharmacology are developing very well. Her liaison skills are perhaps a little bit more in need of development. But overall, she's doing excellent work with you. And so this morning, as usual, excellent work pre-charting. She spent the whole morning looking at the patients that you're going to see with her. And so you're going to let her lead the way. Next slide. And so the first place is the closest, convenient, to the ICU. And so you are about to see a 76-year-old Caucasian gentleman. You're told that he has a past history of depression, HIV, diabetes mellitus type 2, and more pressing, a recent history of recurrent hospitalizations. And all of these have been related to diabetes and the complications from them. And so right now, he's admitted with an infection. And there's a very, very high chance that he will have to have a left below-the-knee amputation. As far as you can tell, the consult was placed for capacity because it seems like he's been refusing his medications most recently. But your resident has actually reviewed all of his care. And so up until this point, she's noticed that there's never been a documented discussion about goals of care. And she really feels that she's concerned about his overall trajectory, particularly because of this possible amputation. And you agree. It seems very appropriate. And so you let her lead the way, of course, knocking before you two enter. Next slide. You enter. Your patient is reclined in bed watching TV. And a man is next to him who jumps up and introduces himself as his husband. Your resident, very friendly, both of you walk in, introduce yourselves. And the patient regards you casually. He keeps watching TV. It must be interesting. He says that he's totally fine talking with you as long as his partner can also stay, which, of course, you agree to. So your resident prepares. She begins to explain why both you and her are there and begins to interview. And then after a few moments, the patient leans over to his husband and loud enough so that both of you can hear, turns and makes this comment. And it's something that both of you can hear and your resident pauses. And so I want us to take a pause here as well. So just to review. You are a second year attending. You are with your PGYC resident. You both have been back to CL, the consult service, for about two weeks. Have a rather long list of patients to see this morning. The patient has just made a racially charged comment towards your resident colleague. And the question is, how do you react? Next slide. And so there are a couple of choices here. And really, again, I would want people to choose the one that they feel is most reasonable. They might not necessarily reflect how you yourself might react. The first option is to ask your resident to ignore the comment and move on. It's possible that he's delirious. Tell the resident to respond for herself. She is an adult and it's very likely that you will have to deal with these situations in the future. C, tell the patient that his words will not be tolerated and then also demand that he apologize to your resident. D, tell the patient that his language is truly unacceptable and explain why both you and your resident colleague will have to leave and that you'll give him some time to collect himself and return later. E, tell him that really these views have no place in this hospital. Explain to him and his partner that unfortunately, neither you nor your resident will be able to continue aiding him in his care. And so I'll give everyone a chance to make a vote. We'll give everyone about 10 more seconds. Oh, yeah. Okay, we can close it. Okay. It looks like the majority of people chose D, and then a couple of people chose B. Well, so, to review again, we can start off with D. D is to explain to him that his language is unacceptable, why it is, and then also explain that you and your colleague will have to leave and that you will return later to collect himself. And in response to this, there could be a couple of things that could happen. He may look at you and tell you next time to come back with somebody American. He could also look at you, look quietly at both of you, and then nod and acknowledge your plan without saying anything. And so, in thinking about this response, while some models do suggest that starting off by exploring the patient's mindset, perhaps examining why in the situation the patient might have said this, this answer doesn't necessarily do that, but it does recognize the incident openly and address it in real time while also attempting to remain professional and support your resident colleague at the same time. It also does give you both the chance to regroup and debrief before actually reengaging with the patient, which are all benefits. Option B, allow your resident time to respond. She is an adult, and there is a very good chance that she might have to deal with these sorts of situations in the future on her own. And so, one option or one resulting conclusion to that is that she might sharply correct him and say that she's Vietnamese, only for him to aggressively comment that there's little difference. Or, she may make a pointed request that he not use that language with her, and while the interview is short and tense, it's completed thoroughly. And one benefit to this is that it does offer the chance for self-advocacy, which is important, and I think everybody who's worked in a clinical setting can see it's important for you to be able to advocate for yourself. It does prove challenging depending on the tools that she's either encountered or that she's been offered before in terms of managing a difficult situation. It also doesn't recognize the issue openly, which may pose a challenge in the future when offering support. And so, thank you for everyone. We're gonna keep going. Next slide. And so, after you respond, his partner quickly steps in and quiets his husband, and he delicately asks you if it's possible for both of you to speak with him outside of the room. Once outside, he quickly apologizes, says that's not typically like his husband, and then he moves closer to you to sort of whisper. Unfortunately, it does cut off your resident's ability to both see and hear the conversation very clearly. He says to you what's on the screen now. And so, I again want to take a pause in this situation. So, to review, he's apologized to both you and your resident. His behavior and his body stance could be seen as dismissive to your resident, and he's also made comments that could be seen as either a very direct request. It can also be seen as a possible microaggression. How should you respond? Next slide. Explain that there aren't, unfortunately, any other psychiatrists available at this time, and that both you and your resident will return together at the end of the day and end the conversation there. Explain that you are the only available board certified psychiatrist available, and then offer to do the assessment alone. Ask directly if he's insinuating that he would prefer a white clinician. Say yes and offer to have your colleague's team come and interview the patient. Last, say yes, but explain that his partner will likely not get seen if he transfers his care to his colleague, to your colleague. And so, we'll take a moment for everybody to vote on what they feel is best course of action. All right, looks like we can close it. Okay, so it looks like the majority of people chose option C, and then some people also chose option A. Okay, well, let's see what happens. I will openly admit, even though I was writing these questions, it seemed very difficult to see what I would do in this situation. So it looks like the majority of people chose to ask directly if he was insinuating that he would prefer a white clinician. And so this could go a couple of ways. One is, he may look at a loss for words and then stutter and say he would never. Absolutely not. He might also be stunned and then tell you quite frankly, yes, and he would prefer if you didn't make a big thing of this. So one benefit to the response is very, very clearly it makes the invisible visible, which is important when dealing with microaggressions because they can be subversive and challenging to manage unless they're actually brought forward. It can also be seen as adversarial, but it does disarm the microaggression. And it could set the stage for empathic education on your part if you feel like you have the time in the moment, or you can consider doing it later. It'll really be up to you. A. Explain that there aren't any other psychiatrists available at this time and that both you and your resident will return later and make it very pointed and end. And so he may look confused at you and your resident and then say he needs to talk to his husband's primary doctor before that. He might also say he can't promise that his husband will be different, but he will promise that he will be there also. And so the benefit of this response is, well, a couple, that the response does disarm any possible microaggressions by setting limits clearly. While it doesn't necessarily openly make those statements, it also does, does still do that. And it shows a commitment to care. And so we're going to move and continue on with this case. And so after responding to the husband, both you and your resident are very clear that it's time for you to go. You have a long list. It's still early in the morning. But after you're partway down the hall, your resident stops and asks if you would mind stopping to debrief. And when you look at her, you can tell that she's visibly shaken. And so you two take a pause right before a quiet stairwell, someplace where you feel the two of you might not be disturbed for at least a couple of minutes. And she asks you this question on screen. And so I'd like to ask everyone, how do you feel it's best to respond? Next slide. So to be honest with her and tell her this will happen in the future, and she will unfortunately have to learn to let things like this not bother her. To tell her that it may happen, but to also encourage her to talk with one of your Asian colleagues who happens to work in the outpatient clinic about his experience in practice. To share a quick story about a time that someone, a patient, said something much worse to one of your colleagues while you were also in training. To tell her a story of a difficult interview that you yourself had, and then to encourage her to talk more with you once perhaps rounds are over. To encourage her to begin her own personal psychotherapy so that she can take the time to reflect on this and possibly other things in the future in a safe space. And so we'll give everyone a chance to answer. Okay, well, looks like we can end it. We can close it now. Perfect. Thank you. So, it looks like everyone chose option D. And so, the interview option D is to share with her a deferral interview that you had and to encourage her to talk with you more after rounds. And, in response, she may brighten up slightly and say, thank you for listening, and say that you'll plan to finish notes early, so the two of you can talk more. And so, the benefit of this response is that it attempts to form a connection with her over shared difficult experience and also possibly suggest tools that you yourself have used, and either way, also suggests that there will be time that you two can debrief again and talk more about her experiences and her concerns that she might not have been able to really come to at this point. And so, since that was the only choice, we can move on. And so, I want to thank everybody again for participating in this roleplay. And so, again, these responses are fractions of the possible responses. It's certain that, in the moment, you all would give more nuanced responses. In this situation, it is complicated to give a response because of the balance of beneficence, both in the face of microaggressions and or very real racial violence, and that can be very challenging, particularly when there are multiple parties present. This is also a situation where we can see both the minority tax and double consciousness mentioned by Dr. Espada earlier in action, and a few of the challenges that providers of color may sometimes run into. And so, if any of these situations resonated with you, but perhaps maybe a response didn't exactly encompass that, or even if the response was not necessarily what you thought it might be, I encourage you to examine that response a little bit more. Rarely is a moment, particularly teachable ones, clean cut and seamlessly superimposable onto perhaps a framework that we might have learned. And yet, frameworks are also an excellent place to start because they give you the building blocks and the tools. I would particularly say, if any, if this case in particular did resonate with you, I would highly suggest the ERASE model, which, again, Dr. Espada mentioned earlier, as that deals specifically with dealing with difficult situations like this while there are trainees present. Next slide. And so, I have the responsibility of concluding it. I'm concluding this presentation. And so, I want to thank everyone for reviewing this topic with us today. I think that we all, all three of us, see this as an exciting time in the area of diversity in the study of ethnic and racial politics in medicine. While POC voices in this area have historically all too often been ignored, this is changing. This is changing rapidly. And we are still only in the beginning of this, of even institutional recognition and acceptance. And our presentation can't begin to encompass everything and all the previous work that's going on, nor all the ongoing work that's still happening. And that's why we would also encourage you to continue to explore, continue to discuss these kinds of topics, because they are important. You may need the time to process your own experiences. Take the time you need. No one should thrust you into the position of teacher unless you are willing to accept that role. If you feel the need to process any things like this with someone else, look for that chance. There are always people there willing to help you and go through this with you. And if you feel the calling to help others with that work, or to perhaps help with their lack of understanding, or their perhaps lack of understanding of their own pain, please do it. Whatever you do, please just make sure this is not the last time you have these kinds of conversations. Thank you. And so I want to make sure those are references that we get to. Next slide. The how to claim your credit, just that everybody has. We'll leave this up there, but we'll also open it up to questions in case anybody has any. I think that I'm looking at some of the comments on here. I think there again there could have been a sixth choice. I would encourage everybody if any of these resonated with you to also remember these are because of the setting that we actually are in right now. It's very limited in terms of how we can actually interact and engage everyone. But I absolutely recognize there are multiple ways that people could have responded and I'm happy that people are thinking about that. In the past, we have presented that trainee supervisor situation as an active role play exercise in the room, and I think one of the common experiences when working through the role play was recognizing the importance of the trainee having the opportunity to have agency. So I appreciated Dave kind of remark that the trainee getting to, to be active in terms of determining what what happened next without obligation is really the goal in that in that type of situation. I think what's really helpful in in thinking about how you adapt communication scripts as you'll see that I had one slide where it talks about the race model talks about action and talks about other types of models to consider. And also in that slide is a article by Paul and meal and it'll be in our references slide but in terms of thinking about like larger systems and algorithms to manage care, especially when it comes to requests of for a physician of a different race. It's fair. It's challenging right and what I really like about that article is it. It puts forward a proposed algorithm and thinking about this as a larger system. Because I think that these scripts, only go so far. Only go so far, because those really have to be rooted in sort of institutional values and institutional change those cultures take time right like this is so entrenched and it's so challenging to start start to start moving them. And so I'd encourage all of you to, it goes beyond kind of simply sort of a equity and diversity statement from an institution, I would encourage you all to look at the policies and practices of how your institution handles these requests, and also to utilize the resources and references we have in this presentation to think more critically about the algorithms kind of that would work for your institution when these requests come up and the idea of having to having and wanting to preserve patient care and the well being of the provider. I think oftentimes we're so committed to kind of kind of bleeding endlessly for care in ways that can be really harmful and really contributes position burnout and mental well being. So I would encourage you to kind of look at both your own communication scripts also that your institution was from larger, larger, larger system questions. I would absolutely if I would piggyback off of that with Dr Aspana in saying if you are in that situation to also consider reaching out and seeing who else can offer any sort of mentorship I know that the three of us were lucky to have each other mentors, and it can be as Dr Aspana said it can be a lot of work, and it does take its toll on people sometimes and that's, again, why we would want to encourage people to think about their own well being to also think about the well being of just providers in general, because this is a very very difficult subject to try and balance both well being of, just like Dr Aspana said, both the patient and the provider. And I see a comment here about, about kind of having kind of feeling like you still want to sort of make a difference and and and be able to address address kind of these issues when they come up and sometimes something that a tool that I use is when in the moment, if there's a situation where they're requesting different provider they don't want to see me. I sometimes I'll say hey I want to know a little bit more about that right I leave with curiosity but also if someone says a comment that is incredibly disrespectful I use language of, I want to challenge something that you just said, and that what that does is, is it begins to invite that hey I'm going to push back on something. And I think there's a there's a language and a body language we can kind of, we can show that said hey, this isn't quite right, I want to push back on this. In my experience, X, Y, and Z. And so sometimes that can be a way, way to kind of introduce a different perspective right is that you're not, you're not willing to necessarily accommodate but you are saying hey, I hear what you're saying this is why it's problematic. and also, I see a comment about the APA maybe doing like a role-play opportunity. That would be awesome, and if you haven't already, I would look also into your institution to see if they are doing sort of workshops like this. They're really powerful to do in a room, sort of like, it can be hard virtually, but it can still be done virtually, but it's really powerful when you're in a room, and you can kind of feel the texture of things, because what's powerful about these prompts, and we kind of did it in the poll format today, but what's most powerful is being able to say, hey, here's how I would respond, and someone would say, you know, this is how my script might be different, or you can pilot it, like, hey, well, what if the person responded this way? What might you do, and how would you triage patient care? How would you triage the well-being of trainees? How would you triage your needs as maybe attending on service, and how do you juggle all those responsibilities? What's also powerful is when those rooms are multidisciplinary, is that when you have representation from nursing staff, social work, MAs, everyone's sitting in the room together and joining in this, because we're all either on the receiving end of racial violence or bystanders or witnesses to it, and it's an invaluable tool for everyone, and I think it's such an invaluable tool for the function of a team, for the heart of a team, to know what to do, and for that to be backed by institutional support and policy. and I just want to say I really appreciate everyone's participation today. I think it's really brave. It's really brave to answer questions. I know that we were asking questions about evidence of racial disparities in care, but also asking questions that were a little more nuanced about the human experience, and it required you to kind of put yourself in someone else's shoes, and I would say don't let that, don't let that practice stop here, though this was kind of a safe way to get at trialing some scripts, to get a safe way at thinking about what would happen if I responded this way or that way, but I think working with each other to find a script that that's compatible for you and your practice with others around you is critical, so taking it from this kind of safe place in a presentation format with polls to then maybe taking another step out and trying this out in practice and seeing how it goes. We're all going to make mistakes, and it's okay. It's okay to make mistakes. It's okay. You just get back up. You apologize when you make a mistake, and you just carry forward. It looks like we hit 12 o'clock right now, or I suppose we're all in different time zones, but I want to be respectful of everybody's time. Again, thank you everyone for being here. It is amazing to share these kinds of spaces with everyone, and I hope that we can continue to do things like this.

racial violence in mental health

addressing racism in healthcare

communication strategies

role-play scenarios

racial disparities in care

supportive healthcare environment

anti-racist practices

equity in healthcare

mental health treatment